Accountable Care Organizations and Transaction Cost Economics

Using a Transaction Cost Economics (TCE) approach, this paper explores which organizational forms Accountable Care Organizations (ACOs) may take. A critical question about form is the amount of vertical integration that an ACO may have, a topic central to TCE. We posit that contextual factors outside and inside an ACO will produce variable transaction costs (the non-production costs of care) such that the decision to integrate vertically will derive from a comparison of these external versus internal costs, assuming reasonably rational management abilities. External costs include those arising from environmental uncertainty and complexity, small numbers bargaining, asset specificity, frequency of exchanges, and information impactedness. Internal costs include those arising from human resource activities including hiring and staffing, training, evaluating (i.e., disciplining, appraising, or promoting), and otherwise administering programs. At the extreme, these different costs may produce either total vertical integration or little to no vertical integration with most ACOs falling in between. This essay demonstrates how TCE can be applied to the ACO organization form issue, explains TCE, considers ACO activity from the TCE perspective, and reflects on research directions that may inform TCE and facilitate ACO development

Clustered and Distinct: A Taxonomy of Local Multihospital Systems

Despite their prevalence and power in markets throughout the United States, local multihospital systems (LMSs)—also referred to as hospital-based “clusters”—remain an understudied organizational form, with studies instead primarily focusing either upon individual hospitals or viewing hospital systems collectively without distinguishing the local “sub-systems” that comprise larger regional or national hospital chains. To better understand these organizational forms, we develop a taxonomy specifically devoted to LMSs, applying taxonomic analysis methods to a sample of LMSs in six U.S. states while accounting for LMSs’ geographic arrangements and non-hospital-based service locations. Our analysis identifies five distinct LMS categories, with forms clearly distinguished according to their varying degrees of differentiation and integration. The study’s results accentuate the importance of accounting for hospital systems’ activities and arrangements in local markets—including their non-hospital-based sites—and highlight differences in systems’ achievement of integration and coordination across services and locations, providing considerations in light of U.S. health system reform as well as international patterns of regional system formation

Whooping crane use of riverine stopover sites

Migratory birds like endangered whooping cranes (Grus americana) require suitable nocturnal roost sites during twice annual migrations. Whooping cranes primarily roost in shallow surface water wetlands, ponds, and rivers. All these features have been greatly impacted by human activities, which present threats to the continued recovery of the species. A portion of one such river, the central Platte River, has been identified as critical habitat for the survival of the endangered whooping crane. Management intervention is now underway to rehabilitate habitat form and function on the central Platte River to increase use and thereby contribute to the survival of whooping cranes. The goal of our analyses was to develop habitat selection models that could be used to direct riverine habitat management activities (i.e., channel widening, tree removal, flow augmentation, etc.) along the central Platte River and throughout the species’ range. As such, we focused our analyses on two robust sets of whooping crane observations and habitat metrics the Platte River Recovery Implementation Program (Program or PRRIP) and other such organizations could influence. This included channel characteristics such as total channel width, the width of channel unobstructed by dense vegetation, and distance of forest from the edge of the channel and flow-related metrics like wetted width and unit discharge (flow volume per linear meter of wetted channel width) that could be influenced by flow augmentation or reductions during migration. We used 17 years of systematic monitoring data in a discrete-choice framework to evaluate the influence these various metrics have on the relative probability of whooping crane use and found the width of channel unobstructed by dense vegetation and distance to the nearest forest were the best predictors of whooping crane use. Secondly, we used telemetry data obtained from a sample of 38 birds of all ages over the course of seven years, 2010–2016, to evaluate whooping crane use of riverine habitat within the North-central Great Plains, USA. For this second analysis, we focused on the two metrics found to be important predictors of whooping crane use along the central Platte River, unobstructed channel width and distance to nearest forest or wooded area. Our findings indicate resource managers, such as the Program, have the potential to influence whooping crane use of the central Platte River through removal of in-channel vegetation to increase the unobstructed width of narrow channels and through removal of trees along the bank line to increase unforested corridor widths. Results of both analyses also indicated that increases in relative probability of use by whooping cranes did not appreciably increase with unobstructed views 200 m wide and unforested corridor widths that were 330 m. Therefore, managing riverine sites for channels widths \u3e200 m and removing trees beyond 165 m from the channel’s edge would increase costs associated with implementing management actions such as channel and bank-line disking, removing trees, augmenting flow, etc. without necessarily realizing an additional appreciable increase in use by migrating whooping cranes

The COVID-19 Impact on Health Administration Education: Understanding Student Perspectives on the Transition from In-Person to Remote Course Instruction

COVID-19 has infected millions of Americans. To combat the spread of the virus, state and local officials instituted social distancing guidelines that forced schools to shutter campuses and transition from in-person to remote learning. In this study, we examined health administration (HA) student perspectives on the transition from in-person to remote learning. We sought to understand how schools attempted to manage student concerns, how adaptations to remote learning were implemented, and what influences the transition had on student stress and anxiety. We used a mixed-methods study design that included (1) a survey of undergraduate and graduate students from six geographically diverse HA programs, and (2) a focus group with 6–10 students from each program. Our survey response rate was 52% (n =215). We found that students experienced five phases following the transition: grief, loss of engagement, fatigue, coping, and resilience. Focus groups also revealed stress and anxiety, as well as communication from leaders, as important themes. We present integrated survey and focus group findings, and supplement with exemplary quotes where applicable. We conclude by discussing a number of insights provided by HA students that may help guide program leadership and HA faculty who are teaching future remote courses

Shared and distinct transcriptional programs underlie the hybrid nature of iNKT cells

Invariant natural killer T cells (iNKT cells) are innate-like T lymphocytes that act as critical regulators of the immune response. To better characterize this population, we profiled gene expression in iNKT cells during ontogeny and in peripheral subsets as part of the Immunological Genome Project. High-resolution comparative transcriptional analyses defined developmental and subset-specific programs of gene expression by iNKT cells. In addition, we found that iNKT cells shared an extensive transcriptional program with NK cells, similar in magnitude to that shared with major histocompatibility complex (MHC)-restricted T cells. Notably, the program shared by NK cells and iNKT cells also operated constitutively in γδ T cells and in adaptive T cells after activation. Together our findings highlight a core effector program regulated distinctly in innate and adaptive lymphocytes

The James Webb Space Telescope Mission

Twenty-six years ago a small committee report, building on earlier studies, expounded a compelling and poetic vision for the future of astronomy, calling for an infrared-optimized space telescope with an aperture of at least $4m$. With the support of their governments in the US, Europe, and Canada, 20,000 people realized that vision as the $6.5m$ James Webb Space Telescope. A generation of astronomers will celebrate their accomplishments for the life of the mission, potentially as long as 20 years, and beyond. This report and the scientific discoveries that follow are extended thank-you notes to the 20,000 team members. The telescope is working perfectly, with much better image quality than expected. In this and accompanying papers, we give a brief history, describe the observatory, outline its objectives and current observing program, and discuss the inventions and people who made it possible. We cite detailed reports on the design and the measured performance on orbit.Comment: Accepted by PASP for the special issue on The James Webb Space Telescope Overview, 29 pages, 4 figure

Antioksidativni učinci N-acetilcisteina, lipoične kiseline, taurina i kurkumina u mišićnom tkivu šarana (Cyprinus carpio L.) tretiranih kadmijem

We investigated the muscle tissue of a teleost Cyprinus carpio L. to find out whether N-acetylcysteine (NAC), alpha-lipoic acid (LA), taurine (TAU), and curcumin (CUR) were able to counteract oxidative stress induced by acute exposure to cadmium (Cd). The muscle tissue was dissected 96 h after a single intraperitoneal injection of Cd (5 mg kg-1) and of antioxidant substances (50 mg kg-1). Using spectrophotometry, we determined the glutathione redox status, lipid peroxidation levels and the activities of superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GPx), and glutathione disulphide reductase (GR). Accumulation of Cd in the muscle was analysed using inductively coupled plasma - optical emission spectrometry (ICP-OES). All substances lowered Cd levels in the following order of effi ciency; LA=NAC>TAU=CUR. Cadmium increased SOD activity, but CAT activity declined, regardless of antioxidant treatment. Treatment with CUR induced GPx activity. Treatment with TAU lowered Cd due to higher total glutathione (tGSH). The most effective substances on lipid peroxidation were LA and NAC due to a greater Cd-lowering potential. It seems that the protective role of TAU, LA, and NAC is not necessarily associated with antioxidant enzymes, but rather with their own activity.Cilj istraživanja bio je utvrditi mogu li N-acetilcistein (NAC), α-lipoična kiselina (LA), taurin (TAU) i kurkumin (CUR) svojim antioksidativnim djelovanjem smanjiti razinu oksidativnog stresa u mišićnom tkivu šarana (Cyprinus carpio L.) akutno otrovanih kadmijem. Uzorci mišićnog tkiva skupljeni su 96 h nakon što su ribama intraperitonealno injicirani kadmij (5 mg kg-1) i ispitivani antioksidansi (50 mg kg-1). Primjenom spektrofotometrijskih metoda izmjereni su redoks status glutationa, razine lipidne peroksidacije te aktivnosti enzima superoksid dismutaze (SOD), katalaze (CAT), glutation peroksidaze (GPx) i glutation disulfi d reduktaze (GR). Maseni udio kadmija u mišićnom tkivu izmjeren je s pomoću metode induktivno spregnute plazme – optičke emisijske spektrometrije (ICP-OES). Ispitivani spojevi smanjili su nakupljanje kadmija u tkivu šarana sljedećim redoslijedom: LA=NAC>TAU=CUR. Tretman šarana kadmijem izazvao je porast aktivnosti SOD, ali se aktivnost CAT smanjila bez obzira na primjenu antioksidativnih spojeva. Dodatak CUR pojačao je aktivnost GPx. Dodatak TAU povećao je razinu ukupnoga glutationa te smanjio nakupljanje kadmija. Svi spojevi osim CUR smanjili su razinu lipidne peroksidacije te pretpostavljamo da su LA i NAC pridonijeli detoksifi kaciji kadmija. Rezultati istraživanja upućuju na to da testirani spojevi, osim CUR, imaju antioksidativni učina

The Science Performance of JWST as Characterized in Commissioning

This paper characterizes the actual science performance of the James Webb Space Telescope (JWST), as determined from the six month commissioning period. We summarize the performance of the spacecraft, telescope, science instruments, and ground system, with an emphasis on differences from pre-launch expectations. Commissioning has made clear that JWST is fully capable of achieving the discoveries for which it was built. Moreover, almost across the board, the science performance of JWST is better than expected; in most cases, JWST will go deeper faster than expected. The telescope and instrument suite have demonstrated the sensitivity, stability, image quality, and spectral range that are necessary to transform our understanding of the cosmos through observations spanning from near-earth asteroids to the most distant galaxies.Comment: 5th version as accepted to PASP; 31 pages, 18 figures; https://iopscience.iop.org/article/10.1088/1538-3873/acb29

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570