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(Abstracted from JAMA2023;330(22):2182–2190)Preexisting type 2 diabetes in pregnant people increases the risk for adverse pregnancy outcomes, intrapartum complications, and neonatal hypoglycemia at birth. To achieve normal maternal glucose levels and optimize pregnancy outcomes, management includes maternal blood glucose monitoring, dietary management, and insulin therapy.

Lack of evidence-based outcomes data leads to uncertainty in developing treatment regimens in children who are newly diagnosed with ulcerative colitis. We hypothesised that pretreatment clinical, transcriptomic, and microbial factors predict disease course.

Food and water security have moved to the top of the global agenda following the food and energy price increases that started in 2007. Addressing the food, water and energy nexus is considered increasingly important for transparently and equitably meeting increasing global demand without compromising sustainability. This paper argues that given the unique regional and sector challenges of food, water and energy security, their nexus must be deconstructed to find effective, contextualized solutions. And governance challenges are at the heart of the nexus in each region. Governance is defined in various ways, but, with a few notable exceptions, the definitions have undergone relatively little analysis. In turn, governance issues are imbedded in policy, institutional, technological and financing options exercised at the global, regional, national and local levels. Furthermore, strong interactions between levels prompt policy responses to specific events and outcomes. The cu rent governance arrangements, where they exist at all, are woefully inadequate to address the challenges. They are imbedded in a lack of strategic clarity, and among stakeholders there is an unequal distribution of power, voice and access to information, resources and the capability to exercise a sound influence which will produce equitable and sustainable outcomes. Often there are huge tradeoffs between the short-term wins of individual stakeholders and long-term holistic solutions. This paper uses illustrative examples from recent global developments, as well as from China and India, to make the case for placing empirical analysis of governance issues at the top of the global agenda. At each level, governance is ues affect the choice of policies, institutions and outcomes for addressing these daunting challenges.

Small firms that offer health insurance to their employees may face variable premiums if the firm hires an employee with high‐expected health costs. To avoid expensive premium variability, a small firm may attempt to maintain a workforce with low‐expected health costs. In addition, workers with high‐expected health costs may prefer employment in larger firms with health insurance rather than in smaller firms. This results in employment distortions. We examine the magnitude of these employment distortions in hiring, employment, and separations using the Medical Expenditure Panel Survey from 1996 to 2001. We find that workers with high‐expected health costs are less likely to be new hires in insured small firms and are less likely to be employed in insured small firms. We find no evidence that state small group health insurance reforms designed to restrict insurers' ability to deny coverage and restrict premium variability have reduced the extent of these distortions.

This paper examines the role of price in health insurance coverage decisions within the family to guide policy in promoting whole family coverage. We analyze the factors that affect individual health insurance coverage among families, and explore family decisions about whom to cover and whom to leave uninsured. The analysis uses household data from California combined with abstracted individual health plan benefit and premium data. We find that premium subsidies for individual insurance would increase family coverage; however, their effect likely would be small relative to their implementation cost.

Introduction:Malgré les progrès au niveau des soins de réanimation lors des dernières années, le pronostic des patients souffrant d'un arrêt cardiorespiratoire (ACR) demeure abyssal et aucun médicament ne semble influencer leur devenir au long cours. Cependant, les résultats de quelques études évaluant l'impact des bêtabloqueurs chez cette population s'avèrent cependant très encourageants. L'objectif de cette revue systématique, est d’évaluer l’évidence disponible quant à l'impact des bêtabloqueurs sur le devenir des patients traités pour un ACR dont le rythme initial est défibrillable. Methods:La présente revue systématique a été préalablement enregistrée sur Prospero (CRD42018105453). Les moteurs de recherche Medline, Embase et CENTRAL ont été fouillés de leur création jusqu'au 17 octobre 2018. La recherche de littérature grise s'est faite via Web of Science et Google Scholar. Les références de tous les articles inclus ainsi que des méta-analyses existantes sur le sujet ont également été révisées. Tous les types de devis ont été considérés, sauf les études de cas et les séries de cas. Les études devaient inclure des adultes (16 ans et plus) en ACR dont le rythme initial était défibrillable, dont une partie avait reçu un médicament bêtabloquants par voie intraveineuse pendant leur ACR et l'autre un traitement standard, et présenter une mesure de résultat centrée sur le patient (retour de circulation spontanée [RCS], survie ou bon devenir neurologique). La qualité des articles a été évaluée à l'aide du ‘Newcastle Ottawa scale’. Results:Deux études observationnelles rétrospectives, menées auprès d'un total de 66 patients, ont été incluses. Il y avait une association positive entre l'administration de bêtabloquants et l'occurrence d'un RCS (rapport de cotes [RC] = 5.76 [intervalle de confiance {IC} à 95% = 1.79-18.52], p = 0.003), ainsi qu'avec la présence d'un bon devenir neurologique (RC = 4.42 [IC95% = 1.05 - 18.56], p = 0.04). Une telle association n'a cependant pas été observée par rapport à la survie au congé hospitalier. Conclusion:L'administration de bêtabloquants semble associé à un meilleur devenir chez les patients en ACR avec un rythme initial défibrillable. Étant donné la nature du devis de ces études et leur petite taille, une étude prospective de qualité serait nécessaire afin de déterminer l'efficacité de cette classe de médicament et de faire une recommandation forte à ce sujet.

The individual insurance market is perceived by many to provide primarily transition coverage, but there is limited research about how long people stay in this market and what affects their disenrollment decisions. We examine these issues using administrative records and survey data for those enrolled in the individual market in California. We conclude that there is less turnover in this market than is commonly believed. We find that economic factors and coverage characteristics are important in the decision to disenroll, but that perceptions about insurance and the health care system also affect this decision.

A previously disclosed series of non-nucleoside allosteric inhibitors of the NS5B polymerase of the hepatitis C virus (HCV) was optimized to yield novel compounds with improved physicochemical properties and activity in cell-based assays. Replacement of ionizable carboxylic acids with neutral substituents in lead compounds produced inhibitors with cellular permeability and antiviral activity in a cell-based assay of subgenomic HCV RNA replication (replicon EC50 as low as 1.7 μM). The improvement in potency in this ex vivo model of HCV RNA replication validates, in part, the mechanism by which this class of allosteric benzimidazole derivatives inhibits the polymerase and represents a significant step forward in the discovery of novel HCV therapeutics.

The managed care backlash led many to predict the demise of health maintenance organizations (HMOs). This paper examines trends in HMO enrollment in all metropolitan communities from 1994 to 2000 to identify factors that led to diminishing enrollment in the backlash era and circumstances in which HMOs maintained or expanded their presence. We use a database constructed from a wide variety of sources that describe HMO penetration and other characteristics of all metropolitan statistical areas. We found the backlash is not evidenced in a large degree of consumer switching. However, HMOs were more likely to maintain their presence in areas with high-cost growth and with greater managed care experience. Medicaid HMO growth continued to expand rapidly, indicating the possibility of a two-tiered system in which low-income beneficiaries have less choice than the privately insured.

Policymakers and researchers are concerned that changes in the healthcare market have stressed and weakened the safety net nationwide.

The extent to which persons enrolling in new public insurance programs substitute the public coverage for private insurance is of concern to policy makers.

Insurance expansions and service delivery system expansions are alternative policy instruments used to try to improve birth outcomes for low-income women.

This paper examines how varying the level of subsidies affects participation in a public insurance program, crowd-out of private insurance, and adverse selection. We study the experience in Washington's Basic Health program in 1997. Findings show that adverse selection is not a problem in voluntary public programs. Increasing subsidies have only modest effects on participation in subsidized programs, though the gains are not at the expense of the private market. Overall participation in the subsidized plan is also modest, even though participants benefit from it. The challenge to policymakers is to find program design characteristics, beyond subsidies, that attract the uninsured.

Many policy initiatives to increase health insurance coverage would subsidize employers to offer coverage or subsidize employees to participate in their employers' health plans. Using data from the 1997 Robert Wood Johnson Foundation Employer Health Insurance Survey, we contrast “low-wage employers” with all other employers. Employees in low-wage businesses have significantly worse access to employment-based insurance than other employees do; they are less likely to work for an employer that offers insurance, less likely to be eligible if working in a business that offers insurance, and less likely to be enrolled if eligible. Low-wage employers contribute lower shares of premiums and offer less generous benefits than other employers do. Policies that would target subsidies to selected employers to increase insurance offers to low-wage workers are difficult to design, however, because several commonly mentioned employer characteristics (including firm size) are found to be poor indicators of low-wage worker concentration. Programs that would set minimum standards for employer plans to be eligible for “buy-ins” need to base these standards on the less generous terms offered by low-wage employers in order to effectively reach low-wage workers and their dependents.

Natriuretic peptide receptor-A (NPR-A), a particulate guanylyl cyclase receptor, is composed of an extracellular domain (ECD) with a ligand binding site, a transmembrane spanning, a kinase homology domain (KHD), and a guanylyl cyclase domain. Atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), the natural agonists, bind and activate the receptor leading to cyclic GMP production. This receptor has been reported to be spontaneously dimeric or oligomeric. In response to agonists, the KHD-mediated guanylate cyclase repression is removed, and it is assumed that ATP binds to the KHD. Since NPR-A displays a pair of juxtamembrane cysteines separated by 8 residues, we hypothesized that the removal of one of those cysteines would leave the other unpaired and reactive, thus susceptible to form an interchain disulfide bridge and to favor the dimeric interactions. Here we show that NPR-AC423S mutant, expressed mainly as a covalent dimer, increases the affinity of pBNP for this receptor by enhancing a high affinity binding component. Dimerization primarily depends on ECD since a secreted NPR-A C423S soluble ectodomain (ECDC423S) also documents a covalent dimer. ANP binding to the unmutated ECD yields up to 80-fold affinity loss as compared with the membrane receptor. However, the ECD C423S mutation restores a high binding affinity. Furthermore, C423S mutation leads to cellular constitutive activation (20-40-fold) of basal catalytic production of cyclic GMP by the full-length mutant. In vitro particulate guanylyl cyclase assays demonstrate that NPR-AC423S displays an increased sensitivity to ATP treatment alone and that the effect of ANP + ATP joint treatment is cumulative instead of synergistic. Finally, the cellular and particulate guanylyl cyclase assays indicate that the receptor is desensitized to agonist stimulation. We conclude the following: 1) dimers are functional units of NPR-A guanylyl cyclase activation; and 2) agonists are inducing dimeric contact of the juxtamembranous region leading to the removal of the KHD-mediated guanylyl cyclase repression, hence allowing catalytic activation.

Abstract:This study estimates the effect of universal coverage on the use and cost of health services by the uninsured. Adults lacking insurance for a full year have about 60 percent as many ambulatory contacts and about 70 percent of the inpatient hospital days they would have if they were covered by insurance. This “access gap” is only slightly smaller for children. Providing universal coverage would increase ambulatory contacts and inpatient days by less than 4 percent a year. The dollar cost of these new services is estimated to be $19.9 billion—a 2 percent increase in total health spending.

Abstract:This DataWatch reports key findings from the 1993 Robert Wood Johnson Foundation Employer Health Insurance Survey, through which more than 20,000 employers in ten states were interviewed. Our report contrasts the behavior of four size classes of small businesses (fewer than fifty workers) with that of all other businesses. We examine offer rates by business size; characteristics of employers and workers in businesses offering and not offering insurance; premiums, benefits, and medical underwriting; the extent of choice among plans; and self-insurance. We discuss the implications of our findings for health policy.

Abstract:According to data from the May 1988 Current Population Survey, 18 percent of workers are in firms that do not offer health insurance- The question explored here is whether the absence of insurance in these firms is related to lack of supply (that is, a failure of the firm to offer the benefit because the price it faces is too high or the benefit too low) or lack of demand (that is, employees in these firms would not purchase the insurance even if it were offered). Characteristics hypothesized to affect the supply of insurance by firms (size, rate of turnover, and union status) are found to distinguish whether or not firms offer insurance. The data show near-universal acceptance of group insurance among employees offered the opportunity to participate. Both of these factors suggest a failure of supply. However, employees in firms that do not offer insurance are young, low-wage earners who work part time. These are also characteristics of workers who do not purchase group insurance even when it is offered, suggesting that many of the workers who are not offered group insurance would not participate in a plan even if the supply failure were corrected. These findings have implications for the effectiveness of voluntary strategies to improve access, but they also raise concern over the fairness to workers of mandates requiring that they purchase coverage.

While Preferred Provider Organizations (PPOs) are designed to contain the costs of health care, they may not be able to do so if sicker individuals opt not to use PPO providers. This study examined how level of mental health status and prior use of mental health services affected the decision to use or not use PPO providers for mental health care for employees enrolled in fee-for-service plans with a PPO option. Data were obtained from an employee survey and claims data on three large employee groups. It was not possible to examine effects of sickliness on the intent to select PPO providers for mental health care directly because about one half of employees could not identify who they would visit for mental health care or even how they would select a provider for such care. The intent to use PPO or non-PPO providers for general medical care, however, was not significantly associated with mental health status when other factors were controlled. Furthermore, among persons who used mental health services after implementation of the PPO option, those who had previously visited providers who were to become part of the PPO panel tended to stay with PPO providers, while those who previously visited providers who were not to enter the PPO panel subsequently selected away from PPO providers for mental health care. This pattern of results suggests that established individual patient-provider relationships, rather than sickliness, determined the selection of PPO versus non-PPO providers for mental health care for employees enrolled in these optional PPO fee-for-service plans.

Descriptions of how preferred provider organizations (PPOs), offered as options to employees enrolled in fee-for-service plans, affected use of outpatient mental health services are provided. Data are from the RAND Preferred Provider Organization Study, which has a sample of employees who enrolled in fee-for-service plans 1 year before and 2 years after a PPO option was offered by three employers in two U.S. sites. To study effects of the optional PPOs on access to mental health care, usage patterns among those who initially stated that they did or did not intend to use PPO providers were examined. By the end of the second post-PPO year, employees had a similar annual probability of having an outpatient mental health visit whether or not they initially intended to use PPO providers. However, during the first post-PPO year, there was a decrease in the probability of use for those initially intending to use PPO providers, relative to those who did not intend to do so, among employees who had no regular medical provider. To study effects of the PPO option on usage levels of mental health care services, users of mental health services who primarily visited PPO were compared with those who primarily visited non-PPO providers. Users who visited PPO providers had significantly lower levels of use, controlling for other factors, than those who primarily visited non-PPO providers. Therefore, despite lower cost sharing for services received from PPO providers, the PPO option appeared to lower outpatient mental health care costs while having no more than a transient effect on access. This study did not evaluate mental health outcomes.

Survey data measuring outpatient health expenditure are evaluated for item nonresponse, measurement error, and bias. Item nonresponse is high for persons whose health care is financed through the public sector, but is otherwise manageable.

Longitudinal data from The Rand Corporation's Health Insurance Experiment were used to test the hypothesis that provider continuity can be modeled as one behavioral consequence of patient satisfaction. Bivariate and multivariate analyses (controlling for sociodemographic characteristics, prior use of services, health status, and health insurance plan) supported our hypotheses. A multivariate linear probability function indicated that a 1-point decrease on a general satisfaction scale was associated with a 3.4 percentage-point increase in the probability of provider change. The relationship between satisfaction scores and continuity during the following year appears to be roughly linear; we observed no “threshold” satisfaction level at which the probability of provider change increased markedly. We discuss needed improvements in the measurement of provider continuity and the need for further study of other behavioral consequences of patient satisfaction.

This study estimates the effect of universal coverage on the use and cost of health services by the uninsured. Adults lacking insurance for a full year have about 60 percent as many ambulatory contacts and about 70 percent of the inpatient hospital days they would have if they were covered by insurance. This "access gap" is only slightly smaller for children. Providing universal coverage would increase ambulatory contacts and inpatient days by less than 4 percent a year. The dollar cost of these new services is estimated to be $19.9 billion--a 2 percent increase in health spending.

The authors propose a new coding evaluation for physicians that more accurately reflects the amount of work involved, is easy to record, avoids the complexities of proposed and current coding procedures, and fosters efficient practice. This article presents the results of a study conducted by the Physician Payment Commission to identify factors correlated with actual physician work performed in the course of 19,143 office and hospital visits. Three hundred ninety-nine physicians from three specialties (urology, rheumatology, and internal medicine) participated. They recorded the exact length of an average of 57 concurrent patient visits taking place in the office or hospital room. They also noted the patient’s age, whether the patient was new or returning, whether the visit was the result of a physician referral, the nature of the complaint (new or ongoing), and the presence of any cognitive or physical impairments. For office visits, the encounter time was measured from the moment the patient was escorted to the consultation room to the time the patient left. Hospital visits were measured from the first to the last contact with the patient or the patient’s chart.