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Since the Patient Protection and Affordable Care Act (ACA) has dramatically reduced the number of uninsured, the U.S. healthcare system now faces a tougher challenge: to simultaneously improve quality of care and contain costs. Accountable Care Organizations (ACOs) that hold providers across settings collectively responsible for the quality and costs of care are currently the ACA’s best hope for pursuing the dual goal. Accompanied by the ACO momentum, physicians are increasingly employed by hospitals, leading to greater physician-hospital integration. Though there is evidence that provider consolidation elevated prices, little is known about whether physician-hospital integration in ACOs improves the efficiency of healthcare delivery. This dissertation comprises three studies that seek to understand the impact of physician-hospital integration on ACO efficiency through quantitative analyses of 16 commercial ACOs operating under the Alternative Quality Contract (AQC) launched by Blue Cross and Blue Shield of Massachusetts in 2009. Study 1, Profiling AQC Participants According to Physician-Hospital Integration, investigates whether there are systemic differences in organizational structure, patient population, and composition of healthcare spending between low- and high-integrated AQC participants. The findings suggest that high-integrated organizations tend to be larger in scale, serve more affluent patients, but generally spend more. Study 2, The Impact of Physician-Hospital Integration on ACO Efficiency in Inpatient Care Delivery, examines whether integration leads to improved ACO efficiency in inpatient care delivery. The results indicate that integration is correlated with a reduction in spending aggregated over an episode of inpatient care and a decline in length of stay, with no evidence of elevated readmission rates. Study 3, The Impact of ACO Physician-Hospital Integration on Health Care Spending and Delivery Patterns, explores the association between integration and annual health care expenditures and utilization per person (inpatient, outpatient, and overall). The results suggest that integration is correlated with reduced utilization and increased expenditures; the latter is almost entirely driven by higher spending in outpatient settings. The findings of this dissertation suggest that physician-hospital integration is associated with improved efficiency in inpatient settings. However, when considering a broader scope of health services, its impact on efficiency is mixed.

Modern virtual medical simulators have many advantages over their manikin counterparts. For example, they are more repeatable and reconfigurable. The virtual reality can be upgraded and modified to serve different training purposes. The goal of the Virtual Haptic Human Upper Body (VHHUB) research is to create a physiologically-correct human upper body for osteopathic medical gross motion palpation training using haptics and virtual reality technologies. The virtual human upper body is a 71 degrees-of- freedom multiple end-effectors, multi-branching serial chain model. It has fully movable thoracic and lumbar spinal regions plus two shoulders and two arms with a deformable body. Due to the complexity of the VHHUB model, we present a velocity inverse kinematic problem solver with dynamic pivot point. This method ensures a smooth synchronization rate between graphics and haptic hardware in real time. Fryette’s principles are implemented in the VHHUB. Fryette’s principles are one of the fundamental theories for the osteopathic manipulative medicine (OMM) to diagnose somatic dysfunctions. The VHHUB software is developed in a way to help osteopathic physicians or OMM fellows fine tune the program for their student’s training. The haptic feedback of somatic dysfunctions can be modified by OMM faculty administrators without any knowledge of programming languages. The VHHUB provides an additional training tool for the osteopathic medical students to augment their osteopathic manipulative medicine (OMM) laboratory courses. VHHUB evaluation and recommendations for future research are presented. From the preliminary evaluation data, most medical students gave 7 or up (scale from 1 to 10: 1 is unrealistic and 10 is realistic) on the realism of the VHHUB. Medical students also felt the simulation gave them a useful tool for learning Fryette’s principles.

Atherosclerosis is a chronic inflammatory disease, characterized by the accumulation of oxidized lipoproteins and apoptotic cells, both containing various "oxidation- specific" neoepitopes. Adaptive immune responses to oxidation-specific epitopes have been shown to play an important role in atherogenesis. However, accumulating evidence suggests that these epitopes are also recognized by components of innate immunity, such as scavenger receptors on macrophages, as well as natural antibodies (NAbs). NAbs are mostly of the IgM isotype which are selected by evolution and represent the humoral arc of innate immunity. In my thesis, I provide multiple lines of evidence that oxidation-specific epitopes constitute a dominant, previously unrecognized target of NAbs in both mice and humans. For example, using reconstituted mice expressing solely IgM NAbs, I showed that ̃ 30% of all NAbs bind to model oxidation epitopes, as well as to atherosclerotic lesions and apoptotic cells. Similar observations were made for human natural IgM Abs. Because oxidative processes are ubiquitous, these epitopes might exert selective pressure to expand NAbs, which in turn may play an important role in mediating homeostatic functions consequent to inflammation and cell death. This is demonstrated by the ability of NAbs to facilitate apoptotic cell clearance. These findings provide novel insights into the functions of NAbs in mediating host homeostasis and into their roles in health and diseases, which may lead to novel diagnostic and possibly therapeutic approaches to deal with consequences of oxidative stress such as atherogenesis.

Modeling and simulation of assembly in a free-floating work environment by a free-floating robot