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Background: Adverse childhood experiences (ACEs) are potentially traumatic events, which can have long-term, negative consequences. Few studies have examined ACEs' relationship to marijuana use. Objectives: We examined the association between ACEs and past-month marijuana use among adults and the pathways between childhood adversity and marijuana use. Methods: Adults from five states (n = 22,991) who responded to the 2019 Behavioral Risk Factors Surveillance System were included. We examined the prevalence of ACEs and marijuana use. We employed generalized structural equation modeling to assess the relationship between ACEs and marijuana use and the role of depression and poor mental and physical health as possible mediators. Results: Overall, 65.0% of the population reported 1+ ACE. Heavy marijuana use and past-month marijuana use prevalence rates were 10.3% and 5.0%, respectively. We found mediation effects for depression and poor mental health but not poor physical health. The number of ACEs was associated with a statistically significant increase in any past-month marijuana use-indirect effects ranged from 1.0 (95% CI, 1.0-1.0) to 1.4 (95% CI, 1.2-1.7), direct effects ranged from 1.1 (95% CI, 07-1.7) to 5.3 (95% CI 3.2-8.8), and total effects ranged from 1.1 (95% CI, 0.7-1.7) to 5.9 (95% CI, 3.6-9.8). Women, married persons, and middle aged and older adults had a lower odds of marijuana use. Reporting at least one HIV risk behavior was associated with an increased odds of marijuana use. Conclusion: ACE exposure was positively associated with marijuana use. Depression and poor mental health separately mediated this relationship.

Objective Patient trust in health care providers is associated with better health behaviors and utilization, yet provider trust has not been consistently conceptualized. This study uses qualitative methods to identify the key health provider behaviors that patients report build their trust, and data from a national U.S. survey of adults to test the robustness of the qualitative findings. Methods In this mixed methods study, we conducted 40 semi-structured interviews with a diverse sample to identify the provider behaviors that build trust. We then analyzed a nationally representative survey (n = 6,517) to examine the relationship between respondents’ trust in their usual provider and the key trust-related behaviors identified in the qualitative interviews. Results Interviewees reported that health providers build trust by communicating effectively (listening and providing detailed explanations), caring about their patients (treating them as individuals, valuing their experience, and showing commitment to solving their health issues), and demonstrating competence (being knowledgeable, thorough, and solving their health issues). Trust in one’s provider was highly correlated with all eight survey items measuring communication, caring, and competence. Conclusions To build trust with patients, health providers should actively listen, provide detailed explanations, show caring for patients, and demonstrate their knowledge.

Background: Trust is an essential element of the patient-provider relationship and has been associated with better patient outcomes; however, it is not clear what role trust might play in influencing patients’ willingness to try medical cannabis when it is recommended in states where it has been legalized for medical use. Objectives: To explore the relationship between peoples’ trust in their health care clinicians and hospitals and their willingness to consider using medical cannabis if it is recommended by their clinician or hospital. Methods: We conducted an anonymous, cross-sectional, online survey of adults who participated in the Qualtrics Research Company Panel and used quotas to match our sample to the characteristics of the U.S. population. Results: We received 1120 completed surveys. The vast majority of respondents (84.4%) reported having a regular provider and 42.5% of those who reported having a regular physician and nearly 35.6% of those who reported having another regular provider (e.g., nurse practitioner, physician assistant) reported that they “completely” trusted that clinician. Those who reported “completely” trusting their usual clinician were more than twice as likely to report they would definitely use medical cannabis if recommended (42.5% vs 20.6%). Similarly, the greater respondents’ trust in hospitals, the more likely they were to report a willingness to consider using recommended medical cannabis. Conclusion: Patient trust in their health providers is related to patients’ willingness to use recommended medical cannabis.

Given evidence that anemia in the first year of life is associated with long-term cognitive, motor, and behavioral deficits, reducing infant anemia is important. The primary objective of this research is to examine whether anemia in low income pregnant women in the United States is associated with anemia in the women’s infants. This cohort study linked Centers for Disease Control and Prevention surveillance data on pregnant women with incomes below 185% of the federal poverty level from 2010 and 2011 with data on 6–11 month olds from 2011, resulting in a sample of 21,246 uniquely matched mother-infant pairs. We examined bivariate and multivariate relationship between anemia severity in pregnant women and in their infants. Seventeen percent of women had anemia (13.1% mild and 3.9% moderate to severe) and 20.1% infants had anemia (16.4% mild and 3.7% moderate to severe). For both women and infants, blacks had substantially higher anemia rates than whites. In bivariate analysis and multivariate analyses maternal anemia showed a dose–response relationship to infant anemia. In predicted probabilities from the multivariate models, 27.2% of infants born to pregnant women with moderate to severe anemia had anemia, compared to 23.3% for infants whose mothers had mild anemia, and 18.3% for infants whose mothers did not have anemia. This study provides strong evidence of a relationship between maternal and infant anemia in the United States among people with low incomes. Efforts to reduce anemia during pregnancy may be an important strategy for minimizing childhood anemia.

Background US nursing homes are required to follow Centers for Disease Control guidance for COVID-19 transmission-based precautions (TBP) when admitting COVID-positive patients. Objective To assess how frequently nursing homes had shortages of personal protective equipment (PPE) or staffing in weeks when they admitted COVID-positive patients, which likely made it more difficult to follow TBP, and to compare facility characteristics by admissions practices. Design and setting Facility-level data from the Nursing Home COVID-19 Public File for the period between June 7, 2020 and March 7, 2021 was combined with additional data. The percentages of nursing homes that admitted COVID-positive patients and that had shortages when admitting were calculated for each week. Descriptive statistics and logistic regression models were used to examine the relationship between facility characteristics and the likelihood of admitting COVID-positive patients. Measurements Facilities were categorized as having admitted COVID-positive patients in a week if one or more admissions requiring TBP were reported for that week. Facilities that reported having less than a 1-week supply of any type of PPE or being short any type of staff in a week were defined, respectively, as having a PPE shortage or staffing shortage in that week. Results Over the 40-week study period, 39% of US nursing homes admitted COVID-positive patients in at least 1 week in which they were experiencing PPE or staffing shortages. Facilities that admitted COVID-positive patients with shortages generally had lower Centers for Medicare and Medicaid Services overall five-star ratings than other facilities. Only a small percentage of facilities that admitted COVID-positive patients while facing shortages were located in counties with severe shortages of PPE or staffing. In logistic regression models, shortages were not associated with COVID-positive admissions. Conclusion The widespread practice of admitting COVID-positive patients while facing shortages may have put nursing home residents and staff at heightened risk of COVID-19 infection.

Background Patients’ trust in their regular clinician is relatively high in the United States, but trust in the health care system and in key institutions, such as hospitals, is considerably lower. The purpose of this study was to identify the factors that build patients’ trust in hospitals. Methods In early 2020 the authors conducted 38 semistructured telephone interviews with participants across the United States. Respondents were asked about trust in hospitals generally, as well as what makes them trust and not trust specific hospitals. Interviews were audio recorded, transcribed, and analyzed using a descriptive thematic approach. Results Participants identified three mechanisms through which hospitals build their trust: (1) competence (effectively treating health issues, providing a safe and clean hospital environment, and having clinicians who are knowledgeable and thorough), (2) caring (hospital culture that prioritizes patients’ comfort, welcoming physical environment, and clinicians who are compassionate), and (3) communication (hospital culture of listening to patients and explaining clearly, particularly with treatment and discharge plans). The absence of these three factors resulted in loss of trust. Hospital cost also lost patients’ trust in hospitals. While the cost of hospital care affected some participants’ overall level of trust in hospitals, others separated the trust they had in the medical care received from trust in billing practices. Conclusion The findings underscore the importance of perceived quality of care and hospital safety/hygiene, as well as having an organizational culture that emphasizes caring and effective communication, for building patient trust.

Background It is crucial that nursing homes have adequate personal protective equipment (PPE) and staff to protect residents and staff from COVID-19. Some states have taken actions to mitigate shortages of PPE and staffing in nursing homes, including creating dedicated long-term care (LTC) teams and supporting staffing capacity. Objective To examine whether state actions and nursing home characteristics are associated with shortages of PPE and staffing. Design and setting Facility-level data, released July 31, 2020, from the Nursing Home COVID-19 Public File, were combined with data from other sources. Our sample was the 13,445 facilities with information about PPE and staffing shortages for each of the 5 weeks between the week ending June 21, 2020, and the week ending July 19, 2020. Associations between facility characteristics and shortages were examined using descriptive statistics and logistic regression models. Measurements Outcome variables were whether or not a facility lacked a 1-week supply of PPE ("PPE shortage") and whether or not a facility had a staffing shortage during 1 or more weeks over the 5-week study period. Results Over the 5-week study period, 27.6% of facilities reported 1 or more weeks of PPE shortage, 30.2% of facilities reported at least 1 week of staffing shortage, and 46.5% of facilities lacked PPE and/or staff. Facilities located in states in the Northeast PPE Consortium or with LTC teams were modestly less likely to have had a PPE shortage, and facilities located in states that implemented processes to match job seekers with LTC facilities were marginally significantly less likely to have had a staffing shortage. Conclusion Given that nearly half of U.S. nursing homes recently faced a shortage of PPE and/or staff, and that state budget deficits may limit further state actions, ongoing federal assistance with PPE and staffing of nursing homes is needed.

Given the high concentration of COVID-19 cases in long-term care (LTC) facilities in the United States, individuals working in these facilities are at heightened risk of SARS-CoV-2 exposure. Using data from the nationally-representative 2017 and 2018 National Health Interview Surveys on adults who reported working in LTC facilities, this study examines the extent to which LTC workers are also at increased risk or potentially at increased risk for severe illness from COVID-19 including hospitalization, intubation, or death. We used the Centers for Disease Control and Prevention's list of conditions placing individuals in these risk categories to the extent possible. We also examined the sociodemographic characteristics of LTC workers by occupation and COVID-19 illness severity risk status. One percent (552 out of 52,159) of the weighted NHIS sample worked in LTC facilities. Workers in LTC facilities were disproportionately Black, female, and low income. Half of LTC workers (50%) were at increased risk of severe illness from COVID-19 and another 19.6% were potentially at increased risk. There were few significant differences in demographic characteristics between risk groups, though those at increased risk had lower educational attainment and recent trouble affording prescription medications. Despite the high degree of vulnerability of both LTC residents and workers to severe illness from COVID-19, many LTC facilities still have inadequate supplies of personal protective equipment and COVID-19 tests. Given that state budget deficits due to the COVID-19 pandemic limit the potential for state actions, enhanced federal efforts are needed to protect LTC residents and staff from COVID-19., Highlights • Long-term care workers (LTC) comprised 1.0% of a representative sample of US adults. • LTC workers were disproportionately Black, female, and low income. • Half of LTC workers (50.0%) were at increased risk of severe COVID-19 illness. • An additional 19.6% were potentially at increased risk of severe COVID-19 illness.

Most Latin American and Caribbean (LAC) countries are working toward the provision of universal health coverage, and ensuring equity is a priority for those nations. The goal of this study was to examine the extent to which adults' socioeconomic status was related to health care experience in six LAC countries.This cross-sectional study examined the relationship between educational attainment and seven health experience outcomes in three areas: assessment of the health system, access to care, and experience with general practitioner. For this work, we used data from an Inter-American Development Bank survey of adults in Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama that was conducted in 2012-2014.Brazil and Jamaica, the two countries with unified public coverage, stood out for having substantially greater inequality, according to the results of bivariate analyses, with more-educated respondents reporting better health care experiences for five of the seven outcomes. For Jamaica, educational differences largely remained in multivariate analyses: college graduates were less likely (odds ratio (OR) = 0.37) than those with primary education to report their health system needs major reform and were more likely (OR = 2.57) to have a regular doctor. In Brazil, educational differences were mostly eliminated in multivariate models, though people with private insurance consistently reported better outcomes than those with public coverage. Colombia, in contrast, exhibited the least inequality despite having the highest income inequality of the six countries.Future research is needed to understand the policies and strategies that have resulted in Colombia achieving high levels of equity in patient health care experience, and Jamaica and Brazil demonstrating high levels of inequality.La mayor parte de los países de América Latina y el Caribe está trabajando para lograr la cobertura universal de salud, por lo que asegurar la equidad es una prioridad para esas naciones. La meta de este estudio fue examinar en qué medida la situación socioeconómica de los adultos se relacionaba con la experiencia de atención de salud en seis países de América Latina y el Caribe.En este estudio transversal se examinó la relación entre el nivel educativo alcanzado y siete resultados en cuanto a la experiencia de salud en tres áreas: la evaluación del sistema de salud, el acceso a la atención y la experiencia con un médico general. En este trabajo, se usaron datos de una encuesta del Banco Interamericano de Desarrollo a adultos en Brasil, Colombia, El Salvador, Jamaica, México y Panamá, que se realizó entre el 2012 y el 2014.Brasil y Jamaica, dos países con cobertura pública unificada, se destacaron por tener una desigualdad notablemente mayor, según los resultados de los análisis bivariantes, en los que los entrevistados con mayor instrucción informaron mejores experiencias de atención de salud para cinco de los siete resultados. En el caso de Jamaica, las diferencias educativas permanecieron en gran medida después de los análisis multivariantes: los graduados universitarios (razón de posibilidades [OR] = 0,37) eran menos propensos, en comparación con quienes tenían educación primaria, a manifestar la reforma importante que necesita su sistema de salud y eran más propensos (O = 2,57) a tener a un médico de cabecera. En Brasil, si bien las diferencias educativas se eliminaron en gran parte en los modelos con múltiples variables, las personas con cobertura privada manifestaron constantemente mejores resultados que aquellos con cobertura pública. En cambio, Colombia presentó la menor desigualdad a pesar de tener la desigualdad de ingresos más alta de los seis países.Se precisan investigaciones futuras para comprender las políticas y las estrategias que han llevado a que Colombia alcance niveles altos de equidad en la experiencia de atención de salud de pacientes, y a que Jamaica y Brasil presenten niveles altos de desigualdad.Na América Latina e no Caribe, os países estão trabalhando para alcançar a cobertura universal de saúde e uma das prioridades é assegurar a equidade nestas nações. O objetivo deste estudo foi examinar a relação entre a situação socioeconômica e a experiência em atenção de saúde de adultos em seis países da ALC.Foi realizado um estudo transversal para examinar a relação entre aproveitamento escolar e sete desfechos da experiência em saúde em três áreas distintas: avaliação do sistema de saúde, acesso à assistência e experiência com o clínico geral. Foram usados dados de uma pesquisa do Banco Interamericano de Desenvolvimento realizada com adultos no Brasil, Colômbia, El Salvador, Jamaica, México e Panamá em 2012–2014.O Brasil e a Jamaica, os dois países com um sistema único de cobertura da rede pública de saúde, se destacaram por ter consideravelmente maior desigualdade segundo os resultados das análises bivariadas, sendo que os participantes com maior nível de instrução informaram experiências melhores em atenção de saúde em cinco dos sete desfechos. Na Jamaica, as diferenças relativas ao nível educacional permaneceram em grande parte nas análises multivariadas: em comparação aos indivíduos com nível primário de educação, os adultos com nível universitário (odds ratio [OR] 0,37) apontaram com menor frequência a necessidade de uma ampla reforma no sistema de saúde e indicaram com maior frequência (OR 2,57) ter um médico habitual. No Brasil, as diferenças relativas ao nível educacional foram na sua maior parte eliminadas nos modelos multivariados, apesar de os indivíduos com plano de saúde privado terem consistentemente informado melhores desfechos que os indivíduos atendidos na rede pública. Em contraste, o menor grau de desigualdade foi observado na Colômbia apesar de o país ter a maior desigualdade de renda dos seis países estudados.Osutras pesquisas são necessárias para compreender as políticas e as estratégias responsáveis pelo alto grau de equidade na experiência em atenção de saúde dos pacientes na Colômbia e pelos altos níveis de desigualdade na Jamaica e no Brasil.

Introduction Smoking rates for Medicaid beneficiaries have remained flat in recent years. Medicaid may support smokers in quitting by covering a broad array of tobacco cessation services without barriers such as copays. This study examines the impact of increasing generosity in Medicaid tobacco cessation coverage policies on smoking and cessation behaviors. Methods We used 2010 and 2015 National Health Interview Survey data merged with information on state tobacco, Medicaid cessation, and Medicaid eligibility policies to estimate state fixed effects models of cessation medication use, counseling use, quit attempts, and current smoking. Results Smokers living in states that cover cessation medications but not counseling services were less likely to use counseling. Smokers were more likely to report having tried to quit in states with higher rates of use of cessation medications among Medicaid beneficiaries. We found no impact of Medicaid policies on use of cessation medications. States that impose copays had higher rates of smoking, while those that require counseling as a condition of receiving medication had lower rates of smoking. Additionally, we found that expanding Medicaid eligibility under the Affordable Care Act is associated with decreased smoking prevalence among Medicaid beneficiaries. Conclusion Covering cessation counseling may encourage smokers that want to quit to use this service. Promoting the use of cessation medications may improve the likelihood that smokers try to quit. Medicaid coverage of cessation services is an important but incomplete strategy in addressing smoking among low-income populations. Implications States may be able to improve utilization of cessation counseling by providing Medicaid reimbursement for this service. Encouraging utilization of tobacco cessation medications may help more smokers quit. States should consider how to promote effective cessation methods among clinicians and patients.

Objective To examine whether patient activation is predictive of the course of diabetes over a three year period among patients with and without diabetes. Methods Longitudinal analyses utilized electronic health record data from 2011 to 2014. We examined how the patient activation measure (PAM) was predictive of 2014 diabetes-related outcomes among patients with diabetes (n = 10,071); pre-diabetes (n = 1804); and neither diabetes nor pre-diabetes (n = 46,402). Outcomes were clinical indicators (blood pressure, cholesterol, and trigylcerides), costly utilization, and progression from no diabetes to pre-diabetes or diabetes. Results Higher PAM level predicted better clinical indicator control in patients with diabetes. In patients with pre-diabetes, PAM level predicted better clinical indicator control, and those in the highest level of PAM in 2011 had lower odds of having a hospitalization compared to those in the lowest level. In patients without diabetes or pre-diabetes in 2011, higher PAM level was associated with lower odds of developing pre-diabetes. Conclusions More activated patients with diabetes and pre-diabetes had better outcomes than less activated patients. More activated patients without diabetes or pre-diabetes were less likely to develop pre-diabetes over a three year period. Practice implications Strategies to improve patient activation may be useful to help curb the diabetes epidemic.

Demand for primary care services is rising. Nurse practitioners (NPs) serve vital roles in meeting primary care demands. Workforce planning requires understanding NP retirement intentions. This study examines factors that relate to NPs, aged 55 years and older, and their intent to retire within 5 years.We used the 2012 National Sample Survey of Nurse Practitioners to examine the relationship between NP demographic characteristics (gender, race/ethnicity, marital status, nursing degree), work environment characteristics (part-time vs. full-time status, primary or specialty care, earnings, job satisfaction), and intent to retire. Descriptive, bivariate, and multivariate analyses were conducted. A total of 3171 working NPs, 55 years of age and older, were included.Fifty-nine percent of NPs 60 years and older and 15% of NPs 55-59 intend to retire in the next 5 years. Working part-time and having less than a master's degree were associated with intent to retire. Being "very satisfied" with one's job was related to lower odds of intent to retire versus being "satisfied." Being "dissatisfied" with one's job and working in primary care were related to intending to retire for the NPs 55-59.Given the relationship between higher job satisfaction and lower intent to retire, efforts to increase NPs' job satisfaction may result in less early retirement.

Objective To examine whether the Wellness Incentive and Navigation (WIN) intervention can improve health‐related quality of life (HRQOL) among Medicaid enrollees with co‐occurring physical and behavioral health conditions. Data Sources Annual telephone survey data from 2013 to 2016, linked with claims data. Study Design We recruited 1259 participants from the Texas STAR + PLUS managed care program and randomized them into an intervention group that received flexible wellness accounts and navigator services or a control group that received standard care. We conducted 4 waves of telephone surveys to collect data on HRQOL, patient activation, and other participant demographic and clinical characteristics. Data Collection/Extraction Methods The 3M Clinical Risk Grouping Software was used to extract variables from claims data and group participants based on disease severity. Principal Findings Our results showed that the WIN intervention was effective in increasing patient activation and HRQOL among Medicaid enrollees with co‐occurring physical and behavioral health conditions. Furthermore, we found that this intervention effect on HRQOL was partially mediated by patient activation. Conclusions Providing navigator support with wellness account is effective in improving HRQOL among Medicaid enrollees. The pragmatic nature of the trial maximizes the chance of successfully implementing it in state Medicaid programs.

We explore the extent to which state scope of practice laws are related to nurse practitioners (NPs)’ day-to-day practice autonomy. We found that NPs experienced greater day-to-day practice autonomy when they had prescriptive independence. Surprisingly, there were only small and largely insignificant differences in day-to-day practice autonomy between NPs in fully restricted states and those in states with independent practice but restricted prescription authority. The scope of practice effects were strong for primary care NPs. We also found that the amount of variation in day-to-day practice autonomy within the scope of practice categories existed, which suggests that factors other than state scope of practice laws may influence NP practice as well. Removing barriers at all levels that potentially prevent NPs from practicing to the full extent of their education and training is critical not only to increase primary care capacity but also to make NPs more efficient and effective providers.

Objective To explore using the Patient Activation Measure (PAM) for identifying patients more likely to have ambulatory care–sensitive (ACS) utilization and future increases in chronic disease. Data Sources Secondary data are extracted from the electronic health record of a large accountable care organization. Study Design This is a retrospective cohort design. The key predictor variable, PAM score, is measured in 2011, and is used to predict outcomes in 2012–2014. Outcomes include ACS utilization and the likelihood of a new chronic disease. Data Our sample of 98,142 adult patients was drawn from primary care clinic users. To be included, patients had to have a PAM score in 2011 and at least one clinic visit in each of the three subsequent years. Principal Findings PAM level is a significant predictor of ACS utilization. Less activated patients had significantly higher odds of ACS utilization compared to those with high PAM scores. Similarly, patients with low PAM scores were more likely to have a new chronic disease diagnosis over each of the years of observation. Conclusions Assessing patient activation may help to identify patients who could benefit from greater support. Such an approach may help ACOs reach population health management goals.

After a period of steady decline, out-of-pocket (OOP) costs for general practitioner (GP) consultations in Australia began increasing in the mid-1990s. Following the rising community concerns about the increasing costs, the Australian Government introduced the Strengthening Medicare reforms in 2004 and 2005, which included a targeted incentive for GPs to charge zero OOP costs for consultations provided to children and concession cardholders (older adults and the poor), as well as an increase in the reimbursement for all GP visits. This paper examines the impact of those reforms using longitudinal survey and administrative data from a large national sample of women. The findings suggest that the reforms were effective in reducing OOP costs by an average of $A0.40 per visit. Decreases in OOP costs, however, were not evenly distributed. Those with higher pre-reform OOP costs had the biggest reductions in OOP costs, as did those with concession cards. However, results also reveal increases in OOP costs for most people without a concession card. The analysis suggests that there has been considerable heterogeneity in GP responses to the reforms, which has led to substantial changes in the fees charged by doctors and, as a result, the OOP costs incurred by different population groups. Copyright © 2016 John Wiley & Sons, Ltd.

Within the broadly generalized HIV epidemic in Swaziland, men who have sex with men (MSM) have specific HIV acquisition and transmission risks. In the current era of expanding antiretroviral therapy-based prevention and treatment approaches, condom use remains a core component of mitigating these risks. A cross-sectional study characterizing the vulnerabilities for HIV among MSM in Swaziland was analyzed to describe factors associated with condom use at last sex with a male partner. Bivariate and multivariate logistic regression analyses were conducted to assess correlates of condom use at last sex with both casual and regular male partners. Disclosure of sexual practices to a healthcare provider and being able to count on other MSM to support condom use were significantly associated with condom use at last sex with a causal and a regular partner, respectively. Reporting difficulty insisting on condom use was inversely associated with condom use at last sex with both regular and casual partners. In addition, having faced legal discrimination was similarly inversely associated with condom use at last sex with a regular partner. Condom use among MSM in Swaziland may increase with improved partner communication, provider sensitization to encourage sexual disclosure, and the promotion of safer sex norms within MSM communities. These approaches, in combination with existing and emerging evidence of informed and human rights affirming prevention and HIV treatment approaches may reduce the incidence of HIV among MSM in Swaziland and all those in their sexual networks.

We explored whether supplementing a clinical risk score with a behavioral measure could improve targeting of the patients most in need of supports that reduce their risk of costly service utilization. Using data from a large health system that determines patient self-management capability using the Patient Activation Measure, we examined utilization of hospital and emergency department care by the 15 percent of patients with the highest clinical risk scores. After controlling for risk scores and placing patients within segments based on their level of activation in 2011, we found that the lower the activation level, the higher the utilization and cost of hospital services in each of the following three years. These findings demonstrate that adding a measure of patient self-management capability to a risk assessment can improve prediction of high care costs and inform actions to better meet patient needs.

Motivated by the problem of determining unknotted routes for the scaffolding strand in DNA origami self-assembly, we examine existence and knottedness of A-trails in graphs embedded on the torus. We show that any A-trail in a checkerboard-colorable torus graph is unknotted and characterize the existence of A-trails in checkerboard-colorable torus graphs in terms of pairs of quasitrees in associated embeddings. Surface meshes are frequent targets for DNA nanostructure self-assembly, and so we study both triangular and rectangular torus grids. We show that, aside from one exceptional family, a triangular torus grid contains an A-trail if and only if it has an odd number of vertices, and that such an A-trail is necessarily unknotted. On the other hand, while every rectangular torus grid contains an unknotted A-trail, we also show that any torus knot can be realized as an A-trail in some rectangular grid. Lastly, we use a gluing operation to construct infinite families of triangular and rectangular grids containing unknotted A-trails on surfaces of arbitrary genus. We also give infinite families of triangular grids containing no unknotted A-trail on surfaces of arbitrary nonzero genus., Comment: 23 pages, 20 figures. This version fixes some errors in acknowledgements, typos

Background/objectives Patient activation encompasses the knowledge, skills, and confidence that equip adults to participate actively in their healthcare. Patients with hearing loss may be less able to participate due to poor aural communication. We examined whether difficulty hearing is associated with lower patient activation. Design Cross-sectional study. Setting/participants A nationally representative sample of Americans aged 65 years and older (n = 13 940) who participated in the Medicare Current Beneficiary Survey (MCBS) during the years 2011 to 2013. Measurement Self-reported degree of difficulty hearing ("no trouble," "a little trouble," and "a lot of trouble") and overall activation based on aggregated scored responses to 16 questions from the MCBS Patient Activation Supplement: low activation (below the mean minus 0.5 SDs), high activation (above the mean plus 0.5 SDs), and medium activation (the remainder). Sociodemographic and self-reported clinical measures were also included. Results "A little trouble" hearing was reported by 5655 (40.6%) of respondents, and "a lot of trouble" hearing was reported by 893 (6.4%) of respondents. Difficulty hearing was significantly associated with low patient activation: in analyses using multivariable multinomial logistic regression, respondents with "a little trouble" hearing had 1.42 times the risk of low vs high activation (95% confidence interval [CI] = 1.27-1.58), and those with "a lot of trouble" hearing had 1.70 times the risk of low vs high activation (95% CI = 1.29-2.11), compared with those with "no trouble" hearing. Conclusions Nearly half of people aged 65 years and older reported difficulty hearing, and those reporting difficulty were at risk of low patient activation. That risk rose with increased difficulty hearing. Given the established link between activation and outcomes of care, and in view of the association between hearing loss and poor healthcare quality and outcomes, clinicians may be able to improve care for people with hearing loss by attending to aural communication barriers.

Background Delayed umbilical cord clamping is associated with significant benefits to preterm and term newborns and is recommended for all infants by the World Health Organization and the American College of Obstetricians and Gynecologists (ACOG). Little is known about the cord management practices of U.S. obstetricians. Objective The objective of this study was to describe current cord clamping practices by U.S. obstetricians and investigate factors associated with delayed cord clamping. Study design A cross-sectional survey was sent to 500 members of the American College of Obstetricians and Gynecologists. Umbilical cord practices were assessed, and factors related to delaying cord clamping were examined using Chi-square tests and multivariate logistic regression models. Results The overall response rate was 37% with 74% of those opening the email responding. Sixty-seven percent of respondents reported DCC by one minute or more after vaginal births at term. After preterm and near-term vaginal births, 73% and 79% said they waited at least 30 seconds before clamping. The factor most consistently and strongly related to delaying cord clamping in both bivariate and multivariate analyses was having the belief that the timing of clamping was important. Additional analysis revealed that believing the timing was important was positively associated with the physician's institution having a written policy on the cord clamping. Conclusions In this study, a majority of respondents reported delaying cord clamping and indicated that employing strategies to implement the full uptake of this practice could be valuable. Findings suggest that institutional policies may influence attitudes on cord clamping.

Objective To identify approaches to presenting cost and resource use measures that support consumers in selecting high-value hospitals. Data sources Survey data were collected from U.S. employees of Analog Devices (n = 420). Study design In two online experiments, participants viewed comparative data on four hospitals. In one experiment, participants were randomized to view one of five versions of the same comparative cost data, and in the other experiment they viewed different versions of the same readmissions data. Bivariate and multivariate analyses examined whether presentation approach was related to selecting the high-value hospital. Principal findings Consumers were approximately 16 percentage points more likely to select a high-value hospital when cost data were presented using actual dollar amounts or using the word "affordable" to describe low-cost hospitals, compared to when the Hospital Compare spending ratio was used. Consumers were 33 points more likely to select the highest performing hospital when readmission performance was shown using word icons rather than percentages. Conclusions Presenting cost and resource use measures effectively to consumers is challenging. This study suggests using actual dollar amounts for cost, but presenting performance on readmissions using evaluative symbols.

Both payment reform and patient engagement are key elements of health care reform. Yet the question of how incentivizing primary care providers (PCPs) on quality outcomes affects the degree to which PCPs are supportive of patient activation and patient self-management has received little attention. In this mixed-methods study, we use in-depth interviews and survey data from PCPs working in a Pioneer Accountable Care Organization that implemented a compensation model in which a large percentage of PCP salary is based on quality performance. We assess how much PCPs report focusing their efforts on supporting patient activation and self-management, and whether or not they become frustrated with patients who do not change their behaviors. The findings suggest that most PCPs do not see the value in investing their own efforts in supporting patient self-management and activation. Most PCPs saw patient behavior as a major obstacle to improving quality and many were frustrated that patient behaviors affected their compensation.

BACKGROUND A key consideration in designing pay-for-performance programs is determining what entity the incentive should be awarded to—individual clinicians or to groups of clinicians working in teams. Some argue that team-level incentives, in which clinicians who are part of a team receive the same incentive based on the team’s performance, are most effective; others argue for the efficacy of clinician-level incentives. This study examines primary care clinicians’ perceptions of a team-based quality incentive awarded at the clinic level. METHODS This research was conducted with Fairview Health Services, where 40% of the primary care compensation model was based on clinic-level quality performance. We conducted 48 in-depth interviews to explore clinicians’ perceptions of the clinic-level incentive, as well as an online survey of 150 clinicians (response rate 56%) to investigate which entity the clinicians would consider optimal to target for quality incentives. RESULTS Clinicians reported the strengths of the clinic-based quality incentive were quality improvement for the team and less patient “dumping,” or shifting patients with poor outcomes to other clinicians. The weaknesses were clinicians’ lack of control and colleagues riding the coattails of higher performers. There were mixed reports on the model’s impact on team dynamics. Although clinicians reported greater interaction with colleagues, some described an increase in tension. Most clinicians surveyed (73%) believed that there should be a mix of clinic and individual-level incentives to maintain collaboration and recognize individual performance. CONCLUSION The study highlights the important advantages and disadvantages of using incentives based upon clinic-level performance. Future research should test whether hybrid incentives that mix group and individual incentives can maintain some of the best elements of each design while mitigating the negative impacts.

Patient engagement has become a major focus of health reform. However, there is limited evidence showing that increases in patient engagement are associated with improved health outcomes or lower costs. We examined the extent to which a single assessment of engagement, the Patient Activation Measure, was associated with health outcomes and costs over time, and whether changes in assessed activation were related to expected changes in outcomes and costs. We used data on adult primary care patients from a single large health care system where the Patient Activation Measure is routinely used. We found that results indicating higher activation in 2010 were associated with nine out of thirteen better health outcomes-including better clinical indicators, more healthy behaviors, and greater use of women's preventive screening tests-as well as with lower costs two years later. Changes in activation level were associated with changes in over half of the health outcomes examined, as well as costs, in the expected directions. These findings suggest that efforts to increase patient activation may help achieve key goals of health reform and that further research is warranted to examine whether the observed associations are causal.

Public reporting of health care provider quality is intended to spark consumer informed decision-making, yet there is concern that it might exacerbate disparities. This study explores the extent to which people with chronic conditions are aware of and using comparative quality information (CQI) on hospitals and doctors, and how awareness and use of the information differs by individuals' socio-demographic characteristics. Using a large 2011/2012 survey of adults with chronic conditions, we find low awareness of hospital and doctor CQI (26% and 16% respectively), and lower CQI use (8% and 6% respectively). Findings related to equity in awareness and use by socio-demographic subgroups was mixed. Higher education and income were related to greater CQI awareness, however Whites were less likely to be aware of and use CQI than African Americans and Latinos. The magnitudes of these differences, however, were not large; all groups had modest levels of CQI awareness and use.

This study aimed to compare the efficacy and safety of the Nit-Occlud PDA device (PFM Medical, Cologne, Germany) to benchmarks designed as objective performance criteria (OPC).The Nit-Occlud PDA is a nitinol coil-type patent ductus arteriosus (PDA) occluder with a reverse cone configuration, which is implanted using a controlled delivery system.Patients with4-mm minimum diameter PDA were prospectively enrolled in the Pivotal and the Continuing Access Studies from 15 sites in the United States and were followed up for 12 months post-procedure. Investigator-reported outcomes were compared to OPC including a composite success criterion, efficacy criteria of successful closure (clinical and echocardiographic), and safety criteria incidence of adverse events (serious and of total).The Pivotal Study enrolled patients between November 1, 2002 and October 31, 2005, and the Continuing Access Study enrolled additional patients between September 1, 2006 and October 31, 2007. A total of 357 patients were enrolled, and 347 had successful device implantations. After 12 months, 96.8% had complete echocardiographic closure (OPC = 85%) and 98.1% had clinical closure (OPC = 95%). There were no deaths or serious adverse events (OPC = 1%). The total adverse event rate was 4.7% (OPC = 6%). Composite success was 95.1% in the study patients (OPC = 80%).Closure of small- and medium-sized PDA with the Nit-Occlud PDA is effective and safe when compared with OPC.

Background This study examines the relationship between patient activation, a measure of individuals׳ knowledge, skill, and confidence for managing their health, and rates of depression remission and response among patients with depression. Methods Patients from Fairview Health Services in Minnesota with moderate to severe depression in 2011 and a PHQ-9 score in 2012 were included in the analysis (n=5253). Patient activation in 2011 and other health and demographic features were extracted from the electronic health record. We examined how patient activation predicted depression remission and response rates and changes in depression severity over one year using regression models. We also explored how activation predicted healthy behaviors among depressed patients. Results Higher baseline patient activation predicted lower depression severity and higher depression remission and response rates a year later. The most activated patients had PHQ-9 scores in 2012 two points lower than the lowest activated patients, and they had twice the odds of remission. Activation also predicted increase in healthy behaviors. Limitations We were unable to examine the use of mental health services or control for the number of prior depressive episodes and duration of the current depressive episode in the analysis. Conclusions We found that higher patient activation predicted better depression outcomes. While we are unable to explore the mechanism of this association, we observed that more activated patients are also engaged in more healthy behaviors, suggesting that the mechanism may be behavioral. Support of patient activation may be an effective approach for providers to reduce patients׳ depression severity.

Objective: This study tests whether a personal narrative can persuade people to value comparative data on physician quality. Method: We conducted an online experiment with 850 adults. One group viewed a cartoon narrative on physician quality variation, another saw text on physician quality variation, and there was a control group. Study participants hypothetically selected a physician from a display of four physicians. The top-quality physician was furthest away and most expensive. We conducted multivariate models examining the relationship between experimental group and choice of the top-quality physician. Results: There was no overall relationship between narrative or text information and choice of the highest quality physician. Among higher numerate participants, however, those who viewed the narrative had odds 2.7 times higher of selecting the top-quality physician compared with the control group. Discussion: Personal narratives can persuade higher numerate people to consider quality when selecting physicians.

Background There is growing acknowledgement that patients are key stakeholders in improving quality of medical care, yet a key barrier to integrating patients into quality improvement teams (QITs) as patient partners is the lack of evidence of their impact. This mixed-method study was conducted to identify the ways patient partners influence QITs and to document the extent of patient partners' impact. Methods Focus groups and in-depth interviews were conducted with 17 patient partners and 11 staff at WellSpan Health and Aligning Forces for Quality—South Central Pennsylvania to identify the specific mechanisms through which patients influenced QIT efforts. Online surveys of 47 patient partners and 56 QIT leaders were conducted in summer 2016 to test the ways in which patient partners affected quality improvement (QI) and gauge respondents' perceptions of the impact of patient partners' contributions. Results Patient partners influenced QI through three key mechanisms: symbolism, providing feedback (on written material for patients and new policies), and making suggestions (on office communication, educational materials, physical space, and clinical care processes). Almost three quarters of the patient partners believed they had a moderate to very large impact on their QIT's QI efforts. Eight of the 10 QIT leaders reported that patient partners improved patient-centeredness of QI a "moderate amount" to a "great deal" through one of the three key mechanisms. Conclusion Integrating patient partners into ambulatory care QITs was a largely positive experience for patient partners, QIT leaders, and administrators. The changes that patient partners prompted were meaningful and likely improved patients' experience with care.

© 2017, Springer International Publishing Switzerland. Background: Choosing a new health service provider can be difficult and is dependent on the type and clarity of the information available. This study examines if the presentation of service quality information affects the decisions of consumers choosing a general medical practice. Objectives: The aim was to examine the impact of presentation format on attribute level interpretation and relative importance. Methods: A discrete choice experiment eliciting preferences for a general medical practice was conducted using four different presentation formats for service quality attributes: (1) frequency and percentage with an icon array, (2) star ratings, (3) star ratings with a text benchmark, and (4) percentage alone. A total of 1208 respondents from an online panel were randomised to see two formats, answering nine choices for each, where one was a dominated choice. Logistic regression was used to assess the impact of presentation format on the probability of choosing a dominated alternative. A generalised multinomial logit model was used to estimate the relative importance of the attribute levels. Results: The probability of incorrectly choosing a dominated alternative was significantly higher when the quality information was presented as a percentage relative to a frequency with icon array, star rating or bench-marked star rating. Preferences for a practice did not differ significantly by presentation format, nor did the probability of finding the information difficult to understand. Conclusions: Quantitative health service quality information will be more useful to consumers if presented by combining the numerical information with a graphic, or using a star rating if appropriate for the context.

Background and purpose While male nurses have been shown to earn considerably more than female nurses, there is less evidence on gender disparities in salary among nurse practitioners (NPs). This study examines whether the gender gap in NP salaries persists after controlling for differences in work setting and demographic factors. Methods We analyzed the relationship between gender and salary (2011 pretax earnings) among 6591 NPs working as NPs at least 35 h per week, using the 2012 National Sample Survey of Nurse Practitioners. We first conducted bivariate regression analyses examining the relationship between gender and earnings, and then developed a multivariate model that controlled for individual differences in demographic and work characteristics. Conclusions Male NPs earned $12,859 more than female NPs, after adjusting for individual differences in demographics and work characteristics. The gender gap was $7405 for recent NP graduates, and grew over time. Male NPs earned significantly more than female NPs across all clinical specialty areas. Implications for practice The gender disparities in NP salaries documented here regardless of professional seniority or clinical area should spark healthcare organizations to conduct pay equity assessments of their employees’ salaries to identify and ameliorate pay inequality.

This study's objective was to examine the extent to which individuals exhibit a preference for physicians based upon the race/ethnicity and gender of a physician's name. We conducted an online survey of 915 adults, who viewed a comparative display of four physicians' quality performance. We randomized the name of one physician, whose quality performance was equal to that of one physician and better than two other physicians, to be either typically African American male, African American female, white male, white female, or Middle Eastern (gender ambiguous). In regression models, participants more frequently selected the physician with the randomized name when displayed with a white male name, compared to when presented with an African American male, African American female, or Middle Eastern name (ORs ranging from .59 to .64). White and male study participants exhibited this pattern, while racial/ethnic minority participants did not. If the hypothetical choice bias observed here translates to people's actual selection of physicians, it could be a contributing factor for why women and racial/ethnic minority physicians have lower incomes than white male physicians.

A key component of the Aligning Forces for Quality (AF4Q) program was engaging consumers in their health and healthcare. We examined the extent to which the alliances embraced 4 areas of consumer engagement: self-management, consumer friendliness of reports of healthcare provider quality, involvement of consumers in alliance governance, and the integration of consumers into quality improvement teams.We used a largely qualitative approach. The evaluation team conducted 1100 in-depth interviews with alliance stakeholders. Two authors reviewed the consumer engagement data for each alliance to assess its level of embrace in the 4 consumer engagement areas. For consumer friendliness of public reporting websites, we also assessed alliance public reports for reading level, technical language, and evaluable displays. Population-level effects were also examined for self-management and public reporting.Consumer engagement was new to most alliances, and few had staff with consumer engagement expertise or existing consumer constituencies. For each area of consumer engagement, some alliances enthusiastically embraced the work, other alliances made a concerted but limited effort to develop programs, and a third group of alliances did the minimum work required. Integrating consumers into governance was the area most often embraced, followed by making public reports consumer friendly. Two alliances strongly embraced both self-management and integrating patients into quality improvement efforts. The AF4Q program did not have greater population level effects from self-management or public reporting than were those observed in a national comparison sample.The AF4Q program sparked a few alliances to develop robust consumer engagement programming, while most alliances tried consumer engagement efforts for the first time and developed an appreciation for integrating consumer perspectives into their work.

To report summative evaluation results from the Aligning Forces for Quality (AF4Q) initiative, the Robert Wood Johnson Foundation's (RWJF's) signature effort to improve quality of care from 2005 to 2015.This was a longitudinal mixed methods program evaluation (ie, multiphase triangulated evaluation) of 16 grantee "alliances" from across the country, funded by RWJF as part of the AF4Q initiative. Grantees were selected in a nonexperimental manner and were charged with deploying interventions in 5 main programmatic areas to improve health and healthcare in their communities.Except for a small proportion of outcomes, there were no major differences in the rate of longitudinal improvement in AF4Q communities, compared with control communities, on quantitative outcomes related to the Triple Aim. Although the majority of the measures improved in both AF4Q and non-AF4Q communities, there were some exceptions to this improving trend, most noticeably in the cost of care and population health. There was also considerable heterogeneity across communities in terms of programmatic areas and the scale and scope of interventions in these areas. Although a number of AF4Q alliances implemented robust interventions in specific areas, often advancing strategies useful for others in the field, no AF4Q alliance pursued and aligned all 5 AF4Q programmatic areas in a robust way. In addition, whereas all alliances were able to garner the participation of multiple stakeholders initially, sustaining this participation and securing new sources of funding after RWJF support ended proved challenging for many alliances. Conclusion and Policy and Practice Implications: While the AF4Q program did not attain the ambitious community-level changes predicted by its sponsor at the program's outset, it did produce pockets of success on some dimensions for particular alliances. A number of factors explain the less-than-expected impact of the AF4Q initiative on community health and the observed variation in alliance sustainability and intervention strength. These include differing acceptance of the AF4Q initiative's theory of change, variation in the experience and capacity of the alliance communities selected for the program, differences in alliances' local healthcare market context, and the changing programmatic requirements for alliances participating in the AF4Q initiative. The variation in AF4Q program outcomes offers important lessons for those engaged in regional health improvement work.

The Aligning Forces for Quality (AF4Q) initiative was the Robert Wood Johnson Foundation's (RWJF's) signature effort to increase the overall quality of healthcare in targeted communities throughout the country. In addition to sponsoring this 16-site complex program, RWJF funded an independent scientific evaluation to support objective research on the initiative's effectiveness and contributions to basic knowledge in 5 core programmatic areas. The research design, data, and challenges faced during the summative evaluation phase of this near decade-long program are discussed.A descriptive overview of the summative research design and its development for a multi-site, community-based, healthcare quality improvement initiative is provided.The summative research design employed by the evaluation team is discussed.The evaluation team's summative research design involved a data-driven assessment of the effectiveness of the AF4Q program at large, assessments of the impact of AF4Q in the specific programmatic areas, and an assessment of how the AF4Q alliances were positioned for the future at the end of the program.The AF4Q initiative was the largest privately funded community-based healthcare improvement initiative in the United States to date and was implemented at a time of rapid change in national healthcare policy. The implementation of large-scale, multi-site initiatives is becoming an increasingly common approach for addressing problems in healthcare. The summative evaluation research design for the AF4Q initiative, and the lessons learned from its approach, may be valuable to others tasked with evaluating similarly complex community-based initiatives.

This analysis assessed the evolution of public reporting of provider performance in Aligning Forces for Quality (AF4Q) alliances, contrasted alliances that stopped reporting with those that plan to continue, and drew insights from alliance public reporting efforts for the national transparency movement.Combined with document review, qualitative research methods were used to analyze interview data collected, over a nearly 10-year period, from the 16 participating alliances.AF4Q alliances made their greatest contributions to provider transparency in reporting ambulatory quality and patient experience measures. However, reporting ambulatory cost/efficiency/utilization measures was more challenging for alliances. Alliances contributed the least with respect to measures of inpatient performance. Six alliances ceased reporting at the end of the AF4Q program because of their inability to develop stable funding sources and overcome stakeholder skepticism about the value of public reporting. Insights provided by alliance leaders included the need to: focus on provider, rather than consumer, responses to public reports as the most likely avenue for improving quality; address the challenge of funding the reporting infrastructure from the beginning; explore collaborations with other entities to increase public reporting efficiency; and develop a strategy for responding to efforts at the national level to increase the availability of information on provider performance.The AF4Q initiative demonstrated that a wide variety of voluntary stakeholder coalitions could develop public reports with financial and technical support. However, the contents of these reports varied considerably, reflecting differences in local environments and alliance strategies. The challenges faced by alliances to maintain their reporting efforts were substantial, and not all alliances chose to report. Nevertheless, there are potential roles for alliances going forward in contributing to the national transparency movement.

The Robert Wood Johnson Foundation's (RWJF's) Aligning Forces for Quality (AF4Q) program was the largest privately funded, community-based quality improvement initiative to date, providing funds and technical assistance (TA) to 16 multi-stakeholder alliances located throughout the United States. This article describes the AF4Q initiative's underlying theory of change, its evolution over time, and the key activities undertaken by alliances.Descriptive overview of a multi-site, community-based quality improvement initiative.We summarized information from program documents, program meetings, observation of alliance activities, and interviews with RWJF staff, TA providers, and AF4Q alliance stakeholders.The AF4Q program was a dynamic initiative, expanding and evolving over time. The underlying theory of change was based on the notion that an aligned, multi-stakeholder approach is superior to independent siloed efforts by stakeholders. Participating alliances developed or strengthened programming to varying degrees in 5 main programmatic areas: (1) measurement and public reporting of healthcare quality, patient experience, cost, and efficiency for ambulatory physician practices and hospitals; (2) efforts to engage consumers in health, healthcare, and alliance governance (consumer engagement); (3) adoption and spread of effective strategies to improve care delivery; (4) advancing healthcare equity; and (5) integration of alliance activities with payment reform initiatives.The AF4Q initiative was an ambitious program affecting multiple leverage points in the healthcare system. AF4Q alliances were provided a similar set of expectations, and given financial support and access to substantial TA. There was considerable variation in how alliances addressed the AF4Q programmatic areas, given differences in their composition, market structure, and history.

To summarize the results from the quantitative analyses conducted during the summative evaluation of the Aligning Forces for Quality (AF4Q) initiative.Longitudinal design using linear difference-in-difference (DD) regression models with fixed effects. Outcomes were selected based on the AF4Q program logic model and organized according to the categories of the Triple Aim: improving population health, improving quality and experience of care, and reducing the cost of care.Two primary data sources: the AF4Q Consumer Survey and the National Study of Physician Organizations (NSPO); and 4 secondary data sources: the Dartmouth Atlas Medicare claims database, the Truven Health MarketScan commercial claims database, the Behavioral Risk Factor Surveillance System (BRFSS), and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).In total, 144 outcomes were analyzed, 27 were associated with improving population health, 87 were associated with improving care quality and experience, and 30 were associated with reducing the cost of care. Based on the estimated DD coefficients, there is no consistent evidence that AF4Q regions, over the life of the program, showed greater improvement in these measures compared with the rest of the United States. For less than 12% of outcomes (17/144), the AF4Q initiative was associated with a significant positive impact (P ≤.05), although the magnitude of the impact was often small. Among the remaining outcomes, with some exceptions, similarly improving trends were observed in both AF4Q and non-AF4Q areas over the period of intervention. Conclusion and Policy and Practice Implications: Our quantitative findings, which suggest that the AF4Q initiative had less impact than expected, are potentially due to the numerous other efforts to improve healthcare across the United States, including regions outside the AF4Q program over the same period of time. The limited overall impact may also be due to the variability in the "dose" of the interventions across AF4Q regions. However, these results should not be interpreted as a conclusive statement about the AF4Q initiative. More nuanced discussions of the implementation of interventions in the specific AF4Q programmatic areas and their potential success (or lack thereof) in the participating communities are included in other articles in this supplement.

Starting in 2017, all state and federal health insurance exchanges will present quality data on health plans in addition to cost information. We analyzed variations in the current design of information on state exchanges to identify presentation approaches that encourage consumers to take quality as well as cost into account when selecting a health plan. Using an online sample of 1,025 adults, we randomly assigned participants to view the same comparative information on health plans, displayed in different ways. We found that consumers were much more likely to select a high-value plan when cost information was summarized instead of detailed, when quality stars were displayed adjacent to cost information, when consumers understood that quality stars signified the quality of medical care, and when high-value plans were highlighted with a check mark or blue ribbon. These approaches, which were equally effective for participants with higher and lower numeracy, can inform the development of future displays of plan information in the exchanges.