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Delivering well-coordinated care is essential for optimizing clinical outcomes, enhancing patient care experiences, minimizing costs, and increasing provider satisfaction. The Veterans Health Administration (VA) has built a strong foundation for internally coordinating care. However, VA faces mounting internal care coordination challenges due to growth in the number of Veterans using VA care, high complexity in Veterans' care needs, the breadth and depth of VA services, and increasing use of virtual care. VA's Health Services Research and Development service with the Office of Research and Development held a conference assessing the state-of-the-art (SOTA) on care coordination. One workgroup within the SOTA focused on coordination between VA providers for high-need Veterans, including (1) Veterans with multiple chronic conditions; (2) Veterans with high-intensity, focused, specialty care needs; (3) Veterans experiencing care transitions; (4) Veterans with severe mental illness; (5) and Veterans with homelessness and/or substance use disorders. We report on this workgroup's recommendations for policy and organizational initiatives and identify questions for further research. Recommendations from a separate workgroup on coordinating VA and non-VA care are contained in a companion paper. Leaders from research, clinical services, and VA policy will need to partner closely as they develop, implement, assess, and spread effective practices if VA is to fully realize its potential for delivering highly coordinated care to every Veteran. [ABSTRACT FROM AUTHOR]

This perspective paper seeks to lay out an efficient approach for health care providers, researchers, and other stakeholders involved in interventions aimed at improving care coordination to partner in locating and using applicable care coordination theory. The objective is to learn from relevant theory-based literature about fit between intervention options and coordination needs, thereby bringing insights from theory to enhance intervention design, implementation, and troubleshooting. To take this idea from an abstract notion to tangible application, our workgroup on models and measures from the Veterans Health Administration (VA) State of the Art (SOTA) conference on care coordination first summarizes our distillation of care coordination theoretical frameworks (models) into three common conceptual domains-context of an intervention, locus in which an intervention is applied, and specific design features of the intervention. Then we apply these three conceptual domains to four cases of care coordination interventions ("use cases") chosen to represent various scopes and stages of interventions to improve care coordination for veterans. Taken together, these examples make theory more accessible and practical by demonstrating how it can be applied to specific cases. Drawing from theory offers one method to anticipate which intervention options match a particular coordination situation. [ABSTRACT FROM AUTHOR]

Background: Improving care coordination is a key priority for many healthcare systems. However, initiatives to improve care coordination are complex to implement and have produced mixed results. A better understanding of how to craft and support implementation of effective care coordination strategies is needed.Objective: To identify and understand the challenges and factors encountered by Patient-Aligned Care Team (PACT) staff in performing care coordination tasks in outpatient clinics in the Veterans Health Administration (VA).Design: Qualitative study using semi-structured formative evaluation interviews.Participants: Fourteen interviews with 18 clinical frontline managers and staff from 12 clinic sites across five VA health systems.Interventions: This paper reports on baseline data collected for the Coordination Toolkit and Coaching (CTAC) project. CTAC aims to improve patients' experience of care coordination within VA primary care and between PACT and other outpatient and community settings.Approach: We conducted pre-implementation telephone interviews with frontline managers and staff, primarily nurse managers.Key Results: PACT staff described challenges in aligning care coordination priorities across different levels of the VA system, including staff, patients, and leadership. Additionally, PACT staff noted challenges coordinating care both within and outside the VA, and identified resource barriers impeding their care coordination efforts. To address these challenges, staff made several recommendations for improvement, including (1) contingency staffing to address staff burnout; (2) additional PACT training for new staff; (3) clarification of care coordination roles and responsibilities; and (4) and care coordination initiatives that align both with centrally initiated care coordination programs and frontline needs.Conclusion: In the VA and similarly complex healthcare systems, our findings suggest the need for care coordination strategies that are buttressed by a system-level vision for care coordination, backed up by clear roles and responsibilities for information exchange between primary care staff and other settings, and multidimensional accountability metrics that encompass patient-, staff-, and system-level goals. [ABSTRACT FROM AUTHOR]

With a focus on the United States, this paper addresses the basic social indicators question: How are we doing? More specifically, with respect to children, how are our kids (including adolescents and youths) doing? These questions can be addressed by comparisons: (1) to past historical values, (2) to other contemporaneous units (e.g., comparisons among subpopulations, states, regions, countries), or (3) to goals or other externally established standards. The Child and Youth Well-Being Index (CWI), which we have developed over the past decade, uses all three of these points of comparison. The CWI is a composite index based on 28 social indicator time series of various aspects of the well-being of children and youth in American society that date back to 1975, which is used as a base year for measuring changes (improvements or deterioration) in subsequent years. The CWI is evidence- based not only in the sense that it uses time series of empirical data for its construction, but also because the 28 indicators are grouped into seven domains of well-being or areas of social life that have been found to define the conceptual space of the quality of life in numerous studies of subjective well-being. Findings from research using the CWI reported in the paper include: (1) trends in child and youth well-being in the United States over time, (2) international comparisons, and (3) best-practice analyses. [ABSTRACT FROM AUTHOR]

Racial-ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial-ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial-ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial-ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices. [ABSTRACT FROM AUTHOR]

This paper, a revised version of the keynote address to the Seventh International Conference of the International Society for Third Sector Research (Bangkok, July 2006), explores the increasing tendency of governments to view the third sector as a source of human insecurity and uncivil society in the wake of terrorist attacks. The paper discusses the means governments use to control third sector activity that they view as potentially linked to terrorism, the need for comparative analysis of these measures, and the role of the third sector and scholars in recognizing the responsibilities of governments to prevent third sector organizations being used in terrorism while preserving the independence and vitality of the third sector. [ABSTRACT FROM AUTHOR]

The mission of the Veterans Health Administration's (VHA) quality enhancement research initiative (QUERI) is to enhance the quality of VHA health care by implementing clinical research findings into routine care. This paper presents lessons that QUERI investigators have learned through their initial attempts to pursue the QUERI mission. The lessons in this paper represent those that were common across multiple QUERI projects and were mutually agreed on as having substantial impact on the success of implementation. While the lessons are consistent with commonly recognized ingredients of successful implementation efforts, the examples highlight the fact that, even with a thorough knowledge of the literature and thoughtful planning, unexpected circumstances arise during implementation efforts that require flexibility and adaptability. The findings stress the importance of utilizing formative evaluation techniques to identify barriers to successful implementation and strategies to address these barriers. [ABSTRACT FROM AUTHOR]

Following the report of the Stiglitz Commission, measuring and comparing well-being across countries has gained renewed interest. Yet, analyses that go beyond income and incorporate non-market dimensions of welfare most often rely on the assumption of identical preferences to avoid the difficulties related to interpersonal comparisons. In this paper, we suggest an international comparison based on individual welfare rankings that fully retain preference heterogeneity. Focusing on the consumption-leisure trade-off, we estimate discrete choice labor supply models using harmonized microdata for 11 European countries and the US. We retrieve preference heterogeneity within and across countries and analyze several welfare criteria which take into account that differences in income are partly due to differences in tastes. The resulting welfare rankings clearly depend on the normative treatment of preference heterogeneity with alternative metrics. We show that these differences can indeed be explained by estimated preference heterogeneity across countries-rather than demographic composition. [ABSTRACT FROM AUTHOR]

The kinetics and elemental composition of cellular units that mediate production and respiration are the basis for the metabolic and stoichiometric theories of ecological organization. This theoretical framework extends to the activities of microbial enzymes released into the environment (ecoenzymes) that mediate the release of assimilable substrate from detrital organic matter. In this paper, we analyze the stoichiometry of ecoenzymatic activities in the surface sediments of lotic ecosystems and compare those results to the stoichiometry observed in terrestrial soils. We relate these ecoenzymatic ratios to energy and nutrient availability in the environment as well as microbial elemental content and growth efficiency. The data, collected by US Environmental Protection Agency, include the potential activities of 11 enzymes for 2,200 samples collected across the US, along with analyses of sediment C, N and P content. On average, ecoenzymatic activities in stream sediments are 2-5 times greater per gC than those of terrestrial soils. Ecoenzymatic ratios of C, N and P acquisition activities support elemental analyses showing that microbial metabolism is more likely to be C-limited than N or P-limited compared to terrestrial soils. Ratios of hydrolytic to oxidative activities indicate that sediment organic matter is more labile than soil organic matter and N acquisition is less dependent on humic oxidation. The mean activity ratios of glycosidases and aminopeptidases reflect the environmental abundance of their respective substrates. For both freshwater sediments and terrestrial soils, the mean C:nutrient ratio of microbial biomass normalized to growth efficiency approximates the mean ecoenzymatic C:nutrient activity ratios normalized to environmental C:nutrient abundance. This relationship defines a condition for biogeochemical equilibrium consistent with stoichiometric and metabolic theory. [ABSTRACT FROM AUTHOR]

Over the past few decades, a variety of groups have begun to argue that the US and European patent systems do not adequately represent the public interest in their decision making and that they need to undergo fundamental changes to their structure and orientation. These challengers have adopted similar strategies-in terms of the venues chosen and the arguments, evidence, and rhetoric used-in each context. However, they have experienced more success in Europe than in the United States. This paper begins to explain this difference by arguing that the US and European patent policy domains have different 'expertise barriers'-formal and informal rules that make it difficult for those without the knowledge that is recognized as relevant and legitimate in that domain to engage as equals. [ABSTRACT FROM AUTHOR]

Comparative studies describing the transition from higher education to work have often simplified the complex transition processes involved. In this paper we extend previous research by taking into account several steps that comprise labor market entry, e.g., recurrent education leading to more than one instance of labor market entry. By comparing Germany and the United States we also examine how the tertiary education systems influence these transitions via the mode of stratification (parallel tracks in Germany vs. consecutive tracks in the US), the coordination mechanism (state-controlled vs. market-based) and the degree of standardization in educational programs. In our empirical analyses using large-scale longitudinal survey data we find that transitions in the US are less standardized and regulated than in Germany. Furthermore, differences between students from lower- and higher-tier institutions are less marked than expected, both within and between the two countries. [ABSTRACT FROM AUTHOR]

The article discusses studies on chronic pain selected by the members of the Society of General Internal Medicine. It says that the papers were chosen for their potential to change generalist care of patients with chronic pain. The articles include one on the assessment of pain intensity and interference, a randomized trial on optimized antidepressant therapy and pain self-management to improve pain and depression outcomes, and one on the trends in opioid use in patients with non-cancer pain.

In recent decades, rapid growth of the U.S. Hispanic population has raised concerns about immigrant adaptation, including fertility. Empirical research suggests that Hispanics, especially Mexicans, might not be following the historical European pattern of rapid intergenerational fertility decline (and convergence toward native levels). If confirmed, continued high Hispanic fertility could indicate a broader lack of assimilation into mainstream American society. In this paper, we reexamine the issue of Hispanic and Mexican fertility using an approach that combines biological and immigrant generations to more closely approximate a comparison of immigrant women with those of their daughters' and granddaughters' generation. Contrary to cross-sectional results, our new analyses show that Hispanic and Mexican fertility is converging with that of whites, and that it is similarly responsive to period conditions and to women's level of education. In addition, we employ a mathematical simulation to illustrate the conditions under which cross-sectional analyses can produce misleading results. Finally, we discuss the import of the fertility convergence we document for debates about immigrant assimilation. [ABSTRACT FROM AUTHOR]

The expansion of women in the military is reshaping the veteran population, with women now constituting the fastest growing segment of eligible VA health care users. In recognition of the changing demographics and special health care needs of women, the VA Office of Research & Development recently sponsored the first national VA Women's Health Research Agenda-setting conference to map research priorities to the needs of women veterans and position VA as a national leader in Women's Health Research. This paper summarizes the process and outcomes of this effort, outlining VA's research priorities for biomedical, clinical, rehabilitation, and health services research. [ABSTRACT FROM AUTHOR]

The U.S. health care system is one of the world's most advanced systems. Yet, the health care system suffers from unexplained practice variations, major gaps between evidence and practice, and suboptimal quality. Although information processing, communication, and management are key to health care delivery and considerable evidence links information/communication technology (IT) to improvements in patient safety and quality of care, the health care system has a longstanding gap in its investment. In the Crossing the Quality Chasm and Building a Better Delivery System reports, The Institute of Medicine and National Academy of Engineering identified IT integration as critical to improving health care delivery systems. This paper reviews the state of IT use in the U.S. health care system, its role in facilitating evidence-based practices, and identifies key attributes of an ideal IT infrastructure and issues surrounding IT implementation. We also examine structural, financial, policy-related, cultural, and organizational barriers to IT implementation for evidence-based practice and strategies to overcome them. [ABSTRACT FROM AUTHOR]

While great strides have been made recently in improving end-of-life care in the United States, people with dementia often die with inadequate pain control, with feeding tubes in place, and without the benefits of hospice care. In this paper, we discuss the most important and persistent challenges to providing excellent end-of-life care for patients with dementia, including dementia not being viewed as a terminal illness; the nature of the course and treatment decisions in advanced dementia; assessment and management of symptoms; the caregiver experience and bereavement; and health systems issues. We suggest approaches for overcoming these barriers in the domains of education, clinical practice, and public policy. As the population ages, general internists increasingly will be called upon to provide primary care for a growing number of patients dying with dementia. There are great opportunities to improve end-of-life care for this vulnerable and underserved population. [ABSTRACT FROM AUTHOR]

In this paper, queuing theory is tested through an examination of the occupational attainment of six groups of non-whites in London and New York. Workers in the dominant economy are distinguished from those in the niche economy and emphasis is placed on the former. Black male immigrants in New York and black female immigrants in London hold more favorable occupational status. These results reflect differences in (1) the presence of indigenous minorities--African Americans and Puerto Ricans--in New York but not London, and (2) the relatively low position of indigenous minority males compared to the relatively middling position of indigenous minority females in New York's labor queue. [ABSTRACT FROM AUTHOR]

The article discusses the study on problems posed by language barriers. The authors of this paper turn to a series of papers testing innovative solutions. A pair of interpreters in a hospital ward service has been embedded. A study also compares the use of interpreters to language concordant interactions.

Background/Objectives:The aim of this paper was to compare methods to estimate usual intake distributions of nutrients and foods. As 'true' usual intake distributions are not known in practice, the comparison was carried out through a simulation study, as well as empirically, by application to data from the European Food Consumption Validation (EFCOVAL) Study in which two 24-h dietary recalls (24-HDRs) and food frequency data were collected. The methods being compared were the Iowa State University Method (ISU), National Cancer Institute Method (NCI), Multiple Source Method (MSM) and Statistical Program for Age-adjusted Dietary Assessment (SPADE).Subjects/Methods:Simulation data were constructed with varying numbers of subjects (n), different values for the Box-Cox transformation parameter (λBC) and different values for the ratio of the within- and between-person variance (rvar). All data were analyzed with the four different methods and the estimated usual mean intake and selected percentiles were obtained. Moreover, the 2-day within-person mean was estimated as an additional 'method'. These five methods were compared in terms of the mean bias, which was calculated as the mean of the differences between the estimated value and the known true value. The application of data from the EFCOVAL Project included calculations of nutrients (that is, protein, potassium, protein density) and foods (that is, vegetables, fruit and fish).Results:Overall, the mean bias of the ISU, NCI, MSM and SPADE Methods was small. However, for all methods, the mean bias and the variation of the bias increased with smaller sample size, higher variance ratios and with more pronounced departures from normality. Serious mean bias (especially in the 95th percentile) was seen using the NCI Method when rvar=9, λBC=0 and n=1000. The ISU Method and MSM showed a somewhat higher s.d. of the bias compared with NCI and SPADE Methods, indicating a larger method uncertainty. Furthermore, whereas the ISU, NCI and SPADE Methods produced unimodal density functions by definition, MSM produced distributions with 'peaks', when sample size was small, because of the fact that the population's usual intake distribution was based on estimated individual usual intakes. The application to the EFCOVAL data showed that all estimates of the percentiles and mean were within 5% of each other for the three nutrients analyzed. For vegetables, fruit and fish, the differences were larger than that for nutrients, but overall the sample mean was estimated reasonably.Conclusions:The four methods that were compared seem to provide good estimates of the usual intake distribution of nutrients. Nevertheless, care needs to be taken when a nutrient has a high within-person variation or has a highly skewed distribution, and when the sample size is small. As the methods offer different features, practical reasons may exist to prefer one method over the other. [ABSTRACT FROM AUTHOR]