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While we have the tools to achieve this goal, the persistent barriers to healthcare services experienced by too many individuals will need to be addressed to make significant progress and improve the health and quality of life of all people with human immunodeficiency virus (HIV). The necessary structural changes require actions by federal, state, and local policymakers and range from ensuring universal access to healthcare services to optimizing care delivery to ensuring a robust and diverse infectious diseases and HIV workforce. In this article, we outlines 10 key principles for policy reforms that, if advanced, would make ending the HIV epidemic in the United States possible and could have much more far-reaching effects in improving the health of our nation. [ABSTRACT FROM AUTHOR]

Persons living with human immunodeficiency virus (HIV) and others receiving antiretrovirals are at risk for medication errors during hospitalization and at transitions of care. These errors may result in adverse effects or viral resistance, limiting future treatment options. A range of interventions is described in the literature to decrease the occurrence or duration of medication errors, including review of electronic health records, clinical checklists at care transitions, and daily review of medication lists. To reduce the risk of medication-related errors, antiretroviral stewardship programs (ARVSPs) are needed to enhance patient safety. This call to action, endorsed by the Infectious Diseases Society of America, the HIV Medicine Association, and the American Academy of HIV Medicine, is modeled upon the success of antimicrobial stewardship programs now mandated by the Joint Commission. Herein, we propose definitions of ARVSPs, suggest resources for ARVSP leadership, and provide a summary of published, successful strategies for ARVSP that healthcare facilities may use to develop locally appropriate programs. [ABSTRACT FROM AUTHOR]

The article offers information on the updated position paper on the policies relating to HIV infection in the U.S. The position paper on HIV policy has been established in collaboration with the HIV Medicine Association of the Infectious Diseases Society of America and the American College of Physicians. The updated HIV policy highlights major advances on the treatment of HIV infection, the expansion of HIV as a pandemic and the prevalence of HIV transmission in health care settings. Details on these updates emphasizing public health and clinical imperatives in identifying HIV infection are discussed.

The article presents a position paper for pain medicine, which identifies the history of pain medicine and offers suggestions to improve knowledge on pain medicine. It says that the quality of pain care is low and pain treatment remains to be ineffective thus becoming a problem in the U.S. It highlights notable advances in the history of pain care in the U.S. and the barriers that affect the progress of pain care treatment. It also suggests establishing pain medicine as a medical specialty.

Faster and more widespread implementation could help more patients to benefit more quickly from known effective treatments. So could more effective implementation of better assessment methods, service delivery models, treatments and services. Implementation at scale and 'descaling' are ways for hospitals and health systems to respond to rising demands and costs. The paper proposes ways to provide leaders with the information that would help them to decide whether and how to scale up a proven improvement. We draw on our knowledge of the improvement and implementation literature on the subject and on our experience of scale up programs in Kaiser Permanente, in Swedish county health systems, and in international health. We describe a '3S' scale up infrastructure and other ingredients that appear necessary for successful widespread improvement, and list the resources that we have found useful for developing scale up programs. The paper aims to encourage more actionable research into scale up, and shows the opportunities for researchers to both advance implementation and improvement science and contribute to reducing suffering and costs in a more timely and effective way. [ABSTRACT FROM AUTHOR]

The financial effectiveness of the United States' Medical Assistance Program (Medicaid) depends on sound financial management at all political levels. States receive payments from the Federal Government based on the number, kinds and payment rates of services provided to eligible patients. Because payments can lag services by a considerable time and because claims may be denied, adjusted or re-processed, the state cannot easily predict its total payments for services recently delivered. As a matter of fact, some claims linger as long as 24 months (Arnett & Foster, Pllc., 2002, unpublished data) in the system. This paper presents a procedure to estimate die percentages of payments due in the months following the service delivery month. The procedure relies on the most recent 24 months of services and payments. Service months from die recent past generate fewer monthly payments than those more distant and can have large, unknown outstanding balances. Through a transformation of die available data, our procedure takes into account the dwindling amounts of data available. The procedure, optimal in die sense of constrained least squares, results in estimates of the percentages paid as a function of time elapsed since service. A dynamic programming procedure stabilizes tail area percentages and a hold-out sample provides evidence of good fit. Real-world data illustrate the process. [ABSTRACT FROM AUTHOR]

Health care resource distribution is a subject of debate among health policy analysts, economists, and philosophers. In the United States, there is a widening gap between the more- and less-advantaged socioeconomic sub-populations in terms of both health care resource distribution and outcomes. Conventional wisdom suggests that there is a tradeoff, a zero-sum game, between efficiency and fairness in the distribution of health care resources. Promoting fairness in the distribution of health care resources and outcomes is not efficient in terms of maximization of a health outcome production function. On the other side of the coin, improving efficiency comes at the expense of fairness. Such conventional wisdom is supported in part by standard static Paretian welfare analysis. However, in this paper it is shown that in a dynamic setting in which there are efficiency gains in the health production function, fairness in distribution of health care resources can improve simultaneously. [ABSTRACT FROM AUTHOR]

Background Carbapenem-resistant Enterobacterales (CRE) are an urgent public health threat in the United States. Objective Describe the clinical and molecular epidemiology of CRE in a multicenter pediatric cohort. Methods CRACKLE-1 and CRACKLE-2 are prospective cohort studies with consecutive enrollment of hospitalized patients with CRE infection or colonization between 24 December 2011 and 31 August 2017. Patients younger than age 18 years and enrolled in the CRACKLE studies were included in this analysis. Clinical data were obtained from the electronic health record. Carbapenemase genes were detected using polymerase chain reaction and whole-genome sequencing. Results Fifty-one children were identified at 18 healthcare system study sites representing all U.S. census regions. The median age was 8 months, with 67% younger than age 2 years. Median number of days from admission to culture collection was 11. Seventy-three percent of patients had required intensive care and 41% had a history of mechanical ventilation. More than half of children had no documented comorbidities (Q1, Q3 0, 2). Sixty-seven percent previously received antibiotics during their hospitalization. The most common species isolated were Enterobacter species (41%), Klebsiella pneumoniae (27%), and Escherichia coli (20%). Carbapenemase genes were detected in 29% of isolates tested, which was lower than previously described in adults from this cohort (61%). Thirty-four patients were empirically treated on the date of culture collection, but only 6 received an antibiotic to which the CRE isolate was confirmed susceptible in vitro. Thirty-day mortality was 13.7%. Conclusions CRE infection or colonization in U.S. children was geographically widespread, predominantly affected children younger than age 2 years, associated with significant mortality, and less commonly caused by carbapenemase-producing strains than in adults. [ABSTRACT FROM AUTHOR]

According to the 2010 Census, 5.2 million people identified themselves as American Indian or Alaska Native (AIAN) in the United States. This was an increase of 39% from the prior Census, making AIANs one of the nation's fastest growing populations. The health and social programs reaching them, however, have experienced documented devastating shortfalls. Decades of inadequate resources have resulted in significant health and socioeconomic disparities. AIANs are often considered an "invisible minority." In 2012, there were 266,000 AIAN elders 65 or older who claimed one race alone. That number is projected to almost triple by 2030--when the nation's baby boomers move into the ranks of the older population. This article provides an overview of two primary mental health issues--depression and dementia--that will confront this emerging AIAN elder population. Although other health and social issues exist, this article addresses depression and dementia because they are hidden from the community and from health care agencies. This paper focuses both on the unique characteristics of the AIAN population and why it is important to address depression and dementia. The conclusion explores pragmatic policy recommendations for improving the health and long-term mental health care status of AIAN elders. [ABSTRACT FROM AUTHOR]

With an aging global population, the number of dementia cases is growing exponentially. To address the upcoming dementia crisis, the World Health Organization and Alzheimer's Disease International (2012) collaborated on an extensive report, Dementia: A Public Health Priority. In the United Kingdom, Prime Minster David Cameron initiated a national challenge on dementia, forming 3 dementia challenge champion groups aimed at improving health and care, creating dementia-friendly communities, and promoting dementia research. In the U.S., President Obama signed the National Alzheimer's Project Act, which led to the formation of the Advisory Council on Alzheimer's Research, Care, and Services and the launch of the first National Plan to Address Alzheimer's Disease. The term "dementia capable" was introduced in the 2012 Recommendations of the Public Members of the Advisory Council and has since been adopted in both the recommendations and annual updates of the national plan. This paper will first compare and contrast government usage of the concepts dementia friendly and dementia capable, along with another valuable concept, dementia positive, that was added after reviewing the literature. Finally, a new vision statement for the U.S.' national plan will be proposed and recommendations incorporating these 3 concepts in policy, research, and practice will be made. [ABSTRACT FROM AUTHOR]

The impact of the American Civil War on medical modernisation is increasingly being recognised, yet the ways in which the Civil War challenged and changed doctors' understanding of their professional role during the war remains underappreciated. By juxtaposing Union doctors' personal and professional responses to the Civil War with the wider public reaction to Union medical care, this paper explores the tensions that arose between the public and the professional perceptions of medicine as these developed on the battlefields of the nation's internecine conflict. It argues that the intersection between the positive and negative narratives of Union medical provision, specifically surgery, established an important discursive space within which Union doctors could negotiate their public and professional status. It finds that the negative narrative, far from a hindrance, was instrumental to the process of medical modernisation by enabling Union physicians to define, defend and develop a more modern medical role. [ABSTRACT FROM PUBLISHER]

If nothing else, democratic politics requires compromise. Mass polarization, where citizens disagree strongly and those disagreements magnify over time, presents obvious threats to democratic well-being. The overwhelming presumption is that if polarization is occurring, a substantial portion of it is attributable to the fragmentation attendant an increasingly choice-laden media environment where individuals expose themselves only to opinion-reinforcing information. Under what conditions does mass opinion polarization occur? Through two over-time laboratory experiments involving information choice behavior, this paper considers, first, the effects of slant in one’s information environment on over-time opinion dynamics and, second, the moderating role of attitude importance on those effects. The experiments reveal that, despite similar information search behavior, those with strong attitudes are dogmatic, resisting even substantial contrary evidence; those with weak attitudes, by contrast, hear opposing arguments and develop moderate opinions regardless of the prevalence of those arguments in their environment. Evaluations of information, rather than information search behavior per se, explain why individuals with strong attitudes polarize and those with weak attitudes do not. Polarization therefore seems to require more than media fragmentation and, in fact, a more important factor may be the strength of citizens’ prior attitudes on particular issues. [ABSTRACT FROM PUBLISHER]

Introduction: A key objective of this paper is to describe some major challenges and opportunities facing the behavioral medicine field in the current decade. Amidst current US statistics that present a sobering image of the nation's health, there have been a number of notable achievements in the behavioral medicine field that span the scientific/health continuum. However, many of these achievements have received little notice by the public and decision makers. Methods: A case is presented for the potential of scientific narrative for presenting behavioral medicine evidence in ways that engage attention and compel action. Additional areas for behavioral medicine engagement include expanding interdisciplinary connections into new arenas, continuing the growth of activities involving emerging technologies, building international connections, and engaging with policy. Conclusion: Finally, the fundamental importance of an integrated behavioral medicine field that plays an active role in supporting and advancing its members and the field as a whole is discussed. [ABSTRACT FROM AUTHOR]

Rapidly rising deficits at both the federal and state and local government levels, along with prospective long-term financing problems in the Social Security and Medicare programmes, have triggered a one-sided austerity-focused class war in the USA and around the globe. A coalition of the richest and most economically powerful segments of society, conservative politicians who represent their interests and right-wing populist groups like the Tea Party has demanded that deficits be eliminated by severe cuts at all levels of government in spending that either supports the poor and the middle class or funds crucial public investment. It also demands tax cuts for the rich and for business. These demands constitute a deliberate attempt to destroy the New Deal project, begun in the 1930s, whose goal was to subject capitalism to democratic control. In this paper I argue that our deficit crisis is the result of a shift from the New Deal-based economic model of the early postwar period to today’s neoliberal, free-market model. The new model has generated slow growth, rising inequality and rising deficits. Rising deficits in turn created demands for austerity. After tracing the long-term evolution of our current deficit crisis, I show that this crisis should be resolved primarily by raising taxes on upper-income households and large corporations, cutting war spending and adopting a Canadian- or European-style health care system. Calls for massive government spending cuts should be seen as what they are—an attack by the rich and powerful against the basic interests of the American people. [ABSTRACT FROM PUBLISHER]

This paper presents the theoretical framework and rationale for the ACTive intervention which proposes the use of video technology to facilitate patient and family participation in hospice interdisciplinary team meetings where plans of care are determined. It is surmised that patient and family involvement will improve communication and compliance in hospice care. An analysis of data from a pilot project of the ACTive intervention was conducted to explore active participation among family caregivers and the hospice team. Through the use of videophone technology caregivers participated in video-recorded team meetings. The actual communication behaviors of caregivers and team members were analyzed for active participation. Findings revealed that team–prompted caregiver participation was most common, however, team use of supportive talk in this context was considerably less frequent. The study also found that the team's use of active participation behaviors elicits caregiver active participation behaviors. The results of this study suggest the intervention was an effective way to involve family caregivers as active participants in the designing of care for their loved one. Findings also suggest that hospice staff would benefit from education and training on best practices for communicating with caregivers in the team meeting setting. [ABSTRACT FROM AUTHOR]

This paper studies the influence of mass media on U. S. government response to approximately 5,000 natural disasters occurring between 1968 and 2002. These disasters took nearly 63,000 lives and affected 125 million people per year. We show that U. S. relief depends on whether the disaster occurs at the same time as other newsworthy events, such as the Olympic Games, which are obviously unrelated to need. We argue that the only plausible explanation of this is that relief decisions are driven by news coverage of disasters and that the other newsworthy material crowds out this news coverage. [ABSTRACT FROM AUTHOR]

American physicians are increasingly concerned that they are losing professional control. Other analysts of medical power argue that physicians have too much power. This essay argues that current analyses are grounded in a structuralist reading of power. Deploying Michel Foucault's "care of the self" and rhetorician Raymie McKerrow's "critical rhetoric," this essay claims that medical power is better understood as a way that medical actors take on power through rhetoric rather than a force that has power over medical actors. Through a close reading of an essay by Senator Bill Frist, this paper argues that physicians experience a process of "subjection" wherein they are both agents of and objects of medical power as it is combined with state and corporate power in the American "war on terror." This alternative mode of analyzing medical power has implications for our collective understanding of its operations and the means by which we propose alternative enactments of medical power. [ABSTRACT FROM AUTHOR]

Many health surveys conduct an initial household interview to obtain demographic information and then request permission to obtain detailed information on health outcomes from the respondent's health care providers. A ‘complete response’ results when both the demographic information and the detailed health outcome data are obtained. A ‘partial response’ results when the initial interview is complete but, for one reason or another, the detailed health outcome information is not obtained. If ‘complete responders’ differ from ‘partial responders’ and the proportion of partial responders in the sample is at least moderately large, statistics that use only data from complete responders may be severely biased. We refer to bias that is attributable to these differences as ‘partial non-response’ bias. In health surveys it is customary to adjust survey estimates to account for potential differences by employing adjustment cells and weighting to reduce bias from partial response. Before making these adjustments, it is important to ask whether an adjustment is expected to increase or decrease bias from partial non-response. After making these adjustments, an equally important question is ‘How well does the method of adjustment work to reduce partial non-response bias?’. The paper describes methods for answering these questions. Data from the US National Immunization Survey are used to illustrate the methods. [ABSTRACT FROM AUTHOR]

There are two puzzles about health care for children that need explanation. Why is it the sentimentality Americans express about children has not been backed by solid health care programs? If children are to have good health care, how can a case for their high priority be made, particularly in light of the fact that their health is the best of all age groups in the country? The first question is explored, but the second question is the focus of this paper. A priority system for health care is proposed, and at the same time an argument is presented for why children should have a high priority despite their generally good health. [ABSTRACT FROM AUTHOR]

This paper will explore the application of an account of justice in health and health care to the special case of children. It is tempting to hold that children require no special treatment in an account of just health care; justice requires guaranteeing access to at least basic health care services to all persons, whatever their age group, within the constraints of a society's resources. However, I will argue that for a number of reasons we need to address what justice requires specifically for children from the health care system, even if the answer must be embedded within a general account of justice in health and health care. [ABSTRACT FROM AUTHOR]

This paper explores the causes and consequences of business involvement in health care reform. It uses the 50 U.S. states as its focus, analyzing a series of legislative initiatives popular in the 1980s. From an empirical standpoint, it builds on earlier work on business involvement in health care issues; from a theoretical standpoint, it aims to improve our understanding of business involvement in the policy-making process. It considers three theories of the state which, consistent with recent work in this area, seem to provide complementary explanations of the policy-making process. It finds that business' parochial economic interest stimulated business participation in overall health care reform activity while business' general economic interest affected health care coalition formation more specifically. Business involvement was most vibrant in states where large corporations were headquartered and, in the case of overall health care reform activity at least, this was augmented by the presence of major commercial bank headquarters. The presence of large health care companies inhibited overall business reform activity while stimulating formal coalition development. In turn, coalition development, but not more general reform activity, influenced health care reform legislation in the case of one of the three policies under investigation. For the other two types of legislation, business interests, state interests, and state capacities, all contributed to progress toward passage. These findings confirm the wisdom of the recent emphasis on exploring various theories of the state as complementary. [ABSTRACT FROM AUTHOR]

In this paper, I examine the notion of accountability and its historical evolution in health care. Using medical mistakes and adverse patient outcomes as my focus, I examine the interests served by particular models of accountability and argue for a model of collective fiduciary responsibility in U.S. health care today. [ABSTRACT FROM AUTHOR]

Past research has demonstrated that the majority of the American public favor some form of national health insurance (NHI), but the sources of this support have not been clearly identified. This paper shows that support for NHI follows party lines, with Democrats most favoring it, followed by Independents and Republicans. The young, women, blacks, the less educated (among others) also favor NHI more than others, but it is apparently not a "personal need" for the insurance that prompts this support. Lack of adequate insurance coverage, dissatisfaction with current care, or poor access to health care are not associated with support for NHI. Instead, cognizance of the larger socioeconomic issues (particularly rising society-wide health care costs), in addition to political identification, generates support for NHI. [ABSTRACT FROM AUTHOR]

Mental health legislation in California brought about radical changes in commitment procedures. This paper describes the strains mental health personnel experienced in implementing the new law and proposes ways to manage such strains. [ABSTRACT FROM AUTHOR]

The article presents information on effectiveness of social work in meeting mental health needs. Psychiatric social workers in large numbers work closely with psychiatrists, psychologists, nurses, and others in the treatment of the ill. With regard to detection of those becoming ill and community activities to promote mental health, the total social work profession is focally and extensively involved. The concern of this paper, after noting the size and nature of the problem, is to suggest some ways of increasing social work's effectiveness in dealing with it. A few nationwide statistics will serve to indicate the size of the problem of treating the mentally ill. Figures for 1958 show that of the 6,786 hospitals of all types in the United States, 518 are psychiatric. In any year, the mental hospitals care for about 1,070,000 different persons, there are also upward of 60,000 patients in institutions for the mentally retarded. Social workers can extend the social dimensions in mental health work by discreetly extending their own roles to include those of consultant and educator. Even concepts of mental illness and mental health are changing, with accentuation of social factors. The ill or maladjusted person is seen as a product of social and societal forces as well as of organic pathology or intrapsychic conflicts.

Objectives Most older adults with dementia are assisted by multiple caregivers, but the relationship of care network structure with health care access and quality is underexamined. We sought to test the associations of care network characteristics with the physician visit experience for older adults with dementia across diverse racial/ethnic groups. Methods We used data on Medicare beneficiaries (aged 65+) with dementia from the National Health and Aging Trends Study (2015–2019) to fit logistic regression models to test associations between physician visit outcomes and (a) size of the potential care network and (b) proportion of potential care network members (PCNMs) currently helping with daily functioning tasks. We also tested for modifications by race/ethnicity. Results Hispanic respondents had the largest potential care networks (M = 6.89, standard deviation [ SD ] = 3.58) and the smallest proportion of PCNMs providing help with daily functioning (M = 29.89%, SD = 22.29). In models adjusted for demographics and dementia classification, both network size and proportional involvement of PCNMs were positively associated with the presence of a PCNM and assistance during the visit. Associations remained significant at 4-year follow-up for the presence of PCNM at the visit and were robust to further adjustments for insurance type, income, and health factors. Associations were not modified by race/ethnicity. Discussion Larger networks and a higher proportion of PCNMs providing assistance predicted caregiver presence and assistance at the physician visit but not access to care. Findings suggest that strengthening care networks early in the disease may support improved health care outcomes for persons with dementia across diverse populations. [ABSTRACT FROM AUTHOR]

Older adults in North America face similar challenges to successful ageing as other adults around the world, including an increased risk of geriatric syndromes and functional decline, limited access to healthcare professionals specialising in geriatrics and constraints on healthcare spending for Long-Term Services and Supports. Geriatrics as a specialty has long been established, along with the creation of a variety of screening tools for early identification of geriatric syndromes. Despite this, workforce shortages in all older adult care service areas have led to significant gaps in care, particularly in community settings. To address these gaps, innovative programs that expand the reach of geriatric specialists and services have been developed. Opportunities exist for further dissemination of these programs and services, as well as for expansion of an ageing capable workforce. [ABSTRACT FROM AUTHOR]

Background: Using billing data generated through health care delivery to identify individuals with dementia has become important in research. To inform tradeoffs between approaches, we tested the validity of different Medicare claims-based algorithms.Methods: We included 5 784 Medicare-enrolled, Health and Retirement Study participants aged older than 65 years in 2012 clinically assessed for cognitive status over multiple waves and determined performance characteristics of different claims-based algorithms.Results: Positive predictive value (PPV) of claims ranged from 53.8% to 70.3% and was highest using a revised algorithm and 1 year of observation. The tradeoff of greater PPV was lower sensitivity; sensitivity could be maximized using 3 years of observation. All algorithms had low sensitivity (31.3%-56.8%) and high specificity (92.3%-98.0%). Algorithm test performance varied by participant characteristics, including age and race.Conclusion: Revised algorithms for dementia diagnosis using Medicare administrative data have reasonable accuracy for research purposes, but investigators should be cognizant of the tradeoffs in accuracy among the approaches they consider. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to determine the extent that physical function discrete data elements (DDE) documented in electronic health records (EHR) are complete within pediatric rehabilitation settings. Methods: A descriptive analysis on completeness of EHR-based DDEs detailing physical functioning for children with cerebral palsy was conducted. Data from an existing pediatric rehabilitation research learning health system data network, consisting of EHR data from 20 care sites in a pediatric specialty health care system, were leveraged. Completeness was calculated for unique data elements, unique outpatient visits, and unique outpatient records. Results: Completeness of physical function DDEs was low across 5766 outpatient records (10.5%, approximately 2 DDEs documented). The DDE for Gross Motor Function Classification System level was available for 21% (n = 3746) outpatient visits and 38% of patient records. Ambulation level was the most frequently documented DDE. Intercept only mixed effects models demonstrated that 21.4% and 45% of the variance in completeness for DDEs and the Gross Motor Function Classification System, respectively, across unique patient records could be attributed to factors at the individual care site level. Conclusion: Values of physical function DDEs are missing in designated fields of the EHR infrastructure for pediatric rehabilitation providers. Although completeness appears limited for these DDEs, our observations indicate that data are not missing at random and may be influenced by system-level standards in clinical documentation practices between providers and factors specific to individual care sites. The extent of missing data has significant implications for pediatric rehabilitation quality measurement. More research is needed to understand why discrete data are missing in EHRs and to further elucidate the professional and system-level factors that influence completeness and missingness. Impact: Completeness of DDEs reported in this study is limited and presents a significant opportunity to improve documentation and standards to optimize EHR data for learning health system research and quality measurement in pediatric rehabilitation settings. [ABSTRACT FROM AUTHOR]

The objective of this article was to examine the impact on patient care of the growing economic forces in pain medicine. Chronic pain is a growing problem in the United States, as more people seek treatment than ever before. The practice of pain medicine is influenced by many market forces, including industry relationships with pain providers, lawmakers and insurance companies, direct-to-consumer advertising, insurance reimbursement patterns, and competition among health care systems and pain management providers. These economic factors can encourage innovation and efficiency and may increase access to pain treatment. However, they have also resulted in unrealistic expectations for pain relief, increased reliance on medications, widespread use of inadequately tested or unnecessary pain management diagnostic and treatment techniques, decreased use of some effective treatments, and lack of adequate pain education. Patients are undergoing more treatments, but there is little evidence of overall improved function. Following guidelines set out by the industry and pain medicine organizations, safeguarding against false or incomplete advertising, establishing easier methods for questioning advertising content, increasing the practice of evidence-based medicine, increasing government-sponsored research of definitive studies, and improving communication of efficacious treatment will facilitate the practice of ethical pain medicine and improve patient care. [ABSTRACT FROM AUTHOR]

The delivery of medical care services in U.S. nursing homes (NHs) is dependent on a workforce that comprises physicians, nurse practitioners, and physician assistants. Each of these disciplines operates under a unique regulatory framework while adhering to common standards of care. NH provider characteristics and their roles in NH care can illuminate potential links to clinical outcomes and overall quality of care with important policy and cost implications. This perspective provides an overview of what is currently known about medical provider practice in NH and organizational models of practice. Links to quality, both conceptual and established, are presented as is a research and policy agenda that addresses the gaps in the evidence base within the context of our ever-changing health care landscape. [ABSTRACT FROM AUTHOR]

This essay traces the evolution of the motto "health is wealth" from its origins as an anticapitalist argument made by antebellum sanitary reformers to its acceptance as a fundamental principle of organized public health in the United States. Sanitarians originally coined the phrase "health is wealth" to counter the capitalist maxim "labor is wealth." Because city leaders were businessmen who understood economic arguments, public health reformers increasingly gave health a monetary value in order to win over this audience and change urban governance. Although "health is wealth" momentarily co-opted the logic of capitalism in order to successfully make the case for institutionalizing public health within municipal and state governments, the phrase ultimately wrote economic values into the purpose and functions of public health boards and departments. In the course of advancing a proactive public health that prevented both endemic and epidemic diseases, sanitarians reduced the perception of health from a common good to a commodity. The economic logic employed by early reformers is critical, not only for understanding how the long reach of early American capitalism touches us today but also for recognizing that modern public health functions in the way it was created, as a capitalist system. [ABSTRACT FROM AUTHOR]

The Medicare Catastrophic Care Act (MCAA) of 1988 (P.L. 100-360) was the first major expansion of Medicare since its inception in 1965. Just after the legislation passed, controversy erupted, leading to the eventual repeal of most parts of the act. Using two levels of analysis, a structural elite model and a pluralist politics model, this paper demonstrates how, contrary to dominant health policy formation theories, old-age interest groups influenced the policymaking process surrounding MCCA. The importance of the transformative capacity of policy structures is emphasized in arguing that the only structural change embodied in the legislation—a departure from the social insurance model of Medicare financing—was the catalyst for mobilizing financial interests among some old-age interest groups. This mobilization resulted in a cleavage between various old-age interests, and the eventual repeal of the legislation. [ABSTRACT FROM AUTHOR]

ABSTRACT This paper highlights the temporal aspects of social accessibility, demonstrating that time is a major dimension of social organization along which both privacy and professional commitments are defined in modern society. An analysis of the temporal structure of professional commitments within the domain of health care, leads to the claim that the temporally rigid way in which most professional commitments are defined today is one of the key characteristics of modern social organization. A general conceptual scheme, constructed around the temporal structure of social accessibility, is evaluated in terms of its use in helping us identify and differentiate various occupational roles as well as various status rankings within stratification systems. The symbolic significance of the temporal organization of social accessibility is stressed-both in general, and for professional commitments in particular. [ABSTRACT FROM AUTHOR]

Examines the effectiveness of health-based intervention for smoking cessation in the U.S. Increase integration of proven cessation treatments into healthcare delivery; Release of the clinical practice guideline from the Agency for Healthcare Research; Promotion of hospital policies and provision of smoking-cessation services.

Research seeking to improve patient engagement with decision-making, use of evidence-based guidelines, and coordination of multi-specialty care has made important contributions to the decades-long effort to improve cancer care. The National Cancer Institute expanded support for these efforts by including cancer care delivery research in the 2014 formation of the National Cancer Institute Community Oncology Research Program (NCORP). Cancer care delivery research is a multi-disciplinary effort to generate evidence-based practice change that improves clinical outcomes and patient well-being. NCORP scientists and community-based clinicians and organizations rapidly embraced the addition of this type of research into the network, resulting in a robust portfolio of observational studies and intervention studies within the first 5 years of funding. This commentary describes the initial considerations in conducting this type of research in a network previously focused on cancer prevention, control, and treatment studies; characterizes the protocols developed to date; and outlines future directions for cancer care delivery research in the second round of NCORP funding. [ABSTRACT FROM AUTHOR]

The article reports on the move of the U.S. Congress to give health care providers extra time to ensure that written prescriptions for Medicaid patients come from tamper-resistant Medicaid prescriptions. According to a national survey of 407 physicians, 79 percent of them wrote new prescriptions on paper and handed them to patients. Meanwhile, less than 10 percent of the physicians transmit prescriptions electronically by a computer or hand-held device.

In recent years, the applications of Machine Learning (ML) in the health care delivery setting have grown to become both abundant and compelling. Regulators have taken notice of these developments and the U.S. Food and Drug Administration (FDA) has been engaging actively in thinking about how best to facilitate safe and effective use. Although the scope of its oversight for software-driven products is limited, if FDA takes the lead in promoting and facilitating appropriate applications of causal inference as a part of ML development, that leadership is likely to have implications well beyond regulated products. [ABSTRACT FROM AUTHOR]

Background The American Indian (AI) population experiences significant diet-related health disparities including diabetes and cardiovascular disease (CVD). Owing to the relatively small sample size of AIs, the population is rarely included in large national surveys such as the NHANES. This exclusion hinders efforts to characterize potentially important differences between AI men and women, track the costs of these disparities, and effectively treat and prevent these conditions. Objective We examined the sex differences in diabetes prevalence, comorbidity experience, health care utilization, and treatment costs among AIs within a Northern Plains Indian Health Service (IHS) service unit. Methods We assessed data from a sample of 11,144 persons using an IHS service unit in the Northern Plains region of the United States. Detailed analyses were conducted for adults (n  = 7299) on prevalence of diabetes by age and sex. We described sex differences in comorbidities, health care utilization, and treatment costs among the adults with diabetes. Results In our sample, adult men and women had a similar prevalence of diabetes (10.0% and 11.0%, respectively). The prevalence of CVD among men and women with diabetes was 45.7% and 34.0%, respectively. Among adults with diabetes, men had a statistically higher prevalence of hypertension and substance use disorders than women. The men were statistically less likely to have a non–substance use mental health disorder. Although men had higher utilization and costs for hospital inpatient services than women, the differences were not statistically significant. Conclusions In this AI population, there were differences in comorbidity profiles between adult men and women with diabetes, which have differential mortality and cost consequences. Appropriate diabetes management addressing gender-specific comorbidities, such as substance use disorders for men and non–substance use mental health disorders for women, may help reduce additional comorbidities or complications to diabetes. [ABSTRACT FROM AUTHOR]

Providers inconsistently provide recovery-oriented services to adults with serious mental illness despite US federal mandate. An online randomised factorial survey was used to identify and evaluate predictors of social workers' degree of endorsement of recovery-oriented service provision. Respondents (N  = 107) each rated scale items indicating support for recovery-oriented services for four client vignettes (n  = 398) and completed standardised measures of recovery knowledge and expectations. The final predictive model was significant (p < 0.0001), accounting for 61 per cent of the variance of the degree of endorsement of recovery-oriented services. Recovery knowledge explains the largest portion of the variance, followed by psychotic symptoms. The finding that client characteristics predict endorsement of recovery-oriented services suggests a fundamental misunderstanding of recovery. Recommendations include training and supervision to enhance application of recovery-oriented principles to service provision. [ABSTRACT FROM AUTHOR]

Maintaining body temperature is a unique challenge with burn care. We sought to describe core temperature goals in the operating room (OR) and the methods used to achieve and maintain these goals, along with current methods of warming in the intensive care unit (ICU), the perception of effect of increased ambient temperature on work performance, and concerns with contamination of sterile fields due to increased ambient temperature. A 24 question survey was disseminated to burn centers in the United States and Canada. The questions included demographics, target core and ambient temperatures, warming methods, and beliefs on ambient temperature's effects. Of 121 burn centers, 52 questionnaires were completed (43% response rate). The majority of centers targeted a core temperature between 36 and 38°C in the OR and an ambient temperature between 75 and 95°F in the ICU. The most common methods for maintaining core temperature included warmed ambient temperature, forced air devices, and intravenous fluids. Although the majority of centers reported the belief that increased ambient temperature benefits patients, many also reported that there is a negative impact on staff performance and risk of staff perspiration contaminating sterile fields. Burn centers reported a range of target core temperatures and methods to reach target temperatures. More than a third of respondents perceived a negative impact work performance while more than half acknowledged the potential for contamination of sterile fields. A prospective observational study is needed to determine actual temperature regulation practice patterns and its impact on outcomes. [ABSTRACT FROM AUTHOR]

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, type IV hypersensitivity reactions of the skin and mucosa. These reactions (SJS/TEN) are frequently managed in burn units; however, no standardized guidelines exist for the treatment and management of SJS/TEN. To gain insight into current SJS/TEN management practices, a survey on admission, diagnosis, and management, was conducted across accredited burn units in the United States. A 28-item question survey on SJS/TEN management, diagnosis, and treatment practices was distributed among medical directors and co-directors of American Burn Association-verified burn centers. Responses were collected over a 6-week period. In total, 31 (48% response rate) burn unit medical directors/co-directors participated in the survey. The majority of responders indicate that acceptance to their burn unit is based on clinical suspicion of SJS/TEN (74%), and biopsy or dermatological evaluation is not required (67 and 87%, respectively). More than half (61%) of the burn units have their own SJS/TEN protocol in place. No consensus was observed on different treatment aspects, such as infection control, systemic treatment, and wound care. Most directors reported their burn units to consult ophthalmology (77%) and dermatology (54%) for the management of patients with SJS/TEN. Large variability in procedures of admission, treatment, and management of SJS/TEN was identified across burn centers. This study demonstrates the urgent need for SJS/TEN standardized guidelines in the United States. [ABSTRACT FROM AUTHOR]

Background: The quality of healthcare in the US has been progressively addressed by 3 reports from the National Academy of Medicine, the latest of which, entitled "Improving Diagnosis in Health Care," was issued in 2015 from a 21-member panel (the author of this report was a member). The report is a review of the longstanding problem of diagnostic error. The infrastructure of healthcare delivery in the US has inadvertently made diagnostic error a major contributor to the high cost of care and preventable poor patient outcomes. Content: This review describes the failures in US healthcare delivery that have led to the overwhelming number of deaths attributable to diagnostic error. Each failure is associated with recommendations to eliminate it. The review begins with a description of the scope of the diagnostic error problem and then discusses each of the issues that need to be addressed to reduce the number of misdiagnoses. Summary: The problem of diagnostic error in the US is a large one. Some the contributing factors to this large problem can be resolved at a small expense and with modest change; others require a major overhaul of aspects of medical practice. For the first time, Americans have a "to-do list" to reduce our diagnostic error problem and be on par with other developed countries that are recognized as providing less costly care with better patient outcomes. [ABSTRACT FROM AUTHOR]

The authors comment on an article by Dr. M. Laposata on the definition and scope of diagnostic error in the U.S. Topics discussed include significant cause of diagnostic error related to laboratory services, the goals enumerated by Dr. Laposata to address the problems of diagnostic error in the U.S. healthcare, and significance of stewardship programs to the goals listed by Dr. Laposata.

We study contracting between a consumer and an expert in a credence goods model when: (i) the expert's choice of diagnosis effort is not observable; (ii) the expert might misrepresent his private information about the adequate treatment; and (iii) payments can depend only on the consumer's subjective evaluation of treatment success. We show that the first‐best solution can always be implemented if the parties’ discount factor is equal to one; a decrease in the discount factor makes obtaining the first‐best more difficult. The first‐best is also always implementable if separation of diagnosis and treatment is possible. [ABSTRACT FROM AUTHOR]

For 40 years, the Tuskegee Study of Untreated Syphilis in the Negro Male passively monitored hundreds of adult black men with syphilis despite the availability of effective treatment. The study's methods have become synonymous with exploitation and mistreatment by the medical profession. To identify the study's effects on the behavior and health of older black men, we use an interacted difference-in-difference-in-differences model, comparing older black men to other demographic groups, before and after the Tuskegee revelation, in varying proximity to the study's victims. We find that the disclosure of the study in 1972 is correlated with increases in medical mistrust and mortality and decreases in both outpatient and inpatient physician interactions for older black men. Our estimates imply life expectancy at age 45 for black men fell by up to 1.5 years in response to the disclosure, accounting for approximately 35% of the 1980 life expectancy gap between black and white men and 25% of the gap between black men and women. JEL Codes : I14, O15. [ABSTRACT FROM AUTHOR]

Background: Short-term medical missions (STMMs) have increased and are viewed as a way to extend care in low- and middle-income countries (LMICs). Although benefits may exist, visiting teams may lack insight into using medications safely and effectively. The primary objective was to assess prescribing differences between US-based and Dominican Republic (DR) healthcare providers on STMMs in the DR. Methods: A retrospective database review between January 2013 and 2015 was conducted. Data from US and DR groups were compared for differences in diagnoses, medication classes prescribed and prescriptions per patient. Results: The mean number of medical conditions diagnosed per patient in the DR (n=423) and US groups (n=1585) were 1.4±0.9 and 1.0±0.8, respectively. The diagnosis of infectious diseases was the same as noncommunicable diseases. The DR group prescribed more medications at each patient encounter (mean 2.6 vs 2.2, respectively; p<0.001). The US group prescribed more antibiotics for respiratory infections (US 46.2% vs DR 25.0%; p=0.0001), used more metronidazole than albendazole alone for parasite infections (p=0.0022) and used more oral fluconazole for vaginal candidiasis (p<0.0001) and tinea infections (US 44.6%, DR 14.3%, respectively; p=0.0020). Conclusions: Although some significant prescribing differences exist between US and DR providers, many similarities were present. Visiting providers should understand the medication use system and disease burden before providing care in an LMIC. [ABSTRACT FROM AUTHOR]

An introduction is presented in which the author discusses various reports within the issue on topics including history of childbirth in the U.S, the benefits and limitations of medical intervention and technology in birth, and status of women as providers of their own maternity care.