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Health care report cards improve information and are a crucial part of health care reform of the federal government of the United States. I exploit a natural experiment in the home health sector to assess whether a higher rating under the star ratings program affects patient choice. Higher rated agencies increased their market share by 1.4% or 0.25 (95% confidence interval: [−0.63, 1.12]) percentage points, a practically and statistically insignificant amount. I find no evidence of heterogeneous effects across the rating distribution or over time. I also find precise null effects among consumers expected to be more responsive, including community-entry patients and patients in competitive markets with more options and star types. Agencies may have modestly impeded consumer choice by engaging in some patient selection behaviors, although the evidence is only weakly suggestive. The star ratings are unlikely to improve home health quality despite continued policymaker interest. [ABSTRACT FROM AUTHOR]

Transplantation is a high‐risk, high‐cost treatment for end‐stage diseases and is the most strictly regulated area of healthcare in the United States. Thus, achieving success for patients and the program requires skillful and collaborative leadership. Various factors, such as outcomes, volume, and financial health, may measure the success of a transplant program. Strong collaboration between clinical and administrative leaders is key to achieving and maintaining success in those three categories. Clinical leaders of adult programs, such as medical and surgical directors, bear the primary responsibility for a program's volume, outcomes, and patient safety, while administrative directors are focused on business intelligence and regulatory compliance. This paper aims to provide readers with insights into the critical role of collaborative leadership in running a successful program, with a focus on clinical, business, and regulatory perspectives. [ABSTRACT FROM AUTHOR]

Based on published evidence and our expert experience, we provide recommendations to maximize the efficacy, safety, efficiency, andcost-effectiveness of routine colonoscopy. High-quality colonoscopy begins with colon preparationusing a split or same-day dose and preferably a low-volume regimen for optimal patient tolerance and compliance. Successful cecal intubation can be achieved by choosing the correct colonoscope and using techniques to facilitate navigation through challenges such as severe angulations and redundant colons. Safety is a primary goal, and complications such as perforation and splenic rupture can be prevented by avoiding pushing through fixed resistance and avoiding loops in proximal colon. Furthermore, barotrauma can be avoided by converting to water filling only (no gas insufflation) in every patient with a narrowed, angulated sigmoid. Optimal polyp detection relies primarily on compulsive attention to inspection as manifested by adequate inspection time, vigorous probing of the spaces between haustral folds, washing and removing residual debris, and achieving full distention. Achieving minimum recommended adenoma detection rate thresholds (30% in men and 20% in women) is mandatory, and colonoscopists should aspire to adenoma detection rate approaching 50% in screening patients. Distal attachments can improve mucosal exposure and increase detection while shortening withdrawal times. Complete resection of polyps complements polyp detection in preventing colorectal cancer. Cold resection is the preferredmethod for all polyps<10mm. For effective cold resection, an adequate rim of normal tissue should be captured in the snare. Finally, cost-effective high-quality colonoscopy requires the procedure not be overused, as demonstrated by following updated United States Multi Society Task Force on Colorectal Cancer postpolypectomy surveillance recommendations. [ABSTRACT FROM AUTHOR]

The extent to which mental health services for youths embody system-of-care (SOC) principles is an important quality indicator. This study tested whether youth and family experiences of SOC principles varied depending on youths' level of need after adjusting for sociodemographic and treatment factors. The relationship to caregiver-reported clinical outcomes was also examined. Using administrative data and cross-sectional surveys from a stratified random sample of 1124 caregivers of youths ages 5–20 within a statewide system, adjusted analyses indicated caregivers of youths with the most intensive needs were significantly less likely to report receiving care that embodied SOC principles, with deficits on six of nine items. Youths whose services embodied SOC principles experienced significantly greater improvement in caregiver-reported functioning even after adjusting for level of need. Results highlight disparities in SOC principles for youths with intensive needs and the need for policy and intervention development to improve care for this population. [ABSTRACT FROM AUTHOR]

Political appetite for neoliberal education policy has problematised teacher education in a number of countries, including Australia, the US and England. In Australia, dominant policy discourses of quality normalise the regulation and standardisation of teacher education and position teacher educators within a deficit model of education reform. Such positioning has been shown to have a deleterious impact on professional status, dismantling complex conceptualisations of teacher educators' work. Framed by key tenets of positioning theory and conceptualisations of policy enactment, this study investigated, using online semi-structured interviews, the ways in which 16 teacher educators in one Australian university positioned policy as "other", and the ways in which they felt they could or should respond. It found that teacher educators position policy, and engage in the policy process, in complex and varied ways. While many positioned policy as an intruder, with the potential to do harm to the profession, others had made choices that positioned policy as a tool for innovative imagining for programme renewal. Findings also highlight the potential appetite for collaborative positioning between policy makers and teacher educators as partners. These findings have significant implications for future approaches to re-shaping the teacher education policy space both in Australia and beyond. [ABSTRACT FROM AUTHOR]

Understanding approaches to sustainability in cataract surgery and their risks and benefits. In the United States, health care is responsible for approximately 8.5% of greenhouse gas (GHG), and cataract surgery is one of the most commonly performed surgical procedures. Ophthalmologists can contribute to reducing GHG emissions, which lead to a steadily increasing list of health concerns ranging from trauma to food instability. We conducted a literature review to identify the benefits and risks of sustainability interventions. We then organized these interventions into a decision tree for use by individual surgeons. Identified sustainability interventions fall into the domains of advocacy and education, pharmaceuticals, process, and supplies and waste. Existing literature shows certain interventions may be safe, cost-effective, and environmentally friendly. These include dispensing medications at home to patients after surgery, multi-dosing appropriate medications, training staff to properly sort medical waste, reducing the number of supplies used during surgery, and implementing immediate sequential bilateral cataract surgery where clinically appropriate. The literature was lacking on the benefits or risks for some interventions, such as switching specific single-use supplies to reusables or implementing a hub-and-spoke–style operating room setup. Many of the advocacy and education interventions have inadequate literature specific to ophthalmology but are likely to have minimal risks. Ophthalmologists can engage in a variety of safe and effective approaches to reduce or eliminate dangerous GHG emissions associated with cataract surgery. Proprietary or commercial disclosure may be found after the references. [ABSTRACT FROM AUTHOR]

Primary care physicians (PCPs) play an indispensable role in providing comprehensive care and referring patients for specialty care and other medical services. As the COVID-19 outbreak disrupts patient access to care, understanding the quality of primary care is critical at this unprecedented moment to support patients with complex medical needs in the primary care setting and inform policymakers to redesign our primary care system. The traditional way of collecting information from patient surveys is time-consuming and costly, and novel data collection and analysis methods are needed. In this review paper, we describe the existing algorithms and metrics that use the real-world data to qualify and quantify primary care, including the identification of an individual's likely PCP (identification of plurality provider and major provider), assessment of process quality (for example, appropriate-care-model composite measures), and continuity and regularity of care index (including the interval index, variance index and relative variance index), and highlight the strength and limitation of real world data from electronic health records (EHRs) and claims data in determining the quality of PCP care. The EHR audits facilitate assessing the quality of the workflow process and clinical appropriateness of primary care practices. With extensive and diverse records, administrative claims data can provide reliable information as it assesses primary care quality through coded information from different providers or networks. The use of EHRs and administrative claims data may be a cost-effective analytic strategy for evaluating the quality of primary care. [ABSTRACT FROM AUTHOR]

Aims: To assess the impact of community‐level characteristics on the role of magnet designation in relation to hospital value‐based purchasing quality scores, as health disparities associated with geographical location could confound hospitals' ability to meet outcome metrics. Design: This cross‐sectional study was carried out between October 2021 and March 2022 using data from 2016 to 2021. Methods: Propensity score analysis was used to match hospital and community‐level characteristics, implementing nearest neighbour matching to adjust for pre‐treatment differences between magnet and non‐magnet hospitals to account for multi‐level differences. Secondary data were obtained from all operational acute‐care facilities in the United States that participated in the Centers for Medicare and Medicaid Services' hospital value‐based purchasing (HVBP) program. Dependent variables were the four value‐based purchasing domains that comprise the Total Performance Score (TPS; Clinical Care, Person and Community Engagement, Safety, and Efficiency and Cost Reduction). Results: Magnet hospitals had increased odds for better scores in the HVBP domains of Clinical Care and Person and Community Engagement, and decreased odds for having better Safety. However, no statistically significant difference was found for the Efficiency domain or the TPS. Conclusion: Measuring performance equitably across organizations of various sizes serving diverse communities remains a key factor in ensuring distributive justice. Analysing the TPS components can identify complex influences of community‐level characteristics not evident at the composite level. More research is needed where community and nurse‐level factors may indirectly affect patient safety. Impact This study's findings on the role of community contexts can inform policymakers designing value‐based care programs and healthcare management administrators deliberating on magnet certification investments across diverse community settings. No patient or public contribution: For this study of US hospitals' organizational performance, we did not engage members of the patient population nor the general public. However, the multi‐disciplinary research team does include diverse perspectives. [ABSTRACT FROM AUTHOR]

The Scientific Registry of Transplant Recipients (SRTR) provides extensive data regarding the performance of various aspects of the national transplant system and a tier rating system that can aid patients in selecting their transplant center. The role of the SRTR is to provide clear, accurate, and timely information to regulatory agencies and transplant professionals, candidates, and recipients; live organ donors; donor families; and the general public. This overview provides basic information on the history and role of the SRTR, as well as changes made in response to the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

For more than 4 decades, adult day service centers (ADSCs) have provided long-term care services and socialization to hundreds of thousands of people in the United States. An important part of the long-term care continuum, ADSCs serve older adults and adults with disabilities, many of whom have low incomes and are racial and ethnic minorities. Yet, little is known about the quality of ADSCs. To better understand ADSC quality, we examined staffing levels, a key aspect of organizational structure. Staffing levels are an established quality measure associated with resident outcomes in nursing homes. Our study compares ADSC staffing levels between for-profit and nonprofit or government-operated ADSCs. Cross-sectional secondary data analysis using a nationally representative survey of ADSCs. Adult day service center (n = 573) directors completed a survey as part of the 2018 National Study of Long-Term Care Providers. Bivariate comparisons and multivariate linear regression were used to compare staffing, measured as hours per participant day in nonprofit and for-profit ADSCs. Approximately 60% of ADSCs in the sample were nonprofit or government-operated and the remainder were for-profit. For-profit ADSC staffing averaged 1.5 hours per participant day and nonprofit or government-operated ADSC staffing averaged 1.9 hours per participant day. For-profit ADSCs had 15.8% (P =.047) lower hours per participant day compared with nonprofit ADSCs after controlling for center characteristics, such as Medicaid use, participant acuity, and ADSC size. We found that for-profit ADSCs have lower staffing levels compared with nonprofit and government-operated ADSCs. Future research is needed to understand how staffing levels relates to the quality of care in for-profit and nonprofit ADSCs and how these relationships vary by participant characteristics, such as income, race/ethnicity, and acuity. [ABSTRACT FROM AUTHOR]

Background: State-level child care quality rating and improvement systems (QRIS) have been implemented in a majority of states in the U.S.A. One goal is to improve developmental outcomes for young children, especially from families with fewer resources. Research is needed to determine if QRIS can produce quality improvements that will support the development of children from birth to three years. Objective: Explore the association of toddlers' growth trajectories over two years with their participation in varying quality-rated levels of child care. Methods: In this two-year longitudinal study of 75 toddlers (M age = 15.5 months; SD = 2.36) children's cognitive and social-emotional growth trajectories were estimated in three assessments, 12 months apart. All toddlers were low-income Child Care and Development Fund voucher recipients, cared for by child care providers within a Midwestern state's voluntary QRIS. QRIS-rated child care quality, caregiver education level, and child–adult ratio were observed in parallel with individual cognitive and social-emotional child assessments. Growth analyses controlled for parent education, child race, ethnicity, disability status, and gender. Results: Toddlers who received care in settings rated highest by the QRIS and those with caregivers who had higher education levels progressed at significantly higher rates of development in early learning skills, compared with toddlers placed in QRIS-rated lower quality settings or with caregivers with less education. Conclusions: State-level QRIS have the potential to inform parents' and policymakers' decisions about child care quality associated developmental outcomes for children under three years of age. Especially important is the role of QRIS in incentivizing the educational preparation of toddler caregivers. [ABSTRACT FROM AUTHOR]

The National Cardiovascular Data Registry is a group of registries maintained by the American College of Cardiology Foundation. These registries are used by a diverse constituency to improve the quality and outcomes of cardiovascular care, to assess the safety and effectiveness of new therapies, and for research. To achieve these goals, registry data must be complete and reliable. In this article, we review the process of National Cardiovascular Data Registry data collection, assess data completeness and integrity, and report on the current state of the data. Registry data are complete. Accuracy is very good but variable, and there is room for improvement. Knowledge of the quality of data is essential to ensuring its appropriate use. [ABSTRACT FROM AUTHOR]

Introduction: Lower back pain (LBP) is the most common orthopedic complaint in the United States. Physical therapy is recommended as a conservative, non-pharmacological intervention for LBP. While it is thought that skill level and effectiveness of physical therapists differ, there is little understanding regarding characteristics that distinguish high and low performing physical therapists. The purpose of this study was to compare differences in care delivery, termed treatment signatures, between high and low performing physical therapists previously differentiated by a risk-adjusted performance measure.Methods: Using previously published methodology, 1,240 physical therapists were classified as "outperforming", "meeting expectations", or "underperforming" relative to predicted change in Modified Low Back Pain Disability Questionnaire (MDQ) across patients receiving care for LBP. Patients were divided into quartiles of baseline disability per initial MDQ. Two-way analyses of variance were used to compare billed (1) active, exercise-based units per visit (UPV), (2) manual therapy UPV, (3) modality UPV, and (4) the combination of active and manual therapy UPV (broadly termed skilled UPV) by performance cohort and baseline patient disability quartile among physical therapists deemed "outperforming" and "underperforming". Tukey's post hoc tests established mean differences with 95% confidence intervals.Results: Physical therapists that "outperformed" (n=120; 17,404 patients) used more active UPV (mean difference (diff) = 0.1, p<.001), manual therapy UPV (mean diff = 0.2, p<.001), and skilled UPV (mean diff = 0.3, p<.001), and less modality UPV (mean diff = 0.1, P < 0.001) than those that "underperformed" (n=139; 21,800 patients). Tukey's post hoc tests showed that while differences in care were negligible in patients with low baseline disability, the highest performing PT cohort delivered skilled (0.4 UPV), active (0.2 UPV), and manual therapy (0.2 UPV) UPV at a significantly higher mean rate in patients with the highest baseline disability.Conclusions: Clinically effective physical therapists incorporated a treatment signature that included a consistent blend of skilled active and manual therapy interventions that was distinct from lower performing physical therapists. While group mean differences were relatively small, a consistent pattern emerged in which high performing physical therapists maintained a high level of skilled, one-on-one interventions across their entire caseload-while their lower performing counterparts significantly decreased use of the same interventions as baseline disability increased. These differences highlighted a treatment signature that was associated with clinically important improvements for patients with greater baseline disability. Future guideline recommendations should consider the importance of baseline disability and the consistent application of skilled active and manual therapy interventions. [ABSTRACT FROM AUTHOR]

The diverse array of individuals who receive long-term services and supports share one common experience, which is the need for assistance with personal care and/or other daily activities. The direct care workers (including nursing assistants, home health aides, and personal care aides) who provide this assistance play a critical role in keeping individuals safe, supporting their health and well-being, and helping prevent adverse outcomes. Yet despite decades of research, advocacy, and incremental policy and practice reform, direct care workers remain inadequately compensated, supported, and respected. Long-standing direct care job quality concerns are linked to high turnover and job vacancy rates in this workforce, which in turn compromise the availability and quality of essential care for older adults and people with disabilities—which has never been more evident than during the COVID-19 pandemic. This special article makes the case for transforming direct care jobs and stabilizing this workforce as a centerpiece of efforts to reimagine long-term services and supports system in the United States, as a public health priority, and as a social justice imperative. Drawing on research evidence and examples from the field, the article demonstrates that a strong, stable direct care workforce requires: a competitive wage and adequate employment benefits for direct care workers; updated training standards and delivery systems that prepare these workers to meet increasingly complex care needs across settings, while also enhancing career mobility and workforce flexibility; investment in well-trained frontline supervisors and peer mentors to help direct care workers navigate their challenging roles; and an elevated position for direct care workers in relation to the interdisciplinary care team. The article concludes by highlighting federal and state policy opportunities to achieve direct care job transformation, as well as discussing research and practice implications. [ABSTRACT FROM AUTHOR]

What does it mean to be 'excellent', particularly for the higher education institution? Without a definitive answer to that question, university rankings have become a proxy for quality and excellence. As such, higher education institutions are continually seeking ways to improve their rankings, with the implication being that these rankings measure which universities are most excellent. Upper administrators from public four-year higher education institutions in the United States were surveyed regarding their perceptions of factors they considered most important when assessing quality in the higher education institution. Respondents rated graduation and retention as the most important indicator of quality. Survey results were further compared to methodologies of the US News and World Report rankings, Times Higher Education World University Rankings and Quacquarelli Symonds World University Rankings and found that the perceived quality factors identified by survey respondents did not align with methodologies for any of these three rankings. [ABSTRACT FROM AUTHOR]

Advance care planning is a conversation about personal values, future treatment choices, and designation of a surrogate decision-maker, that someone has in advance of a health crisis. Most existing studies on advance care planning have taken place outside of home health among populations with HIV/AIDS, cancer, dementia, and end stage renal disease. The U.S. home health population is living longer with chronic conditions such as pulmonary and cardiovascular illnesses, and hospitalization is a poor outcome. In 2016, Medicare implemented the Home Health Value-Based Purchasing Model, in which reimbursement rates for agencies in 9 regionally representative states were dependent on quantitative measures of quality performance. Part of the program was a process-level mandate requiring agencies to report on advance care planning. The aim of this study was to examine the relationship of home health advance care planning protocols with hospitalization rates. Descriptive and regression analyses were conducted on survey data of protocols and agency data of demographics and outcomes. Statistical significance was found in the positive correlation between advance care planning protocols and hospitalization. Recommendations are made for broadening the scope of evaluation of quality in home health to include goal-concordant care and transitions to appropriate services. [ABSTRACT FROM AUTHOR]

Background: Societal guidelines and payor coverage decisions for transcatheter aortic valve replacement (TAVR) attempt to strike a balance between providing access and maintaining quality. The extent to which dissemination of TAVR has achieved these ideals remains unknown.Objectives: This study sought to define patterns of TAVR dissemination in the United States and their influence on outcomes.Methods: Using data from the TVT (Transcatheter Valvular Therapy) registry, this study identified TAVR sites from 2011 to 2018 and calculated drive-times from existing to new sites. In a contemporary cohort, this study compared site and patient characteristics by annual case volume and density of sites per million Medicare beneficiaries. Using hierarchical regression and Cox methods, this study determined the association between case volumes, site density, and changes in volume and density with patient risk profiles and outcomes.Results: TAVR sites participating in the TVT registry increased from 198 to 556 from 2011 to 2018. Median drive-time from existing to new sites decreased from 403 minutes (interquartile range: 211-587 minutes) to 26 minutes (interquartile range: 17-48 minutes). In a contemporary cohort, higher site density was associated with lower procedural risk as well as with an increased hazard of 30-day risk-adjusted mortality (P = 0.017). Similarly, longitudinal increases in site density over time were associated with a higher hazard of 30-day (P = 0.011) and 1-year (P = 0.013) mortality.Conclusions: TAVR has expanded significantly over time, but with regional clustering of sites. Although procedural risk is lower at higher density sites, these sites demonstrate an increased hazard of mortality. These findings suggest that the expansion of TAVR services in the United States may have had unintended consequences on procedural quality. [ABSTRACT FROM AUTHOR]

Approximately 1%-2% of hospitalizations in the United States result in an against medical advice discharge. Still, the practice of discharging patients against medical advice is highly subjective and variable. Discharges against medical advice are associated with physician distress, patient stigma, and adverse outcomes, including increased morbidity and mortality. This review summarizes discharge against medical advice research, proposes a definition for against medical advice discharge, and recommends a standard approach to a patient's request for discharge against medical advice. [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]

Production of artisan cheeses, including surface-ripened cheeses, has increased in the United States over the past 2 decades. Although many of these cheesemakers report unique quality and spoilage problems during production, a systematic assessment of the quality concerns facing this sector of specialty cheese production has not been conducted. Here we report the effects of microbial spoilage and quality issues on US artisan cheese production. In a survey of 61 cheesemakers, the most common issues reported were undesirable surface molds (71%) and incorrect or unexpected colors or pigments on rinds (54%). When asked, 18% of participants indicated that they were extremely concerned about quality and spoilage problems, and they indicated that their quality standards are frequently not met, either annually (39%) or monthly (33%). Although most of the respondents (62%) said that just 0 to 5% of their cheese was lost or rendered less valuable due to quality issues annually, a small number (7% combined) reported large losses of 20 to 30% or >30% of their product lost or rendered less valuable. Almost all respondents (95%) agreed that improved quality would reduce waste, increase profits, and improve production. The survey respondents indicated in open response questions that they want access to more online resources related to quality issues and digital forums to discuss issues with experts and peers when problems arise. These findings represent the first attempt to document and estimate the effect of quality and spoilage on the American artisan cheese industry. Future work should investigate what technologies, interventions, or information could reduce losses from these problems. [ABSTRACT FROM AUTHOR]

It is unknown which procedures account for the most US dental opioid prescriptions. Moreover, few national studies have assessed opioid prescribing patterns for these procedures. These knowledge gaps impede the optimal targeting of dental opioid stewardship initiatives. The authors analyzed claims data from the 2013 through 2018 IBM MarketScan Dental, Commercial, and Medicaid Multi-State Databases. Patients aged 13 through 64 years undergoing 1 of 120 procedures were identified. "Initial prescriptions" were opioid prescriptions dispensed on the date of procedures to 3 days afterward. For the procedures accounting for the 5 highest proportions of initial prescriptions, the authors fitted linear regression models assessing trends in the probability of 1 or more initial prescriptions and mean total morphine milligram equivalents prescribed—a standardized measure of opioid amount. Regressions were adjusted for demographic characteristics and comorbidities. The 9,482,976 procedures in the sample were associated with 2,721,688 initial prescriptions. Of these prescriptions, 5 procedures accounted for 95.2%: tooth extraction (65.2%), problem-focused limited oral evaluation (17.2%), endodontic therapy (8.4%), alveoloplasty (2.9%), and surgical implant services (1.5%). Among the 5 procedures, the median adjusted annual change in the probability of 1 or more initial prescriptions was −1.3 percentage points. The median adjusted annual change in mean total morphine milligram equivalents was −4.5 (roughly 1 pill containing 5 mg of hydrocodone). In 2018, 45.3% of tooth extractions resulted in 1 or more initial prescriptions. Five procedures accounted for 95.2% of dental opioid prescriptions, and tooth extraction accounted for almost two-thirds of those. Opioid prescribing for tooth extractions is declining but remains common, despite the availability of equally effective nonopioid alternatives. Eliminating routine opioid prescribing for tooth extraction could reduce dental opioid exposure substantially. [ABSTRACT FROM AUTHOR]

Scientific interest in cheese crystals extends back more than a century. However, starting around the 1970s, industry interest, and interest on the part of cheese scientists, grew dramatically as changes in cheesemaking technology and market changes caused the presence of crystals in the marketplace to increase; advanced analytical capabilities enabled new crystalline species to be identified, their origins and causative factors to be elucidated, and their contributions to cheese texture to be better understood. It is now evident that a host of organic- and inorganic-based crystals occur in natural cheeses. Some crystals form preferentially at the surface of rindless or rinded cheeses, others in the irregular openings or spherical eyes that occur within the body of some cheeses, and still others embedded within the cheese matrix. It is also evident that crystals may profoundly influence cheese texture, both as a direct consequence of their abundance, size, shape, and hardness, and as an indirect result of cascading physiochemical events initiated by crystal formation. Consumer response to increased incidence of crystals in the marketplace has been mixed. On the one hand, surface crystals of calcium lactate pentahydrate on Cheddar cheese came to be viewed quite negatively in some markets, often being mistaken for mold growth and spoilage. This triggered industry concern and led to considerable research to determine the underlying causes and to develop strategies to limit or prevent calcium lactate pentahydrate formation. At the same time, other forms of crystallization increasingly came to be viewed as positive features in the growing market dedicated to artisanal and traditional cheeses, giving rise to a bifurcated consumer response to cheese crystals that is evident today. Traditional artisanal cheesemakers perhaps have the most to gain from advances in cheese-crystal research. Traditional artisanal cheeses rely heavily on stories that are weaved around their identity to create uniqueness and add value. A challenge and opportunity for these cheesemakers in the United States and globally will be to translate the fascinating science of their cheese crystals into engaging narratives that capture the imagination, add value to their cheese, and enhance the enjoyment of their cheese by consumers. [ABSTRACT FROM AUTHOR]

Background: This study evaluated the readability and quality of information regarding arteriovenous (AV) fistula for dialysis on the Internet in the English language.Study Design: Using Google© search, the keywords "AV Fistula for dialysis" were searched. The top 75 ranking sites were analyzed. One website was excluded due to repetition. Each landing page was assessed independently by two authors (RB, LR) for readability using the Flesch Reading Ease Score (FRES) and Gunning Fog Index (GFI). Web site quality was assessed using the DISCERN instrument. The individual position of the top 15 websites in the search engine ranking order list was noted. The country of origin, organization type and issuance of Health on the Net (HoN) Certification was recorded. Statistical analyses were performed using unpaired t-tests and ANOVA variance.Results: The mean GFI score was 9.2 and the mean FRES score was 50.6, indicating poor readability. The mean DISCERN score was 48.4, indicating weak quality of websites. Website quality was influenced by the academic/healthcare organization type (p = 0.012). Organization type was not found to impact GFI and FRES scores. Presence of a HoN Certification was not found to impact the quality of information. The majority of sites originated from the United States (61%).Conclusion: Our study demonstrates that internet information pertaining to AV fistula for dialysis is of poor quality necessitating improvements to readability and overall website quality to improve the patient experience. Further research into how to improve healthcare web information is needed. [ABSTRACT FROM AUTHOR]

Background and Objectives: The passage of the Affordable Care Act has ignited a shift from the pay-for-performance model to value-based care with a particular relevance in critical care settings. Provider incentive programs are widely considered as a means to reward providers based on the achievement of preset quality metrics. This article aims to demonstrate the effects of a provider incentive program in the critical care delivery system in a large academic center in the Northeastern United States. Methods: This article describes the results of a retrospective analysis of a performance-driven quality improvement initiative at a critical care facility of an academic medical center using a quasi-experimental pre-/posttest design. A set of quality measures was selected as outcome metrics. Selection criteria for the process measures are as follows: (i) the metric goals should be influenced by the physician's input to a large degree; (ii) the measure must be transparent and accessible within the hospital-wide data reporting system; (iii) the metric that required group effort and interdisciplinary collaboration to achieve; and (iv) the measure must directly affect patient outcome. The outcome metrics are central line--associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs), standardized infection ratio (SIR), Foley catheter and central line utilization standardized utilization ratio (SUR), hand hygiene compliance, and adherence to respiratory recovery pathway goals. These metrics were tracked from for 3 years with success defined as achieving set benchmarks for each metric. Results: The average CLABSI SIR and CAUTI SIR across all intensive care units (ICUs) decreased by 44% (P= .05) and 87% (P= .02) over 3 years as well as the central line and Foley catheter utilization falling by 41% and 30%, respectively. Hand hygiene compliance in the ICUs improved for the same period by 27 percentage points, as did compliance with the respiratory recovery pathway program by 4 percentage points. Conclusion: The use of a physician-driven financial incentive model in a critical care setting measured by outcome metrics dependent on physician input is successful with rigorous implementation and careful evaluation. [ABSTRACT FROM AUTHOR]

Eggs in the United States are typically washed using chemical sanitizers such as quaternary ammonia (QA) or chlorine. Such treatments generate wash water, which could be potentially hazardous to the environment. A novel, nonthermal sanitization technique for washing shell eggs using cold plasma-activated water (PAW) was investigated in this study. The inactivation efficacy of PAW on Klebsiella michiganensis and the impact of PAW on the cuticle of the eggshell and shell strength were tested in comparison to QA. Washing inoculated eggs with PAW and QA achieved a similar microbial reduction (>5.28 log CFU/egg). Colorimetric analysis showed that ∆ E -value for PAW-treated eggs was significantly lower than QA-treated eggs, suggesting higher cuticle coverage in eggs treated with PAW. The texture analysis to test for shell egg strength indicated that washing eggs with PAW did not affect the structural integrity of the eggshell when compared to eggs washed with QA. According to this study, PAW has the potential as an alternative to commercial sanitizers like QA in the egg-washing industry. PAW does not detrimentally impact shell strength or cuticle coverage and provides similar microbial reduction efficacy. [ABSTRACT FROM AUTHOR]

Caring for patients with end‐stage kidney disease (ESKD) in the United States is challenging, due in part to the complex epidemiology of the disease's progression as well as the ways in which care is delivered. As CKD progresses toward ESKD, the number of comorbidities increases and care involves multiple healthcare providers from multiple subspecialties. This occurs in the context of a fragmented US healthcare delivery system that is traditionally siloed by provider specialty, organization, as well as systems of payment and administration. This article describes the role of care fragmentation in the delivery of optimal ESKD care and identifies research gaps in the evidence across the continuum of care. We then consider the impact of care fragmentation on ESKD care from the patient and health system perspectives and explore opportunities for system‐level interventions aimed at improving care for patients with ESKD. [ABSTRACT FROM AUTHOR]

The National Accreditation Program for Breast Centers (NAPBCs) is dedicated to improving the quality of care in patients with breast disease. Geographic distribution of health care resources is an important measure of quality, yet little is known regarding breast center allocation patterns concerning population demand and impact on health outcomes. The purpose of this study was to analyze the distribution of NAPBC programs in the United States (USA) and evaluate the impact on breast cancer survival. Using the Centers for Disease Control and Prevention 2014 data base, we identified the incidence and mortality rates for breast cancer by state. We also determined the concentration of NAPBC programs in each state (ie, the number of centers per 1000 cases of breast cancer). Data were analyzed using Spearman's (nonparametric) rank correlation coefficients. Five hundred and seventy NAPBC programs were identified. Across the United States, there was a mean of 2.8 programs/1000 breast cancer diagnoses. A positive correlation (r =.45) between breast cancer incidence and the number of programs was identified (P =.0009). There was no statistically significant correlation between mortality and NAPBC program concentration (r = −0.20, P =.16). NAPBC‐accredited program distribution within the United States correlates with breast cancer incidence per state. However, the number of NAPBC programs per state did not alter overall mortality rates. Added measures beyond survival, as well as further insight into referral patterns to NAPBC programs, may be required to demonstrate the value and impact of NAPBC accreditation. [ABSTRACT FROM AUTHOR]

Escalating drug costs place patients at risk for financial toxicity and demand that physicians understand and act on the ethical and economic principles related to drug pricing. This manuscript reviews these principles and provides clinicians with a framework to think about the value of the drugs prescribed for patients with neuromuscular diseases. A key component of addressing the drug pricing crisis will be establishing a value based (benefit/cost) drug pricing framework. Determining the value of a drug is difficult and requires estimating the benefit and costs to patients and society while integrating indirect and contextual variables. Other considerations in drug pricing include "externality," the value to society derived from innovation. The Institute for Clinical and Economic Review (ICER) is a leading independent research organization providing clinicians with value-based price "benchmarks." All physicians must educate themselves in drug pricing principles and be prepared to have conversations regarding individual and societal value with the patients they serve. [ABSTRACT FROM AUTHOR]

Objectives: At the onset of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic in the United States, testing was limited to the Centers for Disease Control and Prevention-developed reverse transcription polymerase chain reaction assay. The urgent and massive demand for testing prompted swift development of assays to detect SARS-CoV-2. The objective of this study was to assess the accuracy of these newly developed tests.Methods: The American Proficiency Institute sent 2 test samples to 346 clinical laboratories in order to assess the accuracy of SARS-CoV-2 assays. The positive sample, containing 5,175 viral copies/mL, was fully extractable with SARS-CoV-2 viral capsid protein and RNA. The negative sample, with 3,951 viral copies/mL, contained recombinant virus particles with sequences for targeting human RNAase P gene sequences.Results: Of the laboratories submitting results, 97.4% (302/310) correctly detected the virus when present and 98.3% (296/301) correctly indicated when the virus was not present. Among incorrect results reported in this proficiency challenge, 76.9% (10/13) were likely related to clerical error. This accounts for 1.6% (10/611) of all reported results.Conclusions: Overall performance in this SARS-CoV-2 RNA detection challenge was excellent, providing confidence in the results of these new molecular tests and assurance for the clinical and public health decisions based on these test results. [ABSTRACT FROM AUTHOR]

Background and Objectives Assisted living (AL) is a growing sector of the U.S. long-term care market, with its development driven largely by private market choices. However, consumers need information to choose the right AL community (ALC). This paper examined information available on U.S. state websites concerning ALC quality, costs, and services. Research Design and Methods Based on prior research and their analysis of a sample of state websites, researchers identified 39 key informational elements and grouped them into four categories, (a) ALC characteristics, (b) payment and services, (c) quality, and (d) website usability. Researchers then examined the presence of the 39 elements on 51 websites (U.S. states and the District of Columbia), meeting regularly to discuss findings and resolve differences. Results A majority of states provided basic information about individual ALCs (e.g. number of beds, ownership). Only 35% listed payment(s) accepted (e.g. Medicaid), and 31% indicated the availability of memory care. Nearly 70% posted inspection results, while only 43% provided information about complaints. Many met basic usability guidelines (e.g. type size), but locating content on many sites required multiple steps, and none met 5th-grade-or-below readability standards. Discussion and Implications A majority of websites provided important information, such as inspection results. However, many were lacking key elements concerning payment accepted and services. Finding what was available was burdensome. More work is needed to help states provide information that enables consumers to find ALCs that meet their needs. The lack of such information puts older adults at risk of inappropriate placements. [ABSTRACT FROM AUTHOR]

Background: Communication between clinicians and families of dying children in the pediatric intensive care unit (PICU) is critically important for optimal care of the child and the family. Objective: We examined the current state of clinician perspective on communication with families of dying children in the PICU. Design: Prospective case series over a 15-month study period. Setting/Subjects: We surveyed nurses, psychosocial staff, and physicians who cared for dying children in PICUs at five U.S. academic hospitals. Measurements: Clinicians reported on the location of communication, perceived barriers to end-of-life care, and rated the quality of communication (QOC). Results: We collected 565 surveys from 287 clinicians who cared for 169 dying children. Clinicians reported that the majority of communication occurred at the bedside, and less commonly family conferences and rounds. Ten barriers to care were examined and were reported with frequencies of 2%–32%. QOC was rated higher when the majority of conversations occurred during family conferences (p = 0.01) and lower for patients of non-white race (p = 0.03). QOC decreased when 8 of the 10 barriers to care were reported. Conclusions: When a child is dying, clinicians report that communication with the family occurs most frequently at the child's bedside. This has important implications for future ICU communication research as the majority of previous research and education has focused on family care conferences. In addition, findings that QOC is perceived as lower for non-white patients and when clinicians perceive that barriers hindering care are present can help direct future efforts to improve communication in the PICU. [ABSTRACT FROM AUTHOR]

Medicaid is integral to public health because it insures one in five Americans and half of the nation's births. Nearly two-thirds of all Medicaid recipients are currently enrolled in a health maintenance organization (HMO). Proponents of HMOs argue that they can lower costs while maintaining access and quality. We critically reviewed 32 studies on Medicaid managed care (2011-2019). Authors reported state-specific cost savings and instances of increased access or quality with implementation or redesign of Medicaid managed-care programs. Studies on high-risk populations (e.g., disabled) found improvements in quality specific to a state or a high-risk population. A unique model of managed care (i.e., the Oregon Health Plan) was associated with reduced costs and improved access and quality, but results varied by comparison state. New trends in the literature focused on analysis of auto-assignment algorithms, provider networks, and plan quality. More analysis of costs jointly with access/quality is needed, as is research on managing long-term care among elderly and disabled Medicaid recipients. [ABSTRACT FROM AUTHOR]

Objective: To determine whether the exclusion of patients who die from adjusted 30-day readmission rates influences readmission rate measures and penalties under the Hospital Readmission Reduction Program (HRRP).Data Sources/study Setting: 100% Medicare fee-for-service claims over the period July 1, 2012, until June 30, 2015.Study Design: We examine the 30-day readmission risk across the three conditions targeted by the HRRP: acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia. Using logistic regression, we estimate the readmission risk for three samples of patients: those who survived the 30-day period after their index admission, those who died over the 30-day period, and all patients who were admitted to see how they differ.Data Collection/extraction Methods: We identified and extracted data for Medicare fee-for-service beneficiaries admitted with primary diagnoses of AMI (N = 497 931), CHF (N = 1 047 552), and pneumonia (N = 850 552).Results: The estimated hospital readmission rates for the survived and nonsurvived patients differed by 5%-8%, on average. Incorporating these estimates into overall readmission risk for all admitted patients changes the likely penalty status for 9% of hospitals. However, this change is randomly distributed across hospitals and is not concentrated amongst any one type of hospital.Conclusions: Not accounting for variations in mortality may result in inappropriate penalties for some hospitals. However, the effect of this bias is low due to low mortality rates amongst incentivized conditions and appears to be randomly distributed across hospital types. [ABSTRACT FROM AUTHOR]

Objectives: To examine metabolic monitoring rates in commercially insured children and adolescents treated with a second-generation antipsychotic (SGA) during calendar years (CYs) 2016 and 2017. Methods: In this retrospective study, data were collected from a large national commercial health plan for the period covering January 1, 2016 to December 31, 2017. Commercially insured children and adolescents, aged 8-19 years with ≥2 SGA prescription claims during the CY, were identified for the CY2016 and CY2017 cohorts. The primary outcome of interest was the percentage of subjects with any glucose or lipid metabolism parameter monitoring. Other calculated metabolic testing rates included glucose, hemoglobin A1c (HbA1c), low-density lipoprotein cholesterol (LDL-C), other cholesterol (including triglycerides), and combined glucose and lipid metabolism testing (≥1 test for blood glucose or HbA1c and ≥1 test for LDL-C or other cholesterol). Results: In CY2016 and CY2017, 1502 and 1239 subjects, respectively, were identified for this study. The most common psychiatric diagnoses in CY2016 and CY2017 were major depressive disorder (57.1%, 56.5%, respectively), anxiety disorders (42.9%, 47.5%), attention-deficit/hyperactivity disorder (41.6%, 45.8%), and bipolar disorder (24.1%, 25.9%). The rate of any metabolic testing was 53.5% in CY2016 and 51.3% in CY2017. Glucose testing (50.3%, 46.9%, respectively) was most common in both CYs, followed by LDL-C testing (31.2%, 28.5%). Rates of combined glucose and lipid metabolism testing were 30.7% in CY2016 and 26.9% in CY2017. Conclusions: Given the known potential for adverse cardiometabolic effects, rates of metabolic monitoring associated with SGA use in children and adolescents urgently need to be improved. There is a critical need for understanding barriers to routine monitoring, particularly of lipids, and developing interventions to enhance metabolic monitoring. [ABSTRACT FROM AUTHOR]

Background and Objectives To examine whether nursing homes (NHs) provide better quality when unemployment rates rise (countercyclical) and explore mechanisms contributing to the relationship between quality and unemployment rates. Research Design and Methods The study uses the data on privately owned, freestanding NHs in the continental United States that span a period from 2001 through 2015. The empirical analysis relies on panel fixed-effect regressions with the key independent variable being the county-level unemployment rate. NH quality is measured using deficiencies, outcomes, and care process measures. We also examine nursing staff levels, as well as employee turnover and retention. Results NHs have better quality when unemployment rates increase. Higher unemployment rates are associated with fewer deficiencies and lower deficiency scores. This countercyclical relationship is also found among other quality measures. In terms of mechanisms, we find higher nursing staff levels, lower employee turnover, and better workforce retention when unemployment rates rise. Improvement in staffing is likely contributing to better quality during recessions. Interestingly, these effects predominately occur in for-profit NHs for deficiencies and staffing levels. Discussions and Implications NH quality is countercyclical. With near record-low unemployment rates in 2018, regulatory agencies should pay close attention to NH quality when and where the local economy registers strong growth. On the other hand, the finding of the unemployment rate–staffing/turnover relationship also suggests that policies increasing staffing and reducing employee turnover may not only improve NH quality but also have the potential to smooth quality fluctuations between business cycles. [ABSTRACT FROM AUTHOR]

• The Foundation for the Accreditation of Cellular Therapy (FACT) requires accredited programs to assess patient outcomes, which should meet expected ranges. • Continued 1-year survival that is lower than expected can affect FACT accreditation. • Programs that do not meet expected survival must implement corrective actions. • FACT provides assurance that programs review and improve patient outcomes. The rapid evolution of blood and marrow transplantation (BMT), coupled with diverse outcomes associated with heterogeneous groups of patients, led to the formation of 2 important organizations early in the development of the field: the Center for International Blood and Marrow Transplant Research (CIBMTR) and the Foundation for the Accreditation of Cellular Therapy (FACT). These organizations have addressed 2 of the 9 elements identified by the National Quality Strategy (NQS) for achieving better health care, more affordable care, and healthy people and communities: a registry that promotes improvement of care and accreditation based on quality standards. More recently, a federally mandated database in the United States addresses the third element of the NQS: public reporting of treatment results. Here we describe the current process by which FACT incorporates patient outcomes reported by the CIBMTR into standards for accreditation, the requirements for accredited programs with performance below expected outcomes to maintain accreditation, and preliminary findings of an assessment of corrective action plans intended to improve outcomes. [ABSTRACT FROM AUTHOR]

Zahlreiche Autoren, Autorinnen und kritische Initiativen (z. B. DORA) kritisieren den zu hohen und schädlichen Einfluss quantitativer Daten, welche akademische Instanzen für Evaluationszwecke heranziehen. Wegen des großen Einflusses der globalen Zitatdatenbanken von Thomson Reuters (bzw. Clarivate Analytics) auf die Bewertung der wissenschaftlichen Leistungen von Forscherinnen und Forschern habe ich extensive qualitative und quantitative Fallstudien zur Datenqualität des Social Sciences Citation Index (SSCI) durchgeführt, d. h. die Originaleinträge mit den SSCI-Datensätzen verglichen. Diese Fallstudien zeigten schwerste – nie in der Literatur erwähnte – Fehler, Verstümmelungen, Phantomautoren, Phantomwerke (Fehlerrate in der Fallstudie zu Beebe 2010, Harvard Law Review: 99 Prozent). Über die verwendeten Datenerfassungs- und Indexierungsverfahren von TR bzw. Clarivate Analytics ist nur wenig bekannt. Ein Ergebnis meiner Untersuchungen: Bei der Indexierung von Verweisen in Fußnoten (wie in den Rechtswissenschaften, gerade auch der USA, vorgeschrieben) scheinen die verwendeten Textanalyse-Anwendungen und -Algorithmen völlig überfordert. Eine Qualitätskontrolle scheint nicht stattzufinden. Damit steht der Anspruch des SSCI als einer multidisziplinären Datenbank zur Debatte. Korrekte Zitate in den Fußnoten des Originals können zu Phantom-Autoren, Phantom-Werken und Phantom-Referenzen degenerieren. Das bedeutet: Sämtliche Zeitschriften und Disziplinen, deren Zeitschriften und Büchern dieses oder ähnliche Zitierverfahren verwenden (Oxford-Style), laufen Gefahr, aufgrund starker Zitatverluste falsch, d. h. unterbewertet, zu werden. Wie viele UBOs (Unidentifiable Bibliographic Objects) sich in den Datenbanken SCI, SSCI und AHCI befinden, wäre nur mit sehr aufwändigen Prozeduren zu klären. Unabhängig davon handelt es sich, wie bei fast allen in meinen Untersuchungen gefundenen fatalen Fehlern, eindeutig um endogene Fehler in den Datenbanken, die nicht, wie oft behauptet, angeblich falsch zitierenden Autorinnen und Autoren zugeschrieben werden können, sondern erst im Laufe der Dateneingabe und -verarbeitung entstehen. Numerous authors and critical initiatives (such as DORA) criticize the excessive and damaging influence of quantitative data that academic administrators use for evaluation purposes. Due to the great impact of Thomson Reuters' (TR) or Clarivate Analytics' global citation databases on the evaluation of researchers' scientific achievements, I have conducted extensive qualitative and quantitative case studies on the data quality of the Social Sciences Citation Index (SSCI), in an innovative way by comparing the original references cited with the SSCI records indexed entries. These case studies revealed the most serious – to my knowledge, never mentioned in the literature before – errors, mutilations, phantom authors, phantom works (error rate: 99 % in the case study for Beebe 2010, Harvard Law Review). Little is known about the data collection and indexing techniques used by TR and Clarivate Analytics. A result of my investigations: When indexing references in footnotes (as prescribed in the scientific discipline of law, especially in the USA), the text analysis applications and algorithms seem to be completely overextended; quality control seems not to be in place. This raises the claim of the SSCI to be of a high quality multidisciplinary database. Correct citations in the footnotes of the original can degenerate into phantom authors, phantom works, and phantom references. This means that all journals and disciplines with journals and books using this or similar citation method (Oxford Style) run the risk of being misrepresented (i.e. undervalued) due to heavy citation losses. How many unidentifiable bibliographic objects (UBOs) are in the SCI, SSCI and AHCI databases would only be possible with very complex procedures. Either way, as with almost all the fatal errors found in my investigations, it is clearly a matter of endogenous databases errors that can not be attributed, as so often claimed, to allegedly misquoted authors, but induced only in the course of data entry and processing. [ABSTRACT FROM AUTHOR]

Objective: To examine the relationship between insurer market structure, health plan quality, and health insurance premiums in the Medicare Advantage (MA) program.Data Sources/study Setting: Administrative data files from the Centers for Medicare and Medicaid Services, along with other secondary data sources.Study Design: Trends in MA market concentration from 2008 to 2017 are presented, alongside logistic and linear regression models examining MA plan quality and premiums as a function of insurer market structure for 2011.Data Collection/extraction Methods: Data are publicly available.Principal Findings: MA plans that tend to operate in more concentrated MA markets have a higher predicted probability of receiving a high-quality health plan rating. Operating in more concentrated MA markets was also found to be associated with higher premiums. Among plans that tend to operate in very concentrated MA markets, high-quality MA plans were associated with premiums as much as two times higher than premiums associated with lower-quality plans.Conclusions: Any policies directed at enhancing insurer competition should consider implications for health plan quality, which may be very different than the implications for enrollee premiums. [ABSTRACT FROM AUTHOR]

Millions of children in the United States live in rural areas and often start school with fewer school readiness skills than counterparts in urban areas. Access to high-quality child care could be a mechanism to improve school readiness; however, it is unclear what, if anything, distinguishes child care in rural and urban areas. Focusing specifically on three aspects of child care pertinent to children's school readiness, including type, access, and quality, we review the extant literature on characteristics of child care in rural areas of the United States and identified seventeen studies. Parents in rural (vs. urban) areas more commonly select and can access family- or home-based child care vs. centre-based care. Child care quality bears similar relations with children's outcomes in rural and urban areas. This descriptive review suggests the need for additional research focused on child care in rural areas to better inform child care policy. [ABSTRACT FROM AUTHOR]

Context: State scope of practice (SoP) laws impose significant restrictions on the services that a nurse practitioner (NP) may provide in some states, yet evidence about SoP limitations on the quality of primary care is very limited. Method: This study uses six different classifications of state regulations and bivariate and multivariate analyses to compare beneficiaries attributed to primary care nurse practitioners and primary care physicians in 2013 testing two hypotheses: (1) chronic disease management, cancer screening, preventable hospitalizations, and adverse outcomes of care provided by primary care nurse practitioners are better in reduced and restricted practice states compared to states without restrictions and (2) by decreasing access to care, SoP restrictions negatively affect the quality of primary care. Findings: Results show a lack of consistent association between quality of primary care provided by NPs and state SoP restrictions. Conclusion: State regulations restricting NP SoP do not improve the quality of care. [ABSTRACT FROM AUTHOR]

Due to increasing demand for higher education around the world, concerns regarding the quality of education in higher education institutions have increased. The aim of this study was to determine perceptions of accreditation self-study coordinators and programme administrators on the influence of accreditation on academic quality. Data was collected by means of a scale devised by researchers. To achieve this, a comprehensive literature review was conducted, a pilot scheme was administered, expert opinion and advice were obtained and validity and reliability studies were conducted. The findings revealed that accreditation contributes more to the improvement of processes and practices in institutions in operation for 1–20 years compared to those functioning for more than 41 years. Similarly, accreditation makes a greater contribution during the initial accreditation process compared to re-accreditation. Additionally, accreditation contributes most to importance attached to learning outcomes and least to the number of students who graduate from a programme. [ABSTRACT FROM AUTHOR]

The multitude of comorbidities and disabilities that are prevalent among diabetic patients make their care very challenging for providers. This, in turn, may have a negative effect on measures of patient satisfaction, quality, and outcomes. This study examines the correlation between diabetes ratio as a primary diagnosis in home health agencies (HHAs) with the Home Health Care Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey and the Outcome and Assessment Information Set (OASIS) star ratings. Our result indicates that HHAs with a higher proportion of patients with diabetes have lower ratings in health outcomes (bathing, breathing, moving from the bed, moving around, and controlling pain). The association was stronger in the case of diabetic cases with complications. [ABSTRACT FROM AUTHOR]

Unnecessary surgery has been a focus of health policy concern for decades. Such events are supposed to be prevented by the (a) self-policing of hospital medical staffs, (b) oversight of state medical boards, (c) third-party restrictions on payment, and (d) threat of malpractice lawsuits. While critics may point to failures of will on the part of those responsible for such policing, this case study points to more fundamental problems. The case involved an extension of the diagnosis of Chiari malformation to justify surgery to help relieve symptoms of individuals previously identified as suffering from chronic pain or fatigue syndrome. It illustrates how strenuous efforts to reduce what other members of the medical profession perceived as unnecessary surgery were overcome by (a) uncertainty concerning appropriate diagnosis and treatment, (b) patient desperation-driven self-referrals unrestricted by professional oversight or geographic boundaries, (c)the ambition of a surgeon determined to practice as he or she desired, (d) a business-focused national hospital chain insulated from direct clinical accountability, and (e) the highly profitable nature of the surgery itself. [ABSTRACT FROM AUTHOR]

Over the last 5 decades, the state institution census has decreased 85% in the United States. Despite these radical shifts away from institutionalization, people with intellectual and developmental disabilities (IDD) continue to struggle to be meaningfully included in the community. For these reasons, the aim of this study was to explore if and how residence type affects attainment of quality of life outcomes of people with IDD in the United States. To do so, we analyzed Personal Outcome Measures® interviews from approximately 1,350 people with IDD. Findings suggest much of what has historically been considered deinstitutionalization of people with IDD is transinstitutionalization, particularly with provider-owned or -operated settings. A systemic overhaul is needed to create an effective community infrastructure. [ABSTRACT FROM AUTHOR]

Clinical decision support has been identified by the United States government as a method to decrease inappropriate imaging exams and promote judicious use of imaging resources. The adoption of this method will be incentivized by requiring appropriate use criteria to qualify for Medicare reimbursement starting in January 2020. While Medicare reimbursement is unlikely to directly impact pediatric imaging because of largely disparate patient populations, insurance providers typically use Medicare to benchmark their reimbursement guidelines. Therefore soon after their adoption these guidelines could become relevant to pediatric imaging. In this article we discuss how pediatric imaging was initially underrepresented in the clinical decision support realm, and how this was addressed by a subcommittee involving both American College of Radiology and Society for Pediatric Radiology members. We also present the experience of implementing clinical decision support software at two standalone pediatric hospitals and summarize the lessons learned from these deployments. [ABSTRACT FROM AUTHOR]

During the last 15 years, peer review has been widely incorporated into radiology quality improvement programs. However, current implementations are variable and carry concerns, including subjectivity of numerical scores and a sense of merely satisfying regulatory requirements. The Society for Pediatric Radiology (SPR) Quality and Safety Committee sought to evaluate the state of peer review programs in pediatric radiology practices, including implementation methods, perceived functions, strengths and weaknesses, and opportunities for improvement. We distributed an online 16-question survey to SPR members. Questions pertained to the type of peer review system, the use of numerical scores and comments, how feedback on discordances is given and received, and the use of peer learning conferences. We collected 219 responses (15% of survey invitations), 80% of which were from children's hospitals. Fifty percent of respondents said they use a picture archiving and communication system (PACS)-integrated peer review system. Comment-enhanced feedback for interpretive discordances was either very important or somewhat important to performance improvement in 86% of responses, compared to 48% with a similar perception of numerical scores. Sixty-eight percent of respondents said they either rarely or never check their numerical scores, and 82% either strongly or somewhat agreed that comments are more effective feedback than numerical scores. Ninety-three percent either strongly or somewhat agreed that peer learning conferences would be beneficial to their practice. Forty-eight percent thought that their current peer review system should be modified. Survey results demonstrate that peer review systems in pediatric radiology practices are implemented variably, and nearly half of respondents believe their systems should be modified. Most respondents prefer feedback in the form of comments and peer learning conferences, which are thought to be more beneficial for performance improvement than numerical scores. [ABSTRACT FROM AUTHOR]

Winery owners in the Midwestern states of the United States have been working with each other and their state industry experts to improve the quality of their wines while also struggling to establish state and, at times, regional identities and overcome a widely-held perception that good wine is not made and cannot be made in the region. Drawing on a qualitative sociological study conducted over five years in Ohio, Indiana, Illinois, and Iowa, this article examines the issues with which winery owners and industry specialists have worked to improve quality and establish marketable identities. Challenges include the sourcing of quality grapes, the status of hybrid grapes, the skill-level of winemakers, and the desire to meet demand and please a wide range of customer preferences. Industry efforts to address these challenges are highlighted. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study is twofold: (1) to describe the quality of end‐of‐life care in US hospitals from the perspective of hospital nurses; and (2) to evaluate the relationship between the nurse practice environment and end‐of‐life care quality. Design Cross‐sectional analysis of multiple linked secondary data sources. PARTICIPANTS and SETTING: A total of 12,870 direct care registered nurses in 491 acute‐care hospitals. Measurements Measures of end‐of‐life care quality and nurse practice environment were derived from the 2016 RN4CAST‐US survey of nurses. Nurses reported on end‐of‐life care quality for patients for whom death within a year would not be surprising. Nurse practice environment was measured using the Practice Environment Scale of the Nursing Work Index, a National Quality Forum validated scale. Results: Most nurses gave their hospitals an unfavorable evaluation of end‐of‐life care overall (58%) and said patients often experience painful procedures that were unlikely to change their outcome (53%). The best predictor of poor quality was the nurse practice environment. Nurses in the best environments were 55% less likely than nurses in poor environments to rate their hospital's overall end‐of‐life care quality unfavorably (odds ratio = 0.45; 95% confidence interval = 0.39–0.52; P <.001). Conclusion: Quality of end‐of‐life care in US hospitals is imperfect and is significantly worse in hospitals with poor nurse practice environments than in hospitals with the best environments. This study reinforces the importance of nurses in providing high‐quality end‐of‐life care. J Am Geriatr Soc 67:302–308, 2019. [ABSTRACT FROM AUTHOR]

The paper presents cow raw milk quality and its influence factors in connection with milk price based on a proper approach of the topic using analysis, synthesis, deduction which helped to establish "the state-of art" in the field of the authors' expertise, emphasizing on the particular factors which contribute to the improvement of milk quality which influence milk price in the EU, USA and other countries. Milk quality is determined by milk composition especially by fat and protein percentages, by the sensory, physical and chemical characteristics. Milk quality is assessed from a hygienic point of view in terms of Total Bacteria Counts (TBC) and Bulk Tank Somatic Cells Counts (BTSCC) whose level should be lower than the maximum thresholds mentioned by EU and USA standards in force, as well as regarding the aflatoxins and antibiotics content. The payment system for the quality of milk and the competition between suppliers and processors for milk supply encourages dairy farmers to produce more milk and of high quality. In this purpose, they have to improve breeding, feeding, hygiene and keep under control mastitis, treatments with antibiotics and other medicines and to produce high quality forages without aflatoxins. The reduction of TBC and BTSCC in raw milk will assure food safety and will increase shelf life of milk and dairy products. Business development in dairy farming has to keep pace with the changes in the internal and international markets. Farmers should become aware that they play an important role in raising milk demand and offer of high quality milk and dairy products. [ABSTRACT FROM AUTHOR]

Using data from a subsample of 913 study children and their friends who participated in the NICHD Study of Early Child Care and Youth Development, the interactive contributions of child-reported attribution biases and teacher-reported child emotional intensity (EI) at Grade 4 (M = 9.9 years) to observed child-friend interaction at Grade 6 (M = 11.9 years) were examined. Study children's hostile attribution bias, combined with high EI, predicted more negative child-friend interaction. In contrast, benign attribution bias, combined with high EI, predicted more positive child-friend interaction. The findings are discussed in light of the "fuel" interpretation of EI, in which high-intensity emotions may motivate children to act on their cognitive biases for better or for worse. [ABSTRACT FROM AUTHOR]