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BackgroundThere is growing recognition that health care providers are embedded in networks formed by the movement of patients between providers. However, the structure of such networks and its impact on health care are poorly understood.PurposeWe examined the level of dispersion of patient-sharing networks across U.S. hospitals and its association with three measures of care delivered by hospitals that were likely to relate to coordination.Methodology/approachWe used data derived from 2016 Medicare Fee-for-Service claims to measure the volume of patients that hospitals treated in common. We then calculated a measure of dispersion for each hospital based on how those patients were concentrated in outside hospitals. Using this measure, we created multivariate regression models to estimate the relationship between network dispersion, Medicare spending per beneficiary, readmission rates, and emergency department (ED) throughput rates.ResultsIn multivariate analysis, we found that hospitals with more dispersed networks (those with many low-volume patient-sharing relationships) had higher spending but not greater readmission rates or slower ED throughput. Among hospitals with fewer resources, greater dispersion related to greater readmission rates and slower ED throughput. Holding an individual hospital's dispersion constant, the level of dispersion of other hospitals in the hospital's network was also related to these outcomes.ConclusionDispersed interhospital networks pose a challenge to coordination for patients who are treated at multiple hospitals. These findings indicate that the patient-sharing network structure may be an overlooked factor that shapes how health care organizations deliver care.Practice implicationsHospital leaders and hospital-based clinicians should consider how the structure of relationships with other hospitals influences the coordination of patient care. Effective management of this broad network may lead to important strategic partnerships.

Multi-tiered systems of support (MTSS) is the overarching referent for frameworks designed to target behavioral and academic challenges with a focus on a tiered continuum of evidence-based practices within the context of prevention science and implementation research (Freeman, Sugai, Simonsen, & Everett, 2017). Extensive literature indicates that MTSS programs can be effective in helping teachers address academic and behavioral challenges. However, from the onset of the RtI movement and through its transition into the MTSS paradigm, many middle level schools have faced significant organizational and systemic challenges which hamstring their ability to utilize MTSS programming with fidelity. This essay proposes an alternative framework for the implementation of MTSS programming at the middle level predicated in the theoretical construct of collective teacher efficacy. After reviewing the tenets of collective efficacy, a provision for framework of MTSS implementation is offered followed by discussion of both behaviors inherent to successful implementation and hallmarks of MTSS programming sustainability.

Crossover recombination is essential for accurate chromosome segregation during meiosis. The MutSγ complex, Msh4-Msh5, facilitates crossing over by binding and stabilizing nascent recombination intermediates. We show that these activities are governed by regulated proteolysis. MutSγ is initially inactive for crossing over due to an N-terminal degron on Msh4 that renders it unstable by directly targeting proteasomal degradation. Activation of MutSγ requires the Dbf4-dependent kinase Cdc7 (DDK), which directly phosphorylates and thereby neutralizes the Msh4 degron. Genetic requirements for Msh4 phosphorylation indicate that DDK targets MutSγ only after it has bound to nascent joint molecules (JMs) in the context of synapsing chromosomes. Overexpression studies confirm that the steady-state level of Msh4, not phosphorylation per se, is the critical determinant for crossing over. At the DNA level, Msh4 phosphorylation enables the formation and crossover-biased resolution of double-Holliday Junction intermediates. Our study establishes regulated protein degradation as a fundamental mechanism underlying meiotic crossing over.

Green plants (Viridiplantae) include around 450,000-500,000 species1,2 of great diversity and have important roles in terrestrial and aquatic ecosystems. Here, as part of the One Thousand Plant Transcriptomes Initiative, we sequenced the vegetative transcriptomes of 1,124 species that span the diversity of plants in a broad sense (Archaeplastida), including green plants (Viridiplantae), glaucophytes (Glaucophyta) and red algae (Rhodophyta). Our analysis provides a robust phylogenomic framework for examining the evolution of green plants. Most inferred species relationships are well supported across multiple species tree and supermatrix analyses, but discordance among plastid and nuclear gene trees at a few important nodes highlights the complexity of plant genome evolution, including polyploidy, periods of rapid speciation, and extinction. Incomplete sorting of ancestral variation, polyploidization and massive expansions of gene families punctuate the evolutionary history of green plants. Notably, we find that large expansions of gene families preceded the origins of green plants, land plants and vascular plants, whereas whole-genome duplications are inferred to have occurred repeatedly throughout the evolution of flowering plants and ferns. The increasing availability of high-quality plant genome sequences and advances in functional genomics are enabling research on genome evolution across the green tree of life.

PURPOSE:To improve care coordination for complex cancers, it is critical to establish a more nuanced understanding of the types of providers involved. As the number of provider types increases, strategies to support cancer care coordination must adapt to a greater variety of information needs, communication styles, and treatment strategies. METHODS:We categorized providers into 11 types, using National Provider Identifier specialties. Using Medicare claims, we counted the number of unique combinations of provider types billed during preoperative, operative, and postdischarge care for colon cancer surgery and assessed how this count varies across hospitals. The study included 70,567 beneficiaries in fee-for-service Medicare A and B for 6 months before and 60 days after an admission for colectomy for colon cancer between 2008 and 2011. RESULTS:We observed 1,554 preoperative provider-type combinations, 975 operative combinations, and 1,571 postdischarge combinations. The three most common combinations in the preoperative phase were general medicine only, other medical specialists only, and general medicine and other medical specialists. In the operative phase, the three most common combinations were primary surgery, anesthesiology, and pathology; general medicine, other medical specialists, radiology, primary surgery, anesthesiology, and pathology; and other medical specialists, radiology, primary surgery, anesthesiology, and pathology. In the postdischarge phase, the three most common combinations were general medicine, general medicine and other medical specialists, and general medicine and oncology. On average, each hospital had 15 preoperative, 11 operative, and 15 postoperative combinations. High-volume, larger, teaching, urban, and noncritical access hospitals had more combinations in all phases. CONCLUSION:Many provider-type combinations are involved in colon cancer surgery care. Substantial variation exists across hospitals types, suggesting that certain hospitals need additional resources and more flexible infrastructure to coordinate care.

ObjectiveTo examine the effectiveness of the 3 primary treatments for ureteropelvic junction obstruction (ie, open pyeloplasty, minimally invasive pyeloplasty, and endopyelotomy) as assessed by failure rates.Materials and methodsUsing MarketScan data, we identified adults (ages 18-64 years) who underwent treatment for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was failure (ie, need for a secondary procedure). We fit a Cox proportional hazards model to examine the effects of different patient, regional, and provider characteristics on treatment failure. We then implemented a survival analysis framework to examine the failure-free probability for each treatment.ResultsWe identified 1125 minimally invasive pyeloplasties, 775 open pyeloplasties, and 1315 endopyelotomies with failure rates of 7%, 9%, and 15%, respectively. Compared with endopyelotomy, minimally invasive pyeloplasty was associated with a lower risk of treatment failure (adjusted hazards ratio [aHR] 0.52; 95% confidence interval [CI], 0.39-0.69). Minimally invasive and open pyeloplasties had similar failure rates. Compared with open pyeloplasty, endopyelotomy was associated with a higher risk of treatment failure (aHR 1.78; 95% CI, 1.33-2.37). The average length of stay was 2.7 days for minimally invasive pyeloplasty and 4.2 days for open pyeloplasty (P

Background and purposeUreteropelvic junction obstruction is a common urologic condition that accounts for approximately $12 million in inpatient spending annually. Few studies have assessed the costs related to treatment. We sought to examine the cost of care for patients treated for ureteropelvic junction obstruction.Patients and methodsWe used the MarketScan® database to identify adults from 18 to 64 years old treated with minimally invasive pyeloplasty, open pyeloplasty, and endopyelotomy for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was total expenditures related to the surgical episode, defined as the period from 30 days prior until 30 days after the index surgery. We fit a multinomial linear regression model to evaluate cost of the surgical episode, adjusting for age, gender, comorbidity, benefit plan type, and region of residence.ResultsWe identified 1251 endopyelotomies, 717 open pyeloplasties, and 1048 minimally invasive pyeloplasties. The adjusted mean costs were $16,379 for endopyelotomy, $22,421 for open pyeloplasty, and $22,843 for minimally invasive pyeloplasty (p

Background and purposeUreteropelvic junction obstruction is a common condition that can be treated with open pyeloplasty, minimally invasive pyeloplasty, and endopyelotomy. While all these treatments are effective, the extent to which they are used is unclear. We sought to examine the dissemination of these treatments.Patients and methodsUsing the MarketScan® database, we identified adults 18 to 64 years old who underwent treatment for ureteropelvic junction obstruction between 2002 and 2010. Our primary outcome was ureteropelvic junction obstruction treatment (i.e., open pyeloplasty, minimally invasive pyeloplasty, endopyelotomy). We fit a multilevel multinomial logistic regression model accounting for patients nested within providers to examine several factors associated with treatment.ResultsRates of minimally invasive pyeloplasty increased 10-fold, while rates of open pyeloplasty decreased by over 40%, and rates of endopyelotomy were relatively stable. Factors associated with receiving an open vs a minimally invasive pyeloplasty were largely similar. Compared with endopyelotomy, patients receiving minimally invasive pyeloplasty were less likely to be older (odds ratio [OR] 0.96; 95% confidence interval [CI], 0.95, 0.97) and live in the south (OR 0.52; 95% CI, 0.33, 0.81) and west regions (OR 0.57; 95% CI 0.33, 0.98) compared with the northeast and were more likely to live in metropolitan statistical areas (OR 1.52; 95% CI 1.08, 2.13).ConclusionsOver this 9-year period, the landscape of ureteropelvic junction obstruction treatment has changed dramatically. Further research is needed to understand why geographic factors were associated with receiving a minimally invasive pyeloplasty or an endopyelotomy.

ObjectivesTo assess the impact of ambulatory surgery centers (ASCs) on rates of hospital-based outpatient procedures and adverse events.Data sourcesTwenty percent national sample of Medicare beneficiaries.Study designA retrospective study of beneficiaries undergoing outpatient surgery between 2001 and 2010. Health care markets were sorted into three groups-those with ASCs, those without ASCs, and those where one opened for the first time. Generalized linear mixed models were used to assess the impact of ASC opening on rates of hospital-based outpatient surgery, perioperative mortality, and hospital admission.Principal findingsAdjusted hospital-based outpatient surgery rates declined by 7 percent, or from 2,333 to 2,163 procedures per 10,000 beneficiaries, in markets where an ASC opened for the first time (p  .4 for test between slopes).ConclusionsThe opening of an ASC in a Hospital Service Area resulted in a decline in hospital-based outpatient surgery without increasing mortality or admission. In markets where facilities opened, procedure growth at ASCs was greater than the decline in outpatient surgery use at their respective hospitals.

BackgroundOutpatient surgery is increasingly delivered at freestanding ambulatory surgery centers (ASCs), which are thought to deliver quality care at lower costs per episode. The objective of this study was to understand potential facilitators and/or barriers to the introduction of freestanding ASCs in the United States.MethodsThis is an observational study conducted from 2008 to 2010 using a 20% sample of Medicare claims. Potential determinants of ASC dissemination, including population, system, and legal factors, were compared between markets that always had ASCs, never had ASCs, and those that had new ASCs open during the study. Multivariable logistic regression was used to determine characteristics of markets associated with the opening of a new facility in a previously naïve market.ResultsNew ASCs opened in 67 previously naïve markets between 2008 and 2010. ASCs were more likely to open in hospital service areas that were urban (adjusted odds ratio [OR], 4.10; 95% confidence interval [CI], 1.51-10.96), had higher per capita income (adjusted OR, 3.83; 95% CI, 1.43-10.45), and had less competition for outpatient surgery (adjusted OR, 2.13; 95% CI, 1.02-4.45). Legal considerations and latent need, as measured by case volumes of hospital-based outpatient surgery in 2007, were not associated with the opening of a new ASC.ConclusionsFreestanding ASCs opened in advantageous socioeconomic environments with the least amount of competition. Because of their associated efficiency advantages, policy makers might consider strategies to promote ASC diffusion in disadvantaged markets to potentially improve access and reduce costs.

BackgroundThere has been a strong push to move outpatient surgery from hospital settings to ambulatory surgery centers (ASCs). Despite the efficiency advantages of ASCs, many are concerned that these facilities could increase overall utilization.ObjectiveTo assess the impact of ASC opening on rates of outpatient surgery.DesignThis was a retrospective cohort study of Medicare beneficiaries undergoing outpatient surgery between 2001 and 2010. We compared population-based rates of outpatient surgery in Hospital Service Areas (HSAs) with freestanding ASCs to those without. After adjusting for differences using multiple propensity score methods, we assessed the impact of ASC opening in an HSA previously without one on rates of outpatient surgery.SubjectsPatients included were Medicare beneficiaries with Part B eligibility.Main outcome measureAdjusted HSA-level rates of outpatient surgery.ResultsAdjusted outpatient surgery rates increased from 2806 to 3940 per 10,000 and the number of ASC operating rooms grew from 7036 to 11,223 (both P

ObjectiveTo determine the effect of an ambulatory surgery center (ASC) opening in a healthcare market on utilization and quality of outpatient urologic surgery.MethodsThis is a retrospective cohort study of Medicare beneficiaries undergoing outpatient urologic surgery from 2001 to 2010. Markets were classified into 3 groups based on ASC status (ie, those with ASCs, those without ASCs, and those where ASCs were introduced). Multiple propensity score methods adjusted for differences between markets and general linear mixed models determined the effect of ASC opening on utilization and quality, defined by mortality and hospital admission within 30 days of the index procedure.ResultsDuring the study period, 195 ASCs opened in markets previously without one. Rates of hospital-based urologic surgery in markets where ASCs were introduced declined from 221 to 214 procedures per 10,000 beneficiaries in the 4 years after baseline. In contrast, rates in the other 2 market types increased over the same period (P.5).ConclusionThe introduction of an ASC into a healthcare market lowered rates of outpatient urologic surgery performed in the more expensive hospital setting. This redistribution was not associated with declines in quality or with greater growth in overall outpatient surgery use.

ObjectiveTo evaluate whether socioeconomic environment affects the adoption of new laser technology for treatment of benign prostatic hyperplasia (BPH).MethodsUsing all payer data, we identified all discharges for laser prostatectomy or transurethral resection of the prostate (TURP) performed in Florida (2001-2009). We determined whether or not each of 114 healthcare markets (Hospital Service Areas) offered laser prostatectomy or TURP and assessed the market-level socioeconomic environment using a previously described ZIP code-based summary score. We used generalized estimating equations to examine the association of socioeconomic environment with offering laser prostatectomy or TURP, adjusting for additional market characteristics.ResultsBetter socioeconomic environment was associated with offering laser prostatectomy (odds ratio 1.21 for each 1 point increase in summary score, 95% confidence interval 1.08-1.35, P

Purpose: The ROCKS (Reducing Operative Complications from Kidney Stones) program in MUSIC (Michigan Urological Surgery Improvement Collaborative) was created to optimize ureteroscopy outcomes. Through data collection, distribution of reports, patient education, and standardization of medication, postureteroscopy emergency department visits in Michigan have declined. It is unclear whether this is because of statewide quality efforts or due to national trends. We therefore sought to understand emergency department visit rates in Michigan compared to a national data set. Materials and Methods: We compared the MUSIC ROCKS clinical registry in Michigan against a national cohort, Optum's de-identified Clinformatics Data Mart, from 2016-2021 (excluding Michigan). We identified patients who underwent ureteroscopy and the proportion who had a postoperative emergency department visit within 30 days. Emergency department rates were modeled over time, adjusting for age, gender, comorbidity, and ureteral stenting. Results: We identified 24,688 patients in MUSIC ROCKS and 99,340 in the Clinformatics Data Mart database who underwent ureteroscopy. The riskadjusted emergency department visit rate in MUSIC ROCKS significantly declined over the study period (10.5% in 2016 to 6.9% in 2021, P < 0.001) while the mean emergency department visit rate in the Clinformatics DataMart cohort was 9.9% and did not change over time (9.6% in 2016 to 10% in 2021). Comparing emergency department visits between the cohorts, the MUSIC ROCKS rate significantly declined relative to the Clinformatics Data Mart (P < 0.001) over the study period. Conclusions: Postoperative emergency department visit rates in Michigan have declined significantly after ureteroscopy since the establishment of MUSIC ROCKS. This decline outpaced national rates, providing evidence that systematic quality initiatives can improve urological care. [ABSTRACT FROM AUTHOR]

A study explored the impact of a regular, sustained self-selected reading program on four reading skills measured by a criterion-referenced reading skill test. Fourth graders received reading only, reading/skill instruction, or skill instruction only. Results indicated significant pre- to posttest growth for all groups for all the reading comprehension skills. (SM)

Explored the effect of topic-related attitudes on sixth graders' learning and remembering. Students in control, favorable-attitude, or unfavorable-attitude instruction groups heard neutral, positive, or negative passages read aloud. Results suggest experimentally created topic-related attitudes do not interfere with the immediate recall of text-based information or cause students to selectively encode that information. (SM)

Explores the validity of the reading comprehension skills distinctiveness hypothesis. Finds that results argue for a unitary or holistic view of reading comprehension and suggest increasing the time students spend in sustained reading of self-selected materials as a means for improving students' reading comprehension. (MG)

Determines the potential benefits of using literature webbing in books with predictable narratives. Finds webbing to be an effective means for improving comprehension, reading ability, and story structure knowledge. (RS)