From rhetoric to reality: consumer engagement in 16 multi-stakeholder alliances

OBJECTIVE

A key component of the Aligning Forces for Quality (AF4Q) program was engaging consumers in their health and healthcare. We examined the extent to which the alliances embraced 4 areas of consumer engagement: self-management, consumer friendliness of reports of healthcare provider quality, involvement of consumers in alliance governance, and the integration of consumers into quality improvement teams.

METHODS

We used a largely qualitative approach. The evaluation team conducted 1100 in-depth interviews with alliance stakeholders. Two authors reviewed the consumer engagement data for each alliance to assess its level of embrace in the 4 consumer engagement areas. For consumer friendliness of public reporting websites, we also assessed alliance public reports for reading level, technical language, and evaluable displays. Population-level effects were also examined for self-management and public reporting.

RESULTS

Consumer engagement was new to most alliances, and few had staff with consumer engagement expertise or existing consumer constituencies. For each area of consumer engagement, some alliances enthusiastically embraced the work, other alliances made a concerted but limited effort to develop programs, and a third group of alliances did the minimum work required. Integrating consumers into governance was the area most often embraced, followed by making public reports consumer friendly. Two alliances strongly embraced both self-management and integrating patients into quality improvement efforts. The AF4Q program did not have greater population level effects from self-management or public reporting than were those observed in a national comparison sample.

CONCLUSION

The AF4Q program sparked a few alliances to develop robust consumer engagement programming, while most alliances tried consumer engagement efforts for the first time and developed an appreciation for integrating consumer perspectives into their work.

Evaluating a complex, multi-site, community-based program to improve healthcare quality: the summative research design for the Aligning Forces for Quality initiative

OBJECTIVE

The Aligning Forces for Quality (AF4Q) initiative was the Robert Wood Johnson Foundation's (RWJF's) signature effort to increase the overall quality of healthcare in targeted communities throughout the country. In addition to sponsoring this 16-site complex program, RWJF funded an independent scientific evaluation to support objective research on the initiative's effectiveness and contributions to basic knowledge in 5 core programmatic areas. The research design, data, and challenges faced during the summative evaluation phase of this near decade-long program are discussed.

STUDY DESIGN

A descriptive overview of the summative research design and its development for a multi-site, community-based, healthcare quality improvement initiative is provided.

METHODS

The summative research design employed by the evaluation team is discussed.

RESULTS

The evaluation team's summative research design involved a data-driven assessment of the effectiveness of the AF4Q program at large, assessments of the impact of AF4Q in the specific programmatic areas, and an assessment of how the AF4Q alliances were positioned for the future at the end of the program.

CONCLUSION

The AF4Q initiative was the largest privately funded community-based healthcare improvement initiative in the United States to date and was implemented at a time of rapid change in national healthcare policy. The implementation of large-scale, multi-site initiatives is becoming an increasingly common approach for addressing problems in healthcare. The summative evaluation research design for the AF4Q initiative, and the lessons learned from its approach, may be valuable to others tasked with evaluating similarly complex community-based initiatives.

The longitudinal impact of Aligning Forces for Quality on measures of population health, quality and experience of care, and cost of care

OBJECTIVE

To summarize the results from the quantitative analyses conducted during the summative evaluation of the Aligning Forces for Quality (AF4Q) initiative.

STUDY DESIGN

Longitudinal design using linear difference-in-difference (DD) regression models with fixed effects. Outcomes were selected based on the AF4Q program logic model and organized according to the categories of the Triple Aim: improving population health, improving quality and experience of care, and reducing the cost of care.

DATA

Two primary data sources: the AF4Q Consumer Survey and the National Study of Physician Organizations (NSPO); and 4 secondary data sources: the Dartmouth Atlas Medicare claims database, the Truven Health MarketScan commercial claims database, the Behavioral Risk Factor Surveillance System (BRFSS), and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS).

RESULTS

In total, 144 outcomes were analyzed, 27 were associated with improving population health, 87 were associated with improving care quality and experience, and 30 were associated with reducing the cost of care. Based on the estimated DD coefficients, there is no consistent evidence that AF4Q regions, over the life of the program, showed greater improvement in these measures compared with the rest of the United States. For less than 12% of outcomes (17/144), the AF4Q initiative was associated with a significant positive impact (P ≤.05), although the magnitude of the impact was often small. Among the remaining outcomes, with some exceptions, similarly improving trends were observed in both AF4Q and non-AF4Q areas over the period of intervention. Conclusion and Policy and Practice Implications: Our quantitative findings, which suggest that the AF4Q initiative had less impact than expected, are potentially due to the numerous other efforts to improve healthcare across the United States, including regions outside the AF4Q program over the same period of time. The limited overall impact may also be due to the variability in the "dose" of the interventions across AF4Q regions. However, these results should not be interpreted as a conclusive statement about the AF4Q initiative. More nuanced discussions of the implementation of interventions in the specific AF4Q programmatic areas and their potential success (or lack thereof) in the participating communities are included in other articles in this supplement.

Summative evaluation results and lessons learned from the Aligning Forces for Quality program

OBJECTIVE

To report summative evaluation results from the Aligning Forces for Quality (AF4Q) initiative, the Robert Wood Johnson Foundation's (RWJF's) signature effort to improve quality of care from 2005 to 2015.

METHODS

This was a longitudinal mixed methods program evaluation (ie, multiphase triangulated evaluation) of 16 grantee "alliances" from across the country, funded by RWJF as part of the AF4Q initiative. Grantees were selected in a nonexperimental manner and were charged with deploying interventions in 5 main programmatic areas to improve health and healthcare in their communities.

RESULTS

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

Is Anyone Paying Attention to Physician Report Cards? The Impact of Increased Availability on Consumers' Awareness and Use of Physician Quality Information

OBJECTIVE

To determine if the release of health care report cards focused on physician practice quality measures leads to changes in consumers' awareness and use of this information.

PRIMARY DATA SOURCES

Data from two rounds of a survey of the chronically ill adult population conducted in 14 regions across the United States, combined with longitudinal information from a public reporting tracking database. Both data were collected as part of the evaluation for Aligning Forces for Quality, a nationwide quality improvement initiative funded by the Robert Wood Johnson Foundation.

STUDY DESIGN

Using a longitudinal design and an individual-level fixed effects modeling approach, we estimated the impact of community public reporting efforts, measured by the availability and applicability of physician quality reports, on consumers' awareness and use of physician quality information (PQI).

PRINCIPAL FINDINGS

The baseline level of awareness was 12.6 percent in our study sample, drawn from the general population of chronically ill adults. Among those who were not aware of PQI at the baseline, when PQI became available in their communities for the first time, along with quality measures that are applicable to their specific chronic conditions, the likelihood of PQI awareness increased by 3.8 percentage points. For the same group, we also find similar increases in the uses of PQI linked to newly available physician report cards, although the magnitudes are smaller, between 2 and 3 percentage points.

CONCLUSIONS

Specific contents of physician report cards can be an important factor in consumers' awareness and use of PQI. Policies to improve awareness and use of PQI may consider how to customize quality report cards and target specific groups of consumers in dissemination.

TNFα-activated mesenchymal stromal cells promote breast cancer metastasis by recruiting CXCR2+ neutrophils

Mesenchymal stromal cells (MSCs) tend to infiltrate into tumors and form a major component of the tumor microenvironment. Our previous work demonstrated that tumor necrosis factor α (TNFα)-activated MSCs significantly promoted tumor growth. However, the role of TNFα-treated MSCs in tumor metastasis remains elusive. Employing a lung metastasis model of murine breast cancer, we found that TNFα-activated MSCs strikingly enhanced tumor metastasis compared with normal MSCs. We analyzed the chemokine profiles and found that the expression of CCL5, CCR2 and CXCR2 ligands were enhanced in TNFα-activated MSCs. Using genetic or pharmacological strategies to inhibit CCL5 or CCR2, we demonstrated that CCL5 and CCR2 ligands were indispensable in supporting TNFα-activated MSCs to promote tumor metastasis. Analysis of immune cells revealed that CXCR2 ligands (CXCL1, CXCL 2 and CXCL5) expressed by TNFα-activated MSCs efficiently recruited CXCR2⁺ neutrophils into tumor. These neutrophils were responsible for the pro-metastatic effect of MSCs since inhibition of this chemotaxis abolished increased neutrophil recruitment and tumor metastasis. The interaction between neutrophils and tumor cells resulted in markedly elevated metastasis-related genes by tumor cells, including CXCR4, CXCR7, MMP12, MMP13, IL-6 and TGFβ. Importantly, in IL8^high human breast cancer samples, we also observed similar alterations of gene expression. Collectively, our findings demonstrate that TNFα-activated MSCs promote tumor metastasis via CXCR2⁺ neutrophil recruitment.

Using multi-stakeholder alliances to accelerate the adoption of health information technology by physician practices

BACKGROUND

Multi-stakeholder alliances - groups of payers, purchasers, providers, and consumers that work together to address local health goals - are frequently used to improve health care quality within communities. Under the Aligning Forces for Quality (AF4Q) initiative, multi-stakeholder alliances were given funding and technical assistance to encourage the use of health information technology (HIT) to improve quality. We investigated whether HIT adoption was greater in AF4Q communities than in other communities.

METHODS

Drawing upon survey data from 782 small and medium-sized physician practices collected as part of the National Study of Physician Organizations during July 2007 - March 2009 and January 2012-November 2013, we used weighted fixed effects models to detect relative changes in four measures representing three domains: use of electronic health records (EHRs), receipt of electronic information from hospitals, and patients' online access to their medical records.

RESULTS

Improvement on a composite EHR adoption measure was 7.6 percentage points greater in AF4Q communities than in non-AF4Q communities, and the increase in the probability of adopting all five EHR capabilities was 23.9 percentage points greater in AF4Q communities. There was no significant difference in improvement in receipt of electronic information from hospitals or patients' online access to medical records between AF4Q and non-AF4Q communities.

CONCLUSION

By linking HIT to quality improvement efforts, AF4Q alliances may have facilitated greater adoption of EHRs in small and medium-sized physician practices, but not receipt of electronic information from hospitals or patients' online access to medical records.

IMPLICATIONS

Multi-stakeholder alliances charged with promoting HIT to advance quality improvement may accelerate adoption of EHRs.

Genetic polymorphisms of loci D18S53, D18S59, and D18S488 in fetuses from a Chinese Tianjin Han population

We investigated the genetic polymorphisms of three short tandem repeat (STR) loci, D18S53, D18S59, and D18S488, on chromosome 18 in fetuses from a Chinese Tianjin Han population. Sixty-four villus samples and 374 amniotic fluid samples were collected from fetuses. Quantitative fluorescence polymerase chain reaction was performed to amplify the STR loci, followed by scanned electrophoresis and quantitative analysis of the fluorescence signals. Hardy-Weinberg equilibrium (HWE) analysis was performed based on the genotype distributions of the STR loci to obtain the following population genetic data: genotype frequency, heterozygosity of observation (HO), polymorphism information content (PIC), probability of discrimination power (PD), and probability of exclusion (PE). We detected 15, 13, and 15 alleles of D18S53, D18S59, and D18S488, respectively. The genotype frequencies were found to be in line with HWE. The HO values of the three loci, D18S53, D18S59, and D18S488, were 0.797, 0.847, and 0.792; the PIC values were 0.81, 0.75, and 0.73; the PD values were 0.944, 0.901, and 0.881; and the PE values were 0.593, 0.689, and 0.585, respectively. D18S53, D18S59, and D18S488 loci are good genetic markers of chromosome 18, and show potential for use in the prenatal genetic diagnosis of Edwards' syndrome.

Impact of emergency department visit on disease self-management in adults with depression

Unexpected health-endangering events that lead to an emergency department visit may be perceived as “wake-up calls” and induce significant changes in health-related behavior (“health shock” effect). This study uses two waves of a survey of 826 adults with depression and finds that having an emergency department visit(s) increased medication adherence by 7.6 percentage points ( p < 0.05) relative to non-emergency department visitors but had no significant effect on counseling attendance (0.02% points, p = 0.380). Emergency department visits may provide an opportune teachable moment to initiate targeted interventions for positive behavioral change in adults with depression.

[Effect of hydroquinone on the histone deacetylase in human bone marrow mononuclear cells]

OBJECTIVE

To observe the activity of histone deacetylase and the mRNA expression level of HDAC1 and HDAC2 in human bone marrow mononuclear cells, which induced by hydroquinone and exposed to hydroquinone plus Trichostatin as a histone deacetylase inhibitor for 10 hours respectively.

METHODS

Collect the bone marrow mononuclear cells suspension,divided into control group,HQ group (3 h, 6 h, 12 h, 24 h) , HQ+TSA 10 h group and HQ 10 h group. Extract the nuclear proteins and RNA, test the activity of histone deacetylase with the colorimetric HDAC assay kit and detect the mRNA expression level of HDAC1 and HDAC2 by real-time Polymerase Chain Reaction (PCR).

RESULTS

The HDAC activity of HQ3 h group, HQ6 h group and HQ12 h group were 1.31 times, 1.53 times and 1.148 times than that of control group respectively. And the difference was statistically significant (P<0.05). Except the HQ24 h group (P>0.05) , the HDAC1 mRNA expression of HQ3 h group, HQ6 h group and HQ12 h group were 1.173 times, 1.901 times and 2.348 times than that of control group respectively. And the difference was statistically significant (P<0.05). The HDAC2 mRNA expression of HQ6 h group and HQ12 h group were 1.426 times and 1.766 times than that of the control group respectively. And the difference was statistically significant (P<0.05). No significant difference was observed between HQ3 h group, HQ24 h group and control group (P>0.05). The cells were treated by hydroquinone plus TSA for 10 hours. The HDAC activity of HQ+TSA 10h group was reduced by 25.6% than that of HQ 10 h group (P<0.05) and rised 13.0% compared to the control group (P<0.05). And the difference was statistically significant between groups (P<0.05) .The cells were treated by hydroquinone plus TSA for 10 hours. The HDAC1 mRNA expression of the HQ+TSA 10h group is reduced by 26.9% than that of HQ10h group. The HDAC2 mRNA expression is reduced by 19.3% compared to the HQ 10h group.And the difference was statistically significant between groups (P<0.05). The HDAC1 and HDAC2 mRNA expression is obviously higher than the control group, the difference was statistically significant (P<0.05).

CONCLUSION

Treatment of hydroquinone, the histone deacetylase activity and the mRNA expression of HDAC1 and HDAC2 were increased in a certain time range. The histone deacetylase inhibitor (TSA) can reduce the histone deacetylase activity and the mRNA expression level of HDAC1 and HDAC2 in the bone marrow mononuclear cell induce by hydroquinone.It can be confirmed that hematopoietic damage induced by the benzene metabolites is related to the histone acetylation modification level.

Community-Level Quality Improvement and the Patient Experience for Chronic Illness Care

OBJECTIVE

To determine whether chronically ill adults from communities participating in a community-level quality improvement effort reported greater improvement on four domains of patient experience: care coordination, patient satisfaction, provider interaction and support, and receipt of recommended care for diabetes.

STUDY SETTING

The Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) initiative provides multistakeholder alliances with funding and technical assistance to improve quality in their communities.

STUDY DESIGN

This is a quasi-experimental, pre-post study. We used a difference-in-difference approach to detect relative changes over time on 16 survey-based outcome measures representing the four patient experience domains.

DATA COLLECTION

We surveyed adults with chronic illness(es) in 14 AF4Q communities and a national comparison group. Wave 1 was completed in 2008 (8,140 respondents) and wave 2 in 2012 (9,565 respondents).

PRINCIPAL FINDINGS

Respondents from AF4Q communities reported modestly greater improvement on patient satisfaction and receipt of recommended care for diabetes.

CONCLUSIONS

Results suggest that community-level QI efforts led by multistakeholder alliances hold the potential to improve patient satisfaction and receipt of recommended care for diabetes, but the magnitude of the effect may be limited. However, there is less evidence that community-level QI can improve patient perceptions of care coordination or provider interaction and support.

Blue-emitting and amphibious metal (Cu, Ni, Pt, Pd) nanodots prepared within supramolecular polymeric micelles

We propose a new method for the preparation of blue-emitting and amphibious metal (Cu, Ni, Pt, Pd) nanodots using supramolecular polymeric micelle nanoreactors ​for cellular imaging applications.

[Study on RBC Oxygen-Carrying Function with the Incubation Time]

The cycle of Hemoglobin oxygenation and deoxidation plays an important role in driving structure and regulating function of red blood cell in vivo, has attracted wide attention. But it has not yet been reported about any studies on the oxygen-carrying function of individual living RBC in vitro with the incubation time. This study involved that using confocal Raman scanning microscopic technique, collecting the Raman spectra of living erythrocyte cultured in vitro at different time, analysing the peaks (1636, 1562 cm⁻¹) with characterization of hemoglobin oxygen carrying capacity and the amide III band (1240-1300 cm⁻¹) with sensitivity to conformation for understanding those changes both of hemoglobin oxygen carrying capacity and protein conformation over time. Meanwhile, its corresponding surface micromorphology was observed via scanning electron microscopy (SEM). The results indicated that the during 24 h hemoglobin with stable structure and normal allosteric collaborative function occurred alternately with the oxygen uptake of increase and decrease and conformation K state and T state, while double concave disk red blood cells observed under SEM also alternately between stretch and shrink. The conclusion not only provides a multi-level characteristic parameter from a single living cell for the study of RBC oxygen-carrying function in vitro, but also the potential research ideas for the screening of the active component, the evaluation of drug efficacy and toxicity for RBC in vitro.

Measuring the Dose of Quality Improvement Initiatives

Although intervention dose-defined as the quality and quantity of an intervention and participation-might be key to understanding why some multisite quality improvement (QI) initiatives work and others do not, evaluations rarely consider dose, and there is no widely accepted method for measuring it. In this exploratory study, the authors examined the literature on QI dose, identified four methods for measuring QI dose, applied them to 14 communities participating in a QI initiative, examined whether the dose scores aligned with perceptions of QI dose among individuals knowledgeable of the initiative, and report on lessons learned. They conclude it is feasible to measure QI dose and found a high level of concordance between scores on a comprehensive dose measure and knowledgeable informants' perceptions. However, measuring QI dose presents many challenges, including subjective decisions about the elements of dose to include in a measure and the need for extensive data collection.

Wetting of mono and few-layered WS2 and MoS2 films supported on Si/SiO2 substrates

The recent interest and excitement in graphene has also opened up a pandora's box of other two-dimensional (2D) materials and material combinations which are now beginning to come to the fore. One family of these emerging 2D materials is transition metal dichalcogenides (TMDs). So far there is very limited understanding on the wetting behavior of "monolayer" TMD materials. In this study, we synthesized large-area, continuous monolayer tungsten disulfide (WS2) and molybdenum disulfide (MoS2) films on SiO2/Si substrates by the thermal reduction and sulfurization of WO3 and MO3 thin films. The monolayer TMD films displayed an advancing water contact angle of ∼83° as compared to ∼90° for the bulk material. We also prepared bilayer and trilayer WS2 films and studied the transition of the water contact angle with increasing number of layers. The advancing water contact angle increased to ∼85° for the bilayer and then to ∼90° for the trilayer film. Beyond three layers, there was no significant change in the measured water contact angle. This type of wetting transition indicates that water interacts to some extent with the underlying silica substrate through the monolayer TMD sheet. The experimentally observed wetting transition with numbers of TMD layers lies in-between the predictions of one continuum model that considers only van der Waals attractions and another model that considers only dipole-dipole interactions. We also explored wetting as a function of aging. A clean single-layer WS2 film (without airborne contaminants) was shown to be strongly hydrophilic with an advancing water contact angle of ∼70°. However, over time, the sample ages as hydrocarbons and water present in air adsorb onto the clean WS2 sheet. After ∼7 days, the aging process is completed and the advancing water contact angle of the aged single-layer WS2 film stabilizes at ∼83°. These results suggest that clean (i.e., nonaged) monolayer TMDs are hydrophilic materials. We further show that substitution of sulfur atoms by oxygen in the lattice of aged monolayer WS2 and MoS2 films can be used to generate well-defined 'hydrophobic-hydrophilic' patterns that preferentially accumulate and create microdrop arrays on the surface during water condensation and evaporation experiments.

Are healthcare quality "report cards" reaching consumers? Awareness in the chronically ill population

BACKGROUND

Significant investments have been made to provide comparative healthcare quality information (CQI) to the public, but whether these efforts are increasing awareness of CQI is unknown.

OBJECTIVES

To provide regional estimates of change in awareness of CQI among the chronically ill population residing in 14 geographic regions of the United States between 2008 and 2012. Additionally, to examine its correlation with the changes in the availability of quality reports.

STUDY DESIGN

Data from 2 waves (2008 and 2012) of a random-digit dial survey of 11,896 adults with chronic illness.

METHODS

Regression-adjusted change in the percentage of respondents aware of physician and hospital CQI, and Pearson correlations between regional change in awareness of CQI and regional change in availability of quality reports.

RESULTS

While the number of reports on both hospital quality and physician quality increased between 2008 and 2012, there was significant change in awareness of only physician CQI (12.8% to 16.2%, regression-adjusted change of 3.7 percentage points; P < .05). No significant correlation was found between the change in awareness of CQI and the change in availability of hospital quality reports or physician quality reports.

CONCLUSIONS

Awareness of physician CQI among the chronically ill increased modestly between 2008 and 2012, but no significant increase in awareness of hospital quality was observed. As efforts to report CQI accelerate, more attention to approaches to dissemination may be warranted in order to increase awareness in the chronically ill population.

Taking the long view: how well do patient activation scores predict outcomes four years later?

Patient activation is an important predictor of health outcomes and health care usage, yet we do not know how enduring the benefits of greater patient activation are. This study uses a large panel survey of people with chronic conditions (n = 4,865) to examine whether a baseline patient activation measure predicts outcomes 4 years later, and whether changes in patient activation measure scores are associated with changes in outcomes. The findings indicate that the benefits of health activation are enduring, yielding benefits in the form of better self-management, improved functioning, and lower use of costly health care services over time. Furthermore, the findings indicate that when activation levels change, many outcomes change in the same direction. Patient activation seems to be an important and modifiable factor for influencing chronic disease outcomes; health care delivery systems can use this information to personalize and improve care.

Isoleojaponin, a new Halimane diterpene isolated from Leonurus japonicus

Leojaponin (2), a labdane diterpene, was isolated from the EtOH extract of the herb of Leonurus japonicus together with a new halimane diterpene named isoleojaponin (1). Isoleojaponin has a new diterpene skeleton with a unique cross-conjugated α,β-unsaturated ketone system, Their structures were elucidated by physical and spectroscopic analysis, and the relative configuration of the chiral C-9 carbon was determined by a computational method, and analysis of its possible biogenesis pathways.

Racial-ethnic disparities in use of antidepressants in private coverage: implications for the Affordable Care Act

OBJECTIVE

The objective of this study was to examine racial-ethnic disparities in the use of antidepressants among people with private coverage and people with public insurance or no coverage.

METHODS

Data were from Medical Expenditure Panel Surveys (2006-2010), and logistic regression was used for the analysis.

RESULTS

Among persons with depression and private coverage, racial-ethnic minority groups were significantly less likely than non-Hispanic whites to use antidepressants (N=4,468; adjusted odds ratio [AOR]=.50, 95% confidence interval [CI]=.33-.66 for non-Hispanic blacks; AOR=.70, CI=.55-.89 for Hispanics). No significant racial-ethnic disparity in the use of antidepressants was found in Medicare (N=1,944), Medicaid (N=2,125), and uninsured populations (N=1,679). For all racial-ethnic groups, persons with no insurance coverage had much lower rates of antidepressant use than their insured counterparts.

CONCLUSIONS

A wide racial-ethnic gap in the use of antidepressants existed in private coverage. As the nation continues to implement the Affordable Care Act, which will increase the number of enrollees from racial-ethnic minority groups in private plans, continuing efforts will be needed to reduce racial-ethnic disparities in the use of antidepressants.

iTRAQ-based proteomic profiling of the marine medaka (Oryzias melastigma) gonad exposed to BDE-47

A recent study demonstrated that 2,2',4,4'-tetrabromodiphenyl ether (BDE-47) may have an adverse effect on the reproduction in marine medaka (Oryzias melastigma), but the molecular mechanisms remain largely unknown. In this study, we investigated the protein expression profiles of male and female gonads of O. melastigma exposed to dietary BDE-47 at two dosages (0.65 and 1.30 μg/g/day, respectively) for 21 days. Extracted proteins were labeled with iTRAQ and analyzed on a MALDI TOF/TOF analyzer, as results, 133 and 144 unique proteins were identified in testis and ovary, respective, and they exerted dose- and sex-dependent expression patterns. In testis, among the 42 differentially expressed proteins; down-regulation of histone variants and parvalbumins implicated BDE-47 may disrupt the spermatogenesis and induce sterility in fishes. In ovary, 38 proteins were differentially expressed; the elevation of vitellogenins and apolipoprotein A-I expression indicated BDE-47 acts as an estrogen-mimicking compound and led to reproductive impairment in O. melastigma.

Assessing organizational change in multisector community health alliances

OBJECTIVE

The purpose of this article was to identify some common organizational features of multisector health care alliances (MHCAs) and the analytic challenges presented by those characteristics in assessing organizational change.

DATA SOURCES

Two rounds of an Internet-based survey of participants in 14 MHCAs.

STUDY DESIGN

We highlight three analytic challenges that can arise when quantitatively studying the organizational characteristics of MHCAs-assessing change in MHCA organization, assessment of construct reliability, and aggregation of individual responses to reflect organizational characteristics. We illustrate these issues using a leadership effectiveness scale (12 items) validated in previous research and data from 14 MHCAs participating in the Robert Wood Johnson Foundation's Aligning Forces for Quality (AF4Q) program.

FINDINGS

High levels of instability and turnover in MHCA membership create challenges in using survey data to study changes in key organizational characteristics of MHCAs. We offer several recommendations to diagnose the source and extent of these problems.

Seeking health information online: does limited healthcare access matter?

Consumers facing barriers to healthcare access may use online health information seeking and online communication with physicians, but the empirical relationship has not been sufficiently analyzed. Our study examines the association of barriers to healthcare access with consumers' health-related information searching on the internet, use of health chat groups, and email communication with physicians, using data from 27,210 adults from the 2009 National Health Interview Survey. Individuals with financial barriers to healthcare access, difficulty getting timely appointments with doctors, and conflicts in scheduling during clinic hours are more likely to search for general health information online than those without these access barriers. Those unable to get timely appointments with physicians are more likely to participate in health chat groups and email physicians. The internet may offer a low-cost source of health information and could help meet the heightened demand for health-related information among those facing access barriers to care.

Preparation and characterization of molecularly imprinted poly(hydroxyethyl methacrylate) microspheres for sustained release of gatifloxacin

Molecularly imprinted poly(hydroxyethyl methacrylate) microspheres (PHEMA MIPMs) were prepared via precipitation polymerization in this article, using gatifloxacin (GFLX), hydroxyethyl methacrylate (HEMA), and ethylene glycol dimethacrylate (EGDMA) as template molecule, functional monomer and cross-linker, respectively. The effects of reaction medium, initial total monomers, cross-linker and molecular imprinting on the polymerization were investigated systematically. The interaction between GFLX and HEMA in pre-solution was studied by UV-Visible spectrophotometer, both size and morphology of products were characterized by a scanning electron microscope. When the total initial monomer concentration was 1 vol%, EGDMA content was 70 mol%, a group of uniform PHEMA MIPMs were prepared at different GFLX/MAA molar ratios, with diameter range from 2.06 ± 0.07 to 2.82 ± 0.20 μm. The results of drug loading and in vitro release experiments demonstrated that PHEMA MIPMs could achieve a higher GFLX loading content and a more acceptable sustained release than non-imprinted ones.

Attrition in Chronic Disease Self-Management Programs and Self-Efficacy at Enrollment

Among other goals, the Chronic Disease Self-Management Program (CDSMP) is designed to improve self-efficacy of the chronically ill. However, a substantial proportion of the enrollees often leave CDSMPs before completing the program curriculum. This study examines factors associated with program attrition in a CDSMP implemented in a community setting. We used data from the Our Pathways to Health program, implemented in Humboldt County, California, from 2008 to 2011. Our conceptual framework is based on Bandura’s self-efficacy theory, and we used logistic regression to investigate whether baseline self-efficacy and other members’ efficacy are associated with participants dropping out of the CDSMP. Twenty-three percent of the participants did not complete the program similar to previous studies. Lower baseline self-efficacy increased the odds of dropout, but other members’ efficacy was not associated with differential odds of dropout. Age, educational difference between the individual and the group, weekday sessions, and social/role activity limitations are also found to be associated with program attrition. Our results suggest that participants with low starting self-efficacy may need extra help to complete the program. Further research is needed to understand how to effectively provide additional support to this group.

In situ preparation of fluorescent CdTe quantum dots with small thiols and hyperbranched polymers as co-stabilizers

A new strategy for in situ preparation of highly fluorescent CdTe quantum dots (QDs) with 3-mercaptopropionic acid (MPA) and hyperbranched poly(amidoamine)s (HPAMAM) as co-stabilizers was proposed in this paper. MPA and HPAMAM were added in turn to coordinate Cd2+. After adding NaHTe and further microwave irradiation, fluorescent CdTe QDs stabilized by MPA and HPAMAM were obtained. Such a strategy avoids the aftertreatment of thiol-stabilized QDs in their bioapplication and provides an opportunity for direct biomedical use of QDs due to the existence of biocompatible HPAMAM. The resulting CdTe QDs combine the mechanical, biocompatibility properties of HPAMAM and the optical, electrical properties of CdTe QDs together.

Facile preparation of highly luminescent CdTe quantum dots within hyperbranched poly(amidoamine)s and their application in bio-imaging

A new strategy for facile preparation of highly luminescent CdTe quantum dots (QDs) within amine-terminated hyperbranched poly(amidoamine)s (HPAMAM) was proposed in this paper. CdTe precursors were first prepared by adding NaHTe to aqueous Cd2+ chelated by 3-mercaptopropionic sodium (MPA-Na), and then HPAMAM was introduced to stabilize the CdTe precursors. After microwave irradiation, highly fluorescent and stable CdTe QDs stabilized by MPA-Na and HPAMAM were obtained. The CdTe QDs showed a high quantum yield (QY) up to 58%. By preparing CdTe QDs within HPAMAM, the biocompatibility properties of HPAMAM and the optical, electrical properties of CdTe QDs can be combined, endowing the CdTe QDs with biocompatibility. The resulting CdTe QDs can be directly used in biomedical fields, and their potential application in bio-imaging was investigated.

Pay-for-performance and public reporting program participation and administrative challenges among small- and medium-sized physician practices

A key component of efforts to improve the quality of care in the United States is the use of public reporting and pay-for-performance programs. Little is known, however, about the extent to which small- and medium-sized physician practices are participating in these programs. This study examined the participation of small- and medium-sized physician practices in pay-for-performance and public reporting programs and the characteristics of the participating practices. Using cross-sectional data from a national sample of 1,734 small- and medium-sized physician practices throughout the United States, we found that many practices (61.2%) were participating in at least one program, while far fewer (19.2%) were participating in multiple programs. Among practices participating in multiple programs, relatively few (21.9%) reported high levels of administrative problems due to a lack of standardization on performance measures. The study also suggests that some structural features are associated with participation and may provide leverage points for fostering participation.

National trends in the use of antidepressants between 1997 and 2009 and the role of Medicare Part D implementation

OBJECTIVES

This study examined national trends in antidepressant use before and after implementation of Medicare Part D and compared utilization among individuals with different types of insurance.

METHODS

The data source was the Medical Expenditure Panel Survey Household Component (1997-2009), and logistic regression was used for the analysis.

RESULTS

The odds of antidepressant use among people with depression increased between 1997 and 2009 in each insurance group (Medicare: adjusted odds ratio [AOR]=3.30, 95% confidence interval [CI]=1.84-5.92; Medicaid: AOR=2.97, CI=2.01-4.40; dually eligible for Medicare and Medicaid: AOR=2.24, CI=1.11-4.54; and private coverage: AOR=6.63, CI=5.23-8.42). The odds of antidepressant use after implementation of Part D increased more among Medicare beneficiaries than among Medicaid beneficiaries (AOR=1.35, CI=1.05-1.72).

CONCLUSIONS

The use of antidepressants among people with depression increased in all insurance groups up to 2009; however, the patterns of utilization and the degree of increase over time differed by insurance type.

Graphene drape minimizes the pinning and hysteresis of water drops on nanotextured rough surfaces

Previous studies of the interaction of water with graphene-coated surfaces have been limited to flat (smooth) surfaces. Here we created a rough surface by nanopatterning and then draped the surface with a single-layer graphene sheet. We found that the ultrasheer graphene drape prevents the penetration of water into the textured surface thereby drastically reducing the contact angle hysteresis (which is a measure of frictional energy dissipation) and preventing the liquid contact line from getting pinned to the substrate. This has important technological implications since the main obstacle to the motion of liquid drops on rough surfaces is contact angle hysteresis and contact line pinning. Graphene drapes could therefore enable enhanced droplet mobility which is required in a wide range of applications in micro and nanofluidics. Compared to polymer coatings that could fill the cavities between the nano/micropores or significantly alter the roughness profile of the substrate, graphene provides the thinnest (i.e., most sheer) and most conformal drape that is imaginable. Despite its extreme thinness, the graphene drape is mechanically robust, chemically stable, and offers high flexibility and resilience which can enable it to reliably drape arbitrarily complex surface topologies. Graphene drapes may therefore provide a hitherto unavailable ability to tailor the dynamic wettability of surfaces for a variety of applications.

Facile preparation of luminescent and intelligent gold nanodots based on supramolecular self-assembly

A new strategy for preparing luminescent and intelligent gold nanodots based on supramolecular self-assembly is described in this paper. The supramolecular self-assembly was initiated through electrostatic interactions and ion pairing between palmitic acid and hyperbranched poly(ethylenimine). The resulting structures not only have the dynamic reversible properties of supramolecules but also possess torispherical and highly branched architectures. Thus they can be regarded as a new kind of ideal nanoreactor for preparing intelligent Au nanodots. By preparing Au nanodots within this kind of supramolecular self-assembly, the environmental sensitivity of intelligent polymers and the optical, electrical properties of Au nanodots can be combined, endowing the Au nanodots with intelligence. In this paper, a supramolecular self-assembly process based on dendritic poly(ethylenimine) and palmitic acid was designed and then applied to prepare fluorescent and size-controlled Au nanodots. The pH response of Au nanodots embodied by phase transfer from oil phase to water phase was also investigated.

The patient-centered medical home and patient experience

OBJECTIVE

To examine the relationship between practices' reported use of patient-centered medical home (PCMH) processes and patients' perceptions of their care experience.

DATA SOURCE

Primary survey data from 393 physician practices and 1,304 patients receiving care in those practices.

STUDY DESIGN

This is an observational, cross-sectional study. Using standard ordinary least-squares and a sample selection model, we estimated the association between patients' care experience and the use of PCMH processes in the practices where they receive care.

DATA COLLECTION

We linked data from a nationally representative survey of individuals with chronic disease and two nationally representative surveys of physician practices.

PRINCIPAL FINDINGS

We found that practices' use of PCMH processes was not associated with patient experience after controlling for sample selection as well as practice and patient characteristics.

CONCLUSIONS

In our study, which was large, but somewhat limited in its measures of the PCMH and of patient experience, we found no association between PCMH processes and patient experience. The continued accumulation of evidence related to the possibilities of the PCMH, how PCMH is measured, and how the impact of PCMH is gauged provides important information for health care decision makers.