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Background: Pharmacogenomic testing can optimize drug efficacy and minimize adverse effects. CYP3A5 polymorphisms affect the metabolism of tacrolimus. We sought to estimate the budget impact of preemptive pharmacogenomic testing for CYP3A5 in pediatric heart transplantation patients from an institutional perspective., Methods: A decision tree was constructed to estimate the budget impact of pediatric heart transplant patients (age ≤18 years) initiated on tacrolimus with and without CYP3A5 pharmacogenomic testing. The budget impact of preemptive pharmacogenomic testing versus no pharmacogenomic testing was calculated. One-way sensitivity analysis and alternative analyses were conducted to assess the robustness of results to changes in model parameters., Results: CYP3A5 genotype-guided dosing provided savings of up to $17 225 per patient compared to standard dosing. These savings decreased to $11 759 when using another institution's data for the standard-dosing group. The time to achieve therapeutic concentration in the poor metabolizer genotype-guided dosing group had the largest impact on cost savings while the cost of the pharmacogenetic test had the smallest impact on cost savings., Conclusion: Implementing CYP3A5 testing could save $17 225 per pediatric heart transplant patient receiving tacrolimus. As pharmacogenomic testing becomes more widespread, institutions should track resource requirements and outcomes to determine the best implementation policies going forward., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

States may lose up to 10% of their budgets for vaccinations., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To assess the effect of the Global Budget Revenue (GBR) program on outcomes after surgery., Background: There is limited data summarizing the effect of the GBR program on surgical outcomes as compared with traditional fee-for-service systems., Methods: The Medline, Embase, Scopus, and Web of Science databases were used to conduct a systematic literature search on April 5, 2022. We identified full-length reports of comparative studies involving patients who underwent surgery in Maryland after implementation of the GBR program. A random effects model calculated the overall pooled estimate for each outcome which included complications, rates of readmission and mortality, length of stay, and costs., Results: Fourteen studies were included in the qualitative synthesis, with 8 unique studies included in the meta-analysis. Our analytical sample was comprised of 170,011 Maryland patients, 78,171 patients in the pre-GBR group, and 91,840 patients in the post-GBR group. The pooled analysis identified modest reductions in costs [standardized mean difference (SMD) -0.34; 95% CI, -0.42, -0.25; P <0.001], complications [odds ratio (OR): 0.57; 95% CI, 0.36-0.92, P =0.02], readmission (OR: 0.78; 95% CI, 0.72-0.85, P <0.001), mortality (OR: 0.58; 95% CI, 0.47-0.72, P <0.001), and length of stay (standardized mean difference: -0.26; 95% CI, -0.32, -0.2, P <0.001) after surgery., Conclusions: Implementation of the GBR program is associated with improved outcomes and reductions in costs among Maryland patients who underwent surgical procedures. This is particularly salient given the increasing need to disseminate and scale population-based payment models that improve patient care while controlling health care costs., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

In Pierce County, Washington, 6 Communities of Focus face tough health disparities. To engage members of communities that have been marginalized for generations, Tacoma-Pierce County Health Department piloted participatory budgeting. Through this 5-step process, the health department and its partners make investments significant enough to bring community members to the table, codesign solutions, and put the final decision-making power to fund programs and services in their hands. Sharing power through this process is an innovative approach and has been adapted during the COVID-19 pandemic to build trust essential to resilience and recovery. After a series of successful projects bringing participatory budgeting to scale, the Public Health Centers for Excellence is piloting participatory policy making and disseminating both practices broadly., Competing Interests: The author declares they have no conflict of interest related to the submitted work., (Copyright © 2022 The Author. Published by Wolters Kluwer Health, Inc.)

Background: In 2014, Maryland established a global budget policy for all hospitals in the state. Under this policy, hospitals are incentivized to not only provide clinical care services to individual patients but also address the health needs of their broader patient population through prevention efforts and investment in the upstream social and economic factors that determine health., Purpose: To better understand the incentives created for hospitals under this policy, our study assessed whether the implementation of global budgets changed the levels and patterns of Maryland hospitals' investments in community benefits., Approach: Data on hospital community benefit spending from the Internal Revenue Service Form 990 Schedule H for the years 2010-2016 were utilized for this study., Results: We found that Maryland hospitals' total spending on community benefits decreased under the global budget policy. Unlike hospitals in similar states without a global budget policy, Maryland hospitals did not experience any increases in Medicaid shortfalls between 2014 and 2016. Although Maryland hospitals provided more subsidized health services, their investment in broader community health improvement activities remained unchanged., Conclusion: Our analysis suggests that Maryland hospitals have shifted strategies because of the implementation of the global budget policy. The ability to report community benefit in a way that accurately considers the context and constraints of a state's policies would provide hospitals better means of communicating these efforts to stakeholders., Practice Implications: Our results suggest that global budgets impact the levels and patterns of hospitals' community benefit investments., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Accountable care has changed organizational models adopted by health care organizations profoundly and, consequently, the skill set required for doctor-managers who have become middle managers and must deal with the operational management of their units. Doctor-managers must carry out clinical tasks as well as tasks related to budgeting, goal setting, and performance evaluation. The performance evaluation bias, defined as the misalignment between a ward unit's objective performance (as assessed by technical bodies or agencies) and self-assessed performance by the head of the unit, may have serious consequences for individuals and organizations., Purpose: The aim of this study was to identify determinants of performance appraisal bias based on the mismatch between self-reported and official performance data. Specifically, we analyzed the role played by managerial behavior, training, engagement, and perceived organizational support at the individual level, as well as the particular unit's task diversity, complexity, and predictability., Methodology: We collected primary and secondary data referable to a population of ward unit heads in the Italian National Health Service. A linear regression model predicting performance appraisal bias was employed., Findings: High levels of engagement and perceived organizational support were associated with reduced performance appraisal bias, whereas high levels of predictability and task diversity were associated with increased degree of error. Doctor-managers attending training programs in health care management and ward unit task complexity did not affect bias significantly., Practice Implications: Policy makers and hospital managers should provide heads of units with tools that enable them to conduct ongoing monitoring and accurate appraisal of performance. Doctor-manager performance appraisal bias may be diminished by a perception of having support of the organization and direct superiors. Training programs can be revised to incorporate performance appraisal, and good performance may be incentivized with rewards., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

The COVID-19 pandemic has revealed cracks in the nation's public health infrastructure., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Using an Internet-based survey for the fiscal year 2003 to 2004, 56 community-based family medicine residency programs participated in primary research of current financing and expenditures. A median of $194,125 was invested in training each resident annually. The bulk of funding stemmed from sponsoring institution support and clinical care revenues. The majority of programs did not receive Title VII funds, state, local, or philanthropic support. Clinical care activity continued a historical trend of increases. There were 1,076 patient visits per resident full-time equivalent, producing 39.5% of program financing. The percentage of visits provided to those with Medicaid was 35.9%. Expenses included a calculated malpractice rate of $17,097 per faculty full-time equivalent. This effort provides a database available for further expansion, a comparison to medical school-based residency programs, analyses for reflection on program characteristics, and future comparison of historical trends. [ABSTRACT FROM AUTHOR]

Objective: There are an estimated 38 million people with HIV (PWH), with significant economic consequences. We aimed to collate global lifetime costs for managing HIV., Design: We conducted a systematic review (PROSPERO: CRD42020184490) using five databases from 1999 to 2019., Methods: Studies were included if they reported primary data on lifetime costs for PWH. Two reviewers independently assessed the titles and abstracts, and data were extracted from full texts: lifetime cost, year of currency, country of currency, discount rate, time horizon, perspective, method used to estimate cost and cost items included. Descriptive statistics were used to summarize the discounted lifetime costs [2019 United States dollars (USD)]., Results: Of the 505 studies found, 260 full texts were examined and 75 included. Fifty (67%) studies were from high-income, 22 (29%) from middle-income and three (4%) from low-income countries. Of the 65 studies, which reported study perspective, 45 (69%) were healthcare provider and the remainder were societal. The median lifetime costs for managing HIV differed according to: country income level: $5221 [interquartile range (IQR)]: 2978-11 177) for low-income to $377 820 (IQR: 260 176-541 430) for high-income; study perspective: $189 230 (IQR: 14 794-424 069) for healthcare provider, to $508 804 (IQR: 174 781-812 418) for societal; and decision model: $190 255 (IQR: 13 588-429 772) for Markov cohort, to $283 905 (IQR: 10 558-453 779) for microsimulation models., Conclusion: Estimating the lifetime costs of managing HIV is useful for budgetary planning and to ensure HIV management is affordable for all. Furthermore, HIV prevention strategies need to be strengthened to avert these high costs of managing HIV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: In health care, important phenomena of perceived incompatibility between professional and managerial values have emerged as consequences of New Public Management reforms. Although there is a growing evidence on the variation in the enactment of hybrid roles by medical managers, existing research in health care management is mostly descriptive with little emphasis on the conditions under which hybrid roles are enacted and, importantly, on the effects of this variation on performance., Purpose: In this article, we seek to fill this research gap by empirically examining (a) whether budgetary participation aligns professional and organizational values, (b) the impact of this alignment on employees' work-related feelings and managerial performance, and (c) the effect of professional identity on value congruence., Methodology: Data were collected by a survey conducted in an Italian hospital, and partial least square was used to test the relationships among variables., Results: Overall, results show that (a) high involvement in budgeting is instrumental in facilitating medical managers' value congruence, and this, in turn, positively effects managerial job engagement; (b) the effect of budgetary participation on value congruence depends on the extent of professional identity; and (c) as a result of enhanced value congruence and managerial job engagement, employees tend to deliver superior role performance., Practice Implication: Findings of this study provide some guidance for managers on how organizations can take steps to guarantee effective support to hybrid professionals.

Objective: The objective of this study was to assess the potential health and budgetary impacts of implementing a pharmacist-involved team-based hypertension management model in the United States., Research Design: In 2017, we evaluated a pharmacist-involved team-based care intervention among 3 targeted groups using a microsimulation model designed to estimate cardiovascular event incidence and associated health care spending in a cross-section of individuals representative of the US population: implementing it among patients with: (1) newly diagnosed hypertension; (2) persistently (≥1 year) uncontrolled blood pressure (BP); or (3) treated, yet persistently uncontrolled BP-and report outcomes over 5 and 20 years. We describe the spending thresholds for each intervention strategy to achieve budget neutrality in 5 years from a payer's perspective., Results: Offering this intervention could prevent 22.9-36.8 million person-years of uncontrolled BP and 77,200-230,900 heart attacks and strokes in 5 years (83.8-174.8 million and 393,200-922,900 in 20 years, respectively). Health and economic benefits strongly favored groups 2 and 3. Assuming an intervention cost of $525 per enrollee, the intervention generates 5-year budgetary cost-savings only for Medicare among groups 2 and 3. To achieve budget neutrality in 5 years across all groups, intervention costs per person need to be around $35 for Medicaid, $180 for private insurance, and $335 for Medicare enrollees., Conclusions: Adopting a pharmacist-involved team-based hypertension model could substantially improve BP control and cardiovascular outcomes in the United States. Net cost-savings among groups 2 and 3 make a compelling case for Medicare, but favorable economics may also be possible for private insurers, particularly if innovations could moderately lower the cost of delivering an effective intervention.

Unexplained fever is one of the most common and difficult diagnostic problems faced daily by clinicians. This study evaluated the differences in health service utilization, health care expenditures, and quality of care provided to patients with unexplained fever before and after global budget (GB) implementation in Taiwan.The National Health Insurance Research Database was used for analyzing the health care expenditures and quality of care before and after implementation of the GB system. Patients diagnosed as having unexplained fever during 2000-2001 were recruited; their 2000-2001 and 2004-2005 data were considered baseline and postintervention data, respectively.Data of 259 patients with unexplained fever were analyzed. The mean lengths of stay (LOSs) before and after GB system implementation were 4.22 ± 0.35 days and 5.29 ± 0.70 days, respectively. The mean costs of different health care expenditures before and after implementation of the GB system were as follows: the mean diagnostic, drug, therapy, and total costs increased respectively from New Taiwan Dollar (NT$) 1440.05 ± NT$97.43, NT$3249.90 ± NT$1108.27, NT$421.03 ± NT$100.03, and NT$13,866.77 ± NT$2,114.95 before GB system implementation to NT$2224.34 ± NT$238.36, NT$4272.31 ± NT$1466.90, NT$2217.03 ± NT$672.20, and NT$22,856.41 ± NT$4,196.28 after implementation. The mean rates of revisiting the emergency department within 3 days and readmission within 14 days increased respectively from 10.5% ± 2.7% and 8.3% ± 2.4% before implementation to 6.3% ± 2.2% and 4.0% ± 1.7% after implementation.GB significantly increased LOS and incremental total costs for patients with unexplained fever; but improved the quality of care.

Background: Global budgets have been proposed as a way to control health care expenditures, but experience with them in the United States is limited. Global budgets for Maryland hospitals, the All-Payer Model, began in January 2014., Objectives: To evaluate the effect of hospital global budgets on health care utilization and expenditures., Research Design: Quantitative analyses used a difference-in-differences design modified for nonparallel baseline trends, comparing trend changes from a 3-year baseline period to the first 3 years after All-Payer Model implementation for Maryland and a matched comparison group., Subjects: Hospitals in Maryland and matched out-of-state comparison hospitals. Fee-for-service Medicare beneficiaries residing in Maryland and comparison hospital market areas., Measures: Medicare claims were used to measure total Medicare expenditures; utilization and expenditures for hospital and nonhospital services; admissions for avoidable conditions; hospital readmissions; and emergency department visits. Qualitative data on implementation were collected through interviews with senior hospital staff, state officials, provider organization representatives, and payers, as well as focus groups of physicians and nurses., Results: Total Medicare and hospital service expenditures declined during the first 3 years, primarily because of reduced expenditures for outpatient hospital services. Nonhospital expenditures, including professional expenditures and postacute care expenditures, also declined. Inpatient admissions, including admissions for avoidable conditions, declined, but, there was no difference in the change in 30-day readmissions. Moreover, emergency department visits increased for Maryland relative to the comparison group., Conclusions: This study provides evidence that hospital global budgets as implemented in Maryland can reduce expenditures and unnecessary utilization without shifting costs to other parts of the health care system.

Introduction: Globally, there is increased focus on getting the greatest impact from available health funding. However, the pursuit of overall welfare maximization may mean some are left worse off than before. Pareto efficiency takes welfare shifts into account by ruling out funding reallocations that worsen outcomes for any person or group., Methods: Using the Optima HIV model, studies of HIV response efficiency were conducted in Sudan in 2014 and Togo in 2015. In this article, we estimate the welfare maximizing and Pareto efficient allocations for these two national HIV budgets, using data from the original studies., Results: We estimate that, if the 2013 HIV budget for Sudan was annually available to 2020 but with funds reallocated according to the welfare maximizing allocation, a 36% reduction in cumulative new infections could be achieved between 2014 and 2020. We also find that this is Pareto efficient. In Togo, however, we find that it is possible to reduce overall new infections but applying the Pareto efficiency criterion means that shifts in emphases cannot occur in the HIV response without additional resources., Discussion: Protecting service coverage for key population groups is not necessarily equivalent to protecting health outcomes. In some cases, requiring Pareto efficiency may reduce the potential for population-wide welfare gains, but this is not always the case., Conclusion: Pareto efficiency may be an appropriate addition to the quantitative toolset for evaluating HIV responses.

Background: Transradial access (TRA) for percutaneous coronary intervention (PCI) is associated with a reduced risk of mortality compared with transfemoral access, access site-related bleeding complications, and shorter length of stay. The budget impact from a healthcare system that has largely transitioned to TRA for PCI has not been previously published., Methods and Results: Data from 323 656 patients undergoing PCI between 2010 and 2014 were obtained from the British Cardiovascular Intervention Society database. Costs for TRA and transfemoral access PCI were estimated based on procedure cost, length of stay, and differences in the rates of complications (major bleeding and vascular complications). In the base case, a propensity-matched data set between transfemoral access and TRA was used to directly compare the cost per PCI, whereas in the real-world analysis, the full data set was used. Across all indications and all years, TRA offered an average cost saving of £250.59 per procedure (22% reduction) versus transfemoral access with the majority of cost saving derived from reduced length of stay (£190.43) rather than direct costs of complications (£3.71). In the real-world analysis, adoption of TRA was estimated to have provided cost savings of £13.31 million across England between 2010 and 2014; however, if operators in all regions had adopted TRA at the rate of the region with the highest utilization, cost savings of £33.40 million could have been achieved., Conclusions: The transition to TRA in England has been associated with significant cost savings across the national healthcare system, in addition to the well-established clinical benefits., (© 2018 American Heart Association, Inc.)

Bureaucracy and lack of resources challenge licensing and oversight.

Background: Many countries lack fully functional pharmacovigilance programs, and public budgets allocated to pharmacovigilance in industrialized countries remain low due to resource constraints and competing priorities., Objective: Using 3 case examples, we sought to estimate the public health and economic benefits resulting from public investment in active pharmacovigilance programs to detect adverse drug effects., Research Design: We assessed 3 examples in which early signals of safety hazards were not adequately recognized, resulting in continued exposure of a large number of patients to these drugs when safer and effective alternative treatments were available. The drug examples studied were rofecoxib, cerivastatin, and troglitazone. Using an individual patient simulation model and the health care system perspective, we estimated the potential costs that could have been averted by early systematic detection of safety hazards through the implementation of active surveillance programs., Results: We found that earlier drug withdrawal made possible by active safety surveillance would most likely have resulted in savings in direct medical costs of $773-$884 million for rofecoxib, $3-$10 million for cerivastatin, and $38-$63 million for troglitazone in the United States through the prevention of adverse events. By contrast, the yearly public investment in Food and Drug Administration initiated population-based pharmacovigilance activities in the United States is about $42.5 million at present., Conclusion: These examples illustrate a critical and economically justifiable role for active adverse effect surveillance in protecting the health of the public.

Background: The public health care sector has had an increase in initiatives, mostly inspired by New Public Management principles, aimed at assigning financial accountability to clinical managers. However, clinical managers might experience a scarce alignment between professional values and organizational requirements, which is a potentially important phenomena that may result in negative consequences on clinical managers' job performance., Purposes: Building on Psychological Ownership Theory and adopting a psychology-based management accounting research approach, we focus on the managerial (nonmedical) role the clinical manager fulfills and explore the budgetary participation-performance link via the indirect effects of job-based psychological ownership, role clarity, and clinical managers' affective commitment toward managerial roles., Methodology/approach: The data were collected by a survey conducted in an Italian hospital. The research hypotheses were tested employing a path model., Findings: Our study revealed new insights that shed some light on underexplored processes through which mental states mediate the participation-performance link. Among these latter, the findings demonstrate that (a) budgetary participation has a direct effect on job-based psychological ownership; (b) role clarity mediates participation- and job-based psychological ownership link; (c) role clarity and job-based psychological ownership partially mediate the participation-commitment link; and (d) job-based psychological ownership, role clarity, and commitment fully mediate the participation-performance link., Practice Implications: From a managerial viewpoint, an understanding of how clinical managers' feelings of ownership toward managerial roles could be enhanced is imperative in health care because ownership accounts for important attitudinal and organizational consequences. Results suggest that health care organizations that invest in budgetary participation will directly and indirectly affect clinical managers' psychological ownership, and this, along with role clarity, motivates clinical managers' managerial work attitudes and performance.

Purpose of Review: Use of budget-based payment methodologies (capitation and episode-based bundled payment) has been demonstrated to drive value in healthcare delivery. With a focus on high-volume, high-cost surgical procedures, inclusion of anaesthesiology services in these methodologies is likely. This review provides a summary of budget-based payment methodologies and practical information necessary for anaesthesiologists to prepare for participation in these programmes., Recent Findings: Although few examples of anaesthesiologists' participation in these models exist, an understanding of the structure of these programmes and opportunities for participation are available. Prospective preparation in developing anaesthesiology-specific bundled payment profiles and early participation in pathway development associated with selected episodes of care are essential for successful participation as a gainsharing partner., Summary: With significant opportunity to contribute to care coordination and cost management, anaesthesiology can play an important role in budget-based payment programmes and should expect to participate as full gainsharing partners. Precise costing methodologies and accurate economic modelling, along with identification of quality management and cost control opportunities, will help identify participation opportunities and appropriate payment and gainsharing agreements. Anaesthesiology-specific examples with budget-based payment models are needed to help guide increased participation in these programmes.

Background and Purpose: Recently, the Mobile Stroke Unit (MSU) concept was introduced in Germany demonstrating prehospital treatment of more patients within the first hour of symptom onset. However, the details and complexities of establishing such a program in the United States are unknown. We describe the steps involved in setting up the first MSU in the United States., Methods: Implementation included establishing leadership, fund-raising, purchase and build-out, knitting a collaborative consortium of community stakeholders, writing protocols to ensure accountability, radiation safety, purchasing supplies, licensing, insurance, establishing a base station, developing a communication plan with city Emergency Medical Services, Emergency Medical Service training, staffing, and designing a research protocol., Results: The MSU was introduced after ≈1 year of preparation. Major obstacles to establishing the MSU were primarily obtaining funding, licensure, documenting radiation safety protocols, and establishing a smooth communication system with Emergency Medical Services. During an 8 week run-in phase, ≈2 patients were treated with recombinant tissue-type plasminogen activator per week, one-third within 60 minutes of symptom onset, with no complications. A randomized study to determine clinical outcomes, telemedicine reliability and accuracy, and cost effectiveness was formulated and has begun., Conclusion: The first MSU in the United States has been introduced in Houston, TX. The steps needed to accomplish this are described., (© 2015 American Heart Association, Inc.)

In an era of economic recession and budget cutbacks,Americans may be curious to know how the government is distributing their taxes for medical research, relative to their health needs. Previous reports recommended that the National Institutes of Health (NIH) allocate funding proportional to the burden-of-illness from diseases and conditions. But the most recent publicly available data on burden-of-illness and NIH funding show that infectious diseases are still overfunded relative to their health burden on the American population, especially HIV/AIDS. By contrast, several lifestyle/environmental health conditions are still underfunded, including importantly: chronic obstructive pulmonary disease, lung cancer, stroke, heart disease, depression, violence, and road injury. NIH's allocation of research funding is often disproportionate to the current health needs of the American people. Greater decision-making involvement of Congress and the public would be helpful, if Americans want their taxes spent fairly on the illnesses that actually burden their health.

Federal policies have a significant effect on how businesses spend money. The 2009 HITECH (Health Information Technology for Economic and Clinical Health Act) authorized incentive payments through Medicare and Medicaid to clinicians and hospitals when they use certified electronic health records privately and securely to achieve specified improvements in care delivery. Federal incentive payments were offered in 2011 for hospitals that had satisfied "meaningful use" criteria. A longitudinal study of nonfederal hospital information technology (IT) budgets (N = 493) during the years 2009 to 2011 found increases in the percentage of hospital annual operating budgets allocated to IT in the years leading up to these federal incentives. This increase was most pronounced among hospitals receiving high proportions of their reimbursements from Medicaid, followed by hospitals receiving high proportions of their reimbursements from Medicare, possibly indicating a budget shift during this period to more IT spending to achieve meaningful-use policy guidelines.

Although identification and management of cardiovascular risk markers have provided important population risk insights and public health benefits, individual risk prediction remains challenging. Using sudden cardiac death risk as a base case, the complex epidemiology of sudden cardiac death risk and the substantial new funding required to study individual risk are explored. Complex epidemiology derives from the multiple subgroups having different denominators and risk profiles, while funding limitations emerge from saturation of conventional sources of research funding without foreseeable opportunities for increases. A resolution to this problem would have to emerge from new sources of funding targeted to individual risk prediction. In this analysis, we explore the possibility of a research funding strategy that would offer business incentives to the insurance industries, while providing support for unresolved research goals. The model is developed for the case of sudden cardiac death risk, but the concept is applicable to other areas of the medical enterprise., (© 2015 American Heart Association, Inc.)

Rationale: The American Recovery and Reinvestment Act (ARRA) allowed National Heart, Lung, and Blood Institute to fund R01 grants that fared less well on peer review than those funded by meeting a payline threshold. It is not clear whether the sudden availability of additional funding enabled research of similar or lesser citation impact than already funded work., Objective: To compare the citation impact of ARRA-funded de novo National Heart, Lung, and Blood Institute R01 grants with concurrent de novo National Heart, Lung, and Blood Institute R01 grants funded by standard payline mechanisms., Methods and Results: We identified de novo (type 1) R01 grants funded by National Heart, Lung, and Blood Institute in fiscal year 2009: these included 458 funded by meeting Institute's published payline and 165 funded only because of ARRA funding. Compared with payline grants, ARRA grants received fewer total funds (median values, $1.03 versus $1.87 million; P<0.001) for a shorter duration (median values including no-cost extensions, 3.0 versus 4.9 years; P<0.001). Through May 2014, the payline R01 grants generated 3895 publications, whereas the ARRA R01 grants generated 996. Using the InCites database from Thomson-Reuters, we calculated a normalized citation impact for each grant by weighting each article for the number of citations it received normalizing for subject, article type, and year of publication. The ARRA R01 grants had a similar normalized citation impact per $1 million spent as the payline grants (median values [interquartile range], 2.15 [0.73-4.68] versus 2.03 [0.75-4.10]; P=0.61). The similar impact of the ARRA grants persisted even after accounting for potential confounders., Conclusions: Despite shorter durations and lower budgets, ARRA R01 grants had comparable citation outcomes per $million spent to that of contemporaneously funded payline R01 grants., (© 2015 American Heart Association, Inc.)

Background: As healthcare spending continues to increase, reimbursement cuts have become 1 type of healthcare reform to contain costs. Little is known about the long-term impact of cuts in reimbursement, especially under a global budget cap with fee-for-service (FFS) reimbursement, on processes and outcomes of care. The FFS-based reimbursement cuts have been implemented since July 2002 in Taiwan. We examined the long-term association of FFS-based reimbursement cuts with trends in processes and outcomes of care for stroke., Methods and Results: We analyzed all 411,487 patients with stroke admitted to general acute care hospitals in Taiwan during the period 1997 to 2010 through Taiwan's National Health Insurance Research Database. We used a quasi-experimental design with quarterly measures of healthcare utilization and outcomes and used segmented autoregressive integrated moving average models for the analysis. After accounting for secular trends and other confounders, the implementation of the FFS-based reimbursement cuts was associated with trend changes in computed tomography/magnetic resonance imaging scanning (0.31% per quarter; P=0.013), antiplatelet/anticoagulant use (-0.20% per quarter; P<0.001), statin use (0.18% per quarter; P=0.027), physiotherapy/occupational therapy assessment (0.25% per quarter; P<0.001), and 30-day mortality (0.06% per quarter; P<0.001)., Conclusions: There are improvement trends in processes and outcomes of care over time. However, the reimbursement cuts from the FFS-based global budget cap are associated with trend changes in processes and outcomes of care for stroke. The FFS-based reimbursement cuts may have long-term positive and negative associations with stroke care., (© 2014 American Heart Association, Inc.)

The mark of an "academic health department" includes shared activity by academic and practice partners sustained over time. Despite a long history of productive interactivity, the Pennsylvania Department of Health and the University of Pittsburgh's Graduate School of Public Health often faced administrative hurdles in contracting for projects of mutual interest. Seeking to overcome these hurdles, the Commonwealth of Pennsylvania and the University of Pittsburgh's Graduate School of Public Health negotiated a Master Agreement on the basis of statutes designating both as "public procurement units." This provided a template for project specifications, standard financial terms, and a contracting process. Since taking effect, the Master Agreement has supported projects in policy development, capacity building, workforce development, program evaluation, data analysis, and program planning. This experience suggests an approach potentially useful for other states and localities seeking to solidify academic health department partnerships either envisioned for the future or already in place.

Objectives: To describe changes in the organizational structure of state health-related departments/agencies between 1990 and 2009; to identify factors associated with key organizational structures; and to investigate their relationship with different resource allocations across health policy areas, as represented by state budgets., Design: Original data collection on the organization of state health-related departments/agencies from 1990 to 2009. Analyses included descriptive statistics, logistic regression, and time-series regression modeling., Setting and Participants: All 50 states., Main Outcomes Measures: Organizational structure of state government related to health in 4 areas (Medicaid, public health, mental health, human services); coupling of Medicaid and public health in the same agency; state budget changes in health policy areas, including Medicaid, public health, and hospitals., Results: The housing of 2 or more health-related functions in the same unit was common, with 21 states combining public health and Medicaid at 1 or more points in time. Eighteen states (36%) reorganized their health agencies/departments during the study period. Controlling for numerous economic, social, and political factors, when the state agency responsible for public health is consolidated with Medicaid, the share of the state budget allocated to Medicaid declined significantly, while public health allocations were unchanged. However, consolidating Medicaid with other services did not impact state Medicaid spending., Conclusions: Government organizational structure related to health varies greatly across states and is somewhat dynamic. When Medicaid and public health functions are consolidated in the same stage agency, public health does not "lose" in terms of its share of the state budget. However, this could change as Medicaid costs continue to grow and with the implementation the Patient Protection and Affordable Care Act of 2010.

Background and Purpose: Thrombolysis in acute stroke is effective up to 4.5 hours after symptom onset but relies on early recognition, prompt arrival in hospital, and timely brain scanning. This study aimed to establish the cost-effectiveness of increasing thrombolysis rates through a series of hypothetical change strategies designed to optimize the acute care pathway for stroke., Methods: A decision-tree model was constructed, which relates the acute management of patients with suspected stroke from symptom onset to outcome. Current practice was modeled and compared with 7 change strategies designed to facilitate wider eligibility for thrombolysis. The model basecase consisted of data from consenting patients following the acute stroke pathway recruited in participating hospitals with data on effectiveness of treatment and costs from published sources., Results: All change strategies were cost saving while increasing quality-adjusted life years gained. Using realistic estimates of effectiveness, the change strategy with the largest potential benefit was that of better recording of onset time, which resulted in 3.3 additional quality-adjusted life years and a cost saving of US $46,000 per 100,000 population. All strategies increased the number of thrombolysed patients and the number requiring urgent brain imaging (by 9% to 21% dependent on the scenario). Assuming a willingness-to-pay of US $30,000 per quality-adjusted life year gained, the potential budget available to deliver the interventions in each strategy ranged from US $50,000 to US $144,000., Conclusions: These results suggest that any strategy that increases thrombolysis rates will result in cost savings and improved patient quality of life. Healthcare commissioners could consider this model when planning improvements in stroke care.

The organization and management of specialized cleft lip and palate centers in developing countries are challenging because of the lack of financial resources devoted to the national health care system. The treatment of cleft lip and palate is of low priority for health care and budgets; however, gradual progress is possible. As an example of how care might be improved in the developing world, we suggest guidelines to strengthen the local cleft lip and palate centers in Brazil based on the ideal geographic distribution of cleft centers around the country, to achieve the following objectives: first, avoid patient's migration; second, facilitate patient's adherence; third, focus on a global and continuous multidisciplinary treatment; and fourth, avoid indiscriminate opening of nonprepared cleft lip and palate centers in our country. This ideal scenario would put the cleft lip and palate health attention on the right path in Brazil.

This decadal perspective summarizes novel, insightful observations achieved in exercise science. The topics span genomics and gene function, epigenetics, cell signaling, epidemiological phenomena, and other important areas. A future strategy is presented along two parallel, integrated paths involving the following: 1) a continuance of genomic discovery and gene function, and 2) classical biochemical/physiological approaches toward solving biological- and health/disease-related phenomena.

The purpose of this study was to assess the alignment of state and local health department financing with the 10 essential public health service (10EPHS) categories and National Public Health Performance Standards (NPHPS). To determine this, we collected primary data from the Florida Department of Health (FDOH) for fiscal year 2005-2006 and compared it with secondary data collected in the same year through NPHPS survey instruments. A structured interview technique was used to collect primary budget data from each program office at the FDOH and assign each program budget to 10EPHS categories. Local county health department (CHD) expenditures were assessed through an interview with the director and budget chief of one small, medium, and large CHD, and results were then extrapolated for other local CHDs. It was possible for almost 98 percent of the FDOH budget to be allocated into the 10EPHS categories. A majority of resources (68.7%) were used for individual healthcare services, category 7b (assuring provision of services) and category 7a (linking people to needed services). No direct correlation was found between the level of funding by 10EPHS category and the performance standards scores at state or local levels. Public health continues to utilize a majority of its available resources for individual healthcare services, despite increasing requests for improved population-based programs.

With the increased emphasis on the nursing shortage, many academic institutions are constructing or renovating facilities to meet the needs of growing enrollment. The author provides practical suggestions to assist those engaged in planning and constructing a health sciences and/or nursing facility.