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Background A gender-based compensation gap among physicians is well documented. Even after adjusting for age, experience, work hours, productivity, and academic rank, the gender gap remained and widened over the course of a physician's career. This study aimed to examine if a significant gender pay gap still existed for anesthesiologists in the United States. Methods In 2018, we surveyed 28,812 physician members of the American Society of Anesthesiologists to assess the association of compensation with gender and to identify possible causes of wage disparities. Gender was the primary variable examined in the model, and compensation by gender was the primary outcome. Compensation was defined as the amount reported as direct compensation on a W-2, 1099, or K-1, plus all voluntary salary reductions (eg, 401[k], health insurance). The survey directed respondents to include salary, bonuses, incentive payments, research stipends, honoraria, and distribution of profits to employees. Respondents had the option of providing a point estimate of their compensation or selecting a range in $50,000 increments. Potential confounding variables that could affect compensation were identified based on a scoping literature review and the consensus expertise of the authors. We fitted a generalized ordinal logistic regression with 7 ranges of compensation. For the sensitivity analyses, we used linear regressions of log-transformed compensation based on respondent point estimates and imputed values. Results The final analytic sample consisted of 2081 observations (response rate, 7.2%). This sample represented a higher percentage of women and younger physicians compared to the demographic makeup of anesthesiologists in the United States. The adjusted odds ratio associated with gender equal to woman was an estimated 0.44 (95% confidence interval, 0.37-0.53), indicating that for a given compensation range, women had a 56% lower odds than men of being in a higher compensation range. Sensitivity analyses found the relative percentage difference in compensation for women compared to men ranged from -8.3 to -8.9. In the sensitivity analysis based on the subset of respondents (n = 1036) who provided a point estimate of compensation, the relative percentage difference (-8.3%; 95% confidence interval, -4.7 to -11.7) reflected a $32,617 lower compensation for women than men, holding other covariates at their means. Conclusions Compensation for anesthesiologists showed a significant pay gap that was associated with gender even after adjusting for potential confounding factors, including age, hours worked, geographic practice region, practice type, position, and job selection criteria.

Background While specific practices for perioperative care of older adults have been recommended, little is known regarding adherence by US physician anesthesiologists to such practices. To address this gap in knowledge, the ASA Committee on Geriatric Anesthesia and the ASA Perioperative Brain Health Initiative undertook a survey of ASA members to characterize current practices related to perioperative care of older adults. Methods We administered a web-based questionnaire with items assessing the proportion of practice focused on delivery of care to older adults, adherence to recommended practices for older surgical patients, resource needs to improve care, and practice characteristics. Results Responses were collected between May 24, 2018, and June 29, 2018. A total of 25,587 ASA members were invited to participate, and 1737 answered at least one item (6.8%). 96.4% of respondents reported that they had cared for a patient aged 65 or older within the last year. 47.1% of respondents (95% confidence interval, 44.6%, 49.7%) reported using multimodal analgesia among patients aged 65 and older at least 90% of the time, and 25.5% (95% CI, 23.3%, 27.7%) provided preoperative information regarding postoperative cognitive changes at least 90% of the time. Over 80% of respondents reported that preoperative screening for frailty or dementia, postoperative screening for delirium, and preoperative geriatric consultation occurred in fewer than 10% of cases. Development of practice guidelines for geriatric anesthesia care and expansion of web-based resources were most frequently prioritized by respondents as initiatives to improve care in this domain. Discussion Most survey respondents reported providing anesthesia care to older adults, but adherence to recommended practices varied across the six items assessed. Reported rates of screening for common geriatric syndromes, such as frailty, delirium, and dementia, were low among survey respondents. Respondents identified multiple opportunities for ASA initiatives to support efforts to improve care for older surgical patients.

Cu9.1Te4Cl3 is a new polymorphic compound in the class of coinage metal polytelluride halides. Copper is highly mobile, which results in multiple order-disorder phase transitions in a limited temperature interval from 240 to 370 K. Mainly as a consequence of thermal transport properties, the compound's thermoelectric figure of merit reaches values up to ZT = 0.15 in the temperature range between room temperature and 523 K. Its structure is closely related to that of Ag10Te4Br3, another coinage metal polytelluride halide, which represents the first p-n-p-switchable semiconductor approachable by a simple temperature change. The title compound outperforms Ag10Te4Br3 in terms of thermoelectric properties by 1 order of magnitude and therefore acts as a link between the class of p-n-p compounds and thermoelectric materials.

Summary Delirium and postoperative neurocognitive disorder are the commonest perioperative complications in patients more than 65 yr of age. However, data suggest that we often fail to screen patients for preoperative cognitive impairment, to warn patients and families of risk, and to take preventive measures to reduce the incidence of perioperative neurocognitive disorders. As part of the American Society of Anesthesiologists (ASA) Perioperative Brain Health Initiative, an international group of experts was invited to review published best practice statements and guidelines. The expert group aimed to achieve consensus on a small number of practical recommendations that could be implemented by anaesthetists and their partners to reduce the incidence of perioperative neurocognitive disorders. Six statements were selected based not only on the strength of the evidence, but also on the potential for impact and the feasibility of widespread implementation. The actions focus on education, cognitive and delirium screening, non-pharmacologic interventions, pain control, and avoidance of antipsychotics. Strategies for effective implementation are discussed. Anaesthetists should be key members of multidisciplinary perioperative care teams to implement these recommendations.

Objective To evaluate the efficacy of diamond burr debridement (DBD) vs a combination of diamond burr debridement with superficial grid keratotomy (DBD+SGK) for the treatment of spontaneous chronic corneal epithelial defects (SCCEDs) in dogs. Procedure Medical records of dogs diagnosed with SCCEDs from three different institutions that received a DBD or DBD+SGK between 2003 and 2015 were reviewed. Age, breed, sex, history of a previous SCCED, procedures performed, time to healing, and complications were statistically analyzed. Results One hundred and ninety-four dogs met the inclusion criteria. Eighty-two of 106 eyes (77.4%) received a DBD and healed following the first treatment (13.3 ± 4.9 days to recheck, range 2-27). Sixty-eight of 88 eyes (77.3%) received a DBD+SGK and healed following the first treatment (15.4 ± 5.0 days to recheck, range 5-45). No significant difference in healing outcome was found between the two treatments (P = 1). For SCCEDs that healed after a single treatment (n = 150), complications occurred in 13.3% (n = 20) of eyes with no difference in complications between the DBD and DBD+SGK groups (P = .86). Thirty-five of 44 eyes (80.0%) healed after the second treatment (16 ± 8.2 days from second treatment to third visit, range 5-47); nine of 44 eyes (20.0%) were not healed (12 ± 6.2 days from second treatment to third visit, range 5-25). The second treatment method did not influence healing rates (P = .64). Conclusions DBD and DBD+SGK are equally effective treatment methods for canine SCCEDs. No differences in complication rates after one treatment were observed between DBD and DBD+SGK.

Background In 2001, the Centers for Medicare and Medicaid Services issued a rule allowing U.S. states to “opt out” of the regulations requiring physician supervision of nurse anesthetists in an effort to increase access to anesthesia care. Whether “opt out” has successfully achieved this goal remains unknown. Methods Using Medicare administrative claims data, we examined whether “opt out” reduced the distance traveled by patients, a common measure of access, for patients undergoing total knee arthroplasty, total hip arthroplasty, cataract surgery, colonoscopy/sigmoidoscopy, esophagogastroduodenoscopy, appendectomy, or hip fracture repair. In addition, we examined whether “opt out” was associated with an increase in the use of anesthesia care for cataract surgery, colonoscopy/sigmoidoscopy, or esophagogastroduodenoscopy. Our analysis used a difference-in-differences approach with a robust set of controls to minimize confounding. Results “Opt out” did not reduce the percentage of patients who traveled outside of their home zip code except in the case of total hip arthroplasty (2.2% point reduction; P = 0.007). For patients travelling outside of their zip code, “opt out” had no significant effect on the distance traveled among any of the procedures we examined, with point estimates ranging from a 7.9-km decrease for appendectomy (95% CI, −19 to 3.4; P = 0.173) to a 1.6-km increase (95% CI, −5.1 to 8.2; P = 0.641) for total hip arthroplasty. There was also no significant effect on the use of anesthesia for esophagogastroduodenoscopy, appendectomy, or cataract surgery. Conclusions “Opt out” was associated with little or no increased access to anesthesia care for several common procedures.

PURPOSE Health professions programs have increasingly incorporated interprofessional education (IPE) and interprofessional collaborative practice (IPCP) into their curricula, but barriers exist, including a lack of faculty understanding and buy-in. It is important for faculty to see the value of IPE and IPCP and to have equivalent baseline knowledge to train students of all health professions from first year to graduation and beyond. METHODS An interprofessional team of faculty from four institutions in central Washington engaged health professionals in a professional development program to foster role models in interprofessional collaboration for health professions students. This research explored the impact of attending a structured interactive professional development program on increasing knowledge and value of IPE. Pre- and post-program surveys were administered to health professionals who attended a 3-hour interprofessional faculty development program. RESULTS The interprofessional program was associated with increased knowledge and value of IPE, as well as greater understanding and appreciation for tools available for IPE facilitation. Participating in this interprofessional program increases knowledge and value of IPE in the Washington health care professional community. CONCLUSION This program may serve as a model for shifting cultures and views of IPE at other institutions committed to breaking down barriers associated with IPE and IPCP.

Study Objective To provide estimates of the costs and health outcomes implications of the excess risk of unexpected disposition for nurse anesthetist (NA) procedures. Design A projection model was used to apply estimates of costs and health outcomes associated with the excess risk of unexpected disposition for NAs reported in a recent study. Setting Ambulatory and inpatient surgery. Patients Base-case model parameters were based on estimates taken from peer-reviewed publications when available, or from other sources including data for all hospital stays in the United States in 2013 from the Healthcare Cost and Utilization Project Web site. The impact of parameter uncertainty was assessed using 1-way and 2-way sensitivity analyses. Interventions Not applicable. Measurements Major complication rates, relative risks of complications, anesthesia costs, costs of complications, and cost-effectiveness ratios. Main Results In the base-case model, there were on average 2.3 fewer unexpected dispositions for physician anesthesiologists compared with NAs. Overall, anesthesia-related costs (including the cost of managing unexpected dispositions) were estimated to be about $31 higher per procedure for physician anesthesiologists compared with NAs. Alternative model scenarios in the sensitivity analysis produced estimates of smaller additional costs associated with physician anesthesia administration, to the point of cost savings in some scenarios. Conclusions Provision of anesthesia for ambulatory knee and shoulder procedures by physician anesthesiologists results in better health outcomes, at a reasonable additional cost, compared with procedures with NA-administered anesthesia, at least when using updated cost-effectiveness willingness-to-pay benchmarks.

In 2001, the Center for Medicare and Medicaid Services issued a rule permitting states to "opt-out" of federal regulations requiring physician supervision of nurse anesthetists. We examined the extent to which this rule increased access to anesthesia care for urgent cases.Using data from a national sample of inpatient discharges, we examined whether opt-out was associated with an increase in the percentage of patients receiving a therapeutic procedure among patients admitted for appendicitis, bowel obstruction, choledocholithiasis, or hip fracture. We chose these 4 diagnoses because they represent instances where urgent access to a procedure requiring anesthesia is often indicated. In addition, we examined whether opt-out was associated with a reduction in the number of appendicitis patients who presented with a ruptured appendix. In addition to controlling for patient morbidities and demographics, our analysis incorporated a difference-in-differences approach, with additional controls for state-year trends, to reduce confounding.Across all 4 diagnoses, opt-out was not associated with a statistically significant change in the percentage of patients who received a procedure (0.0315 percentage point increase, 95% confidence interval [CI] -0.843 to 0.906 percentage point increase). When broken down by diagnosis, opt-out was also not associated with statistically significant changes in the percentage of patients who received a procedure for bowel obstruction (0.511 percentage point decrease, 95% CI -2.28 to 1.26), choledocholithiasis (2.78 percentage point decrease, 95% CI -6.12 to 0.565), and hip fracture (0.291 percentage point increase, 95% CI -1.76 to 2.94). Opt-out was associated with a small but statistically significant increase in the percentage of appendicitis patients receiving an appendectomy (0.876 percentage point increase, 95% CI 0.194 to 1.56); however, there was no significant change in the percentage of patients presenting with a ruptured appendix (-0.914 percentage point decrease, 95% CI -2.41 to 0.582). Subanalyses showed that the effects of opt-out did not differ in rural versus urban areas.Based on 2 measures of access, opt-out does not appear to have significantly increased access to anesthesia for urgent inpatient conditions.

Study objective The perioperative surgical home (PSH) is a recent innovation in perioperative care delivery that coordinates the pre-, intra-, and post-operative elements of surgical care under one organizational umbrella. Although significant research supports the efficacy of individual elements of the PSH in improving outcomes, there is not a published systematic review of the efficacy of entire PSH programs in improving patient outcomes. This article summarizes descriptions of PSH programs available in the literature and examines outcomes of original studies of PSH implementation. Design We conducted a systematic literature review to identify relevant articles on PSH implementation and synthesize our findings. Setting The studies included in our review took place at multiple academic and community hospitals in the United States. Patients Patients involved in the PSH studies included surgical patients of various ages and ASA classifications in various surgical specialties. Interventions All studies included in our review involved the implementation of a PSH program. Measurements Outcomes examined include length of stay, postoperative recovery, readmission rates, and patient discharge destination, among others. Main results We identified 11 studies of PSH implementation that met our inclusion and exclusion criteria. Most PSH programs described in these studies included an emphasis on preoperative education, standardization of care protocols in all phases of surgery, use of opioid-sparing multimodal analgesia, and collaborative staffing models. PSH program implementation was often associated with decreased length of stay, decreased utilization of postoperative opioids, decreased utilization of the ICU, and increased probability of discharge to home. PSH implementation was not meaningfully associated with reductions in readmission rates. Findings for cost reductions following PSH implementation were mixed. Conclusions Early evidence indicates that through elements that emphasize care coordination, standardization, and patient-centeredness, PSH programs can improve patient postoperative recovery outcomes and decrease hospital utilization.

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background In the United States, anesthesia care can be provided by an anesthesia care team consisting of nonphysician providers (nurse anesthetists and anesthesiologist assistants) working under the supervision of a physician anesthesiologist. Nurse anesthetists may practice nationwide, whereas anesthesiologist assistants are restricted to 16 states. To inform policies concerning the expanded use of anesthesiologist assistants, the authors examined whether the specific anesthesia care team composition (physician anesthesiologist plus nurse anesthetist or anesthesiologist assistant) was associated with differences in perioperative outcomes. Methods A retrospective analysis was performed of national claims data for 443,098 publicly insured elderly (ages 65 to 89 yr) patients who underwent inpatient surgery between January 1, 2004, and December 31, 2011. The differences in inpatient mortality, spending, and length of stay between cases where an anesthesiologist supervised an anesthesiologist assistant compared to cases where an anesthesiologist supervised a nurse anesthetist were estimated. The approach used a quasirandomization technique known as instrumental variables to reduce confounding. Results The adjusted mortality for care teams with anesthesiologist assistants was 1.6% (95% CI, 1.4 to 1.8) versus 1.7% for care teams with nurse anesthetists (95% CI, 1.7 to 1.7; difference −0.08; 95% CI, −0.3 to 0.1; P = 0.47). Compared to care teams with nurse anesthetists, care teams with anesthesiologist assistants were associated with non–statistically significant decreases in length of stay (−0.009 days; 95% CI, −0.1 to 0.1; P = 0.89) and medical spending (−$56; 95% CI, −334 to 223; P = 0.70). Conclusions The specific composition of the anesthesia care team was not associated with any significant differences in mortality, length of stay, or inpatient spending.

A 1.1 Mb embedded DRAM macro (eDRAM), for next-generation IBM SOI processors, employs 14 nm FinFET logic technology with $\hbox{0.0174}~\mu\hbox{m}^{2}$ deep-trench capacitor cell. A Gated-feedback sense amplifier enables a high voltage gain of a power-gated inverter at mid-level input voltage, while supporting 66 cells per local bit-line. A dynamic-and-gate-thin-oxide word-line driver that tracks standard logic process variation improves the eDRAM array performance with reduced area. The 1.1 $~$ Mb macro composed of 8 $\times$ 2 72 Kb subarrays is organized with a center interface block architecture, allowing 1 ns access latency and 1 ns bank interleaving operation using two banks, each having 2 ns random access cycle. 5 GHz operation has been demonstrated in a system prototype, which includes 6 instances of 1.1 Mb eDRAM macros, integrated with an array-built-in-self-test engine, phase-locked loop (PLL), and word-line high and word-line low voltage generators. The advantage of the 14 nm FinFET array over the 22 nm array was confirmed using direct tester control of the 1.1 Mb eDRAM macros integrated in 16 Mb inline monitor.

The United States spends about $180 billion per year on inpatient surgical procedures in nonfederal hospitals alone.1 The average cost of surgery continues to climb—from $13,000 per hospitalization in 2000 to $18,000 (inflation adjusted) in 2010—and patient safety, outcomes, and readmissions are ongoing concerns.1 Is the perioperative surgical home (PSH) a part of the solution? The concept of a more rigorously coordinated and integrated perioperative patient management system has been implemented, studied, and reported primarily in Canada, Europe, Australia, and the United States within the last 40 years, but the evolution of the PSH concept in the United States seems to be more recent. Earlier, surgical care in the United States followed a general trend of surgical specialties and capabilities moving toward same-day surgery admissions2; market expectations for high-quality surgical outcomes while controlling cost of surgeries by pursuing service-line strategies3; and value-based payment programs launched as a result of the Patient Protection and Affordable Care Act, which could yield significant savings for payers.4 The PSH continues to be defined in both the literature and clinical practice. One of its most recent definitions is based on the PSH model adopted by the University of Alabama at Birmingham, which describes the PSH model as “an innovative, patient-centered, surgical continuity of care model that incorporates shared decision making.”5 PSH programs in the United States have a variety of names, such as “center for perioperative services,” “reengineered perioperative services,” and “perioperative care pathways.” An initial examination of the literature suggests that most definitions feature 2 points of emphasis: stronger continuity, coordination, and integration of surgical care; and greater patient-focused and shared decision making. Because the terminology used to describe the PSH varies widely, we looked at the most recent comprehensive reviews and definitions of this new concept of perioperative medicine and surgical care. In one, Lee and colleagues broadly use the umbrella term “perioperative system” to encompass all the PSH's activities and developments.6 Consistently emerging evidence in the health care literature supports care coordination models like the well-established patient-centered medical home (PCMH), with its underlying principle of a single physician who coordinates the patient's care and engages a team of health care providers and their patient in an individualized treatment and management plan.7 The PCMH embodies principles laid out by the Institute of Medicine intended to improve care coordination and patient satisfaction.8 The PCMH and the PSH share a vision of higher quality and lower cost while at the same time incorporating similar elements of patient engagement and care coordination.5 Unfortunately, surgical care often is not standardized or coordinated, resulting in duplicative or unnecessary preoperative testing and procedures, which cost an estimated $18 billion annually in the United States alone.9 The PSH concept provides a model that addresses this need for perioperative care standardization and coordination, and its impact on both clinical outcomes and cost has recently been evaluated.10

Background: Medicaid Personal Care Services (PCS) help families meet children’s needs for assistance with functional tasks. However, PCS may have other effects on a child’s well-being, but research has not yet established the existence of such effects. Objectives: To investigate the relationship between the number of PCS hours a child receives with subsequent visits to physicians for evaluation and management (E&M) services. Methods: Assessment data for 2058 CSHCN receiving PCS were collected in 2008 and 2009. Assessment data were matched with Medicaid claims data for the period of 1 year after the assessment. Zero-inflated negative binomial and generalized linear multivariate regression models were used in the analyses. These models included patient demographics, health status, household resources, and use of other medical services. Results: For every 10 additional PCS hours authorized for a child, the odds of having an E&M physician visit in the next year were reduced by 25%. However, the number of PCS hours did not have a significant effect on the number of visits by those children who did have a subsequent E&M visit. A variety of demographic and health status measures also affect physician use. Conclusions: Medicaid PCS for CSHCN may be associated with reduced physician usage because of benefits realized by continuity of care, the early identification of potential health threats, or family and patient education. PCS services may contribute to a child’s well-being by providing continuous relationships with the care team that promote good chronic disease management, education, and support for the

The influence of nanoscale on the formation of metastable phases is an important aspect of nanostructuring that can lead to the discovery of unusual material compositions. Here, the synthesis, structural characterization, and electrochemical performance of Ni/Co mixed oxide nanocrystals in the hydrogen evolution reaction (HER) and oxygen evolution reaction (OER) is reported and the influence of nanoscaling on their composition and solubility range is investigated. Using a solvothermal synthesis in tert-butanol ultrasmall crystalline and highly dispersible Ni x Co1− x O nanoparticles with rock salt type structure are obtained. The mixed oxides feature non-equilibrium phases with unusual miscibility in the whole composition range, which is attributed to a stabilizing effect of the nanoscale combined with kinetic control of particle formation. Substitutional incorporation of Co and Ni atoms into the rock salt lattice has a remarkable effect on the formal potentials of NiO oxidation that shift continuously to lower values with increasing Co content. This can be related to a monotonic reduction of the work function of (001) and (111)-oriented surfaces with an increase in Co content, as obtained from density functional theory (DFT+U) calculations. Furthermore, the electrocatalytic performance of the Ni x Co1− x O nanoparticles in water splitting changes significantly. OER activity continuously increases with increasing Ni contents, while HER activity shows an opposite trend, increasing for higher Co contents. The high electrocatalytic activity and tunable performance of the nonequilibrium Ni x Co1− x O nanoparticles in HER and OER demonstrate great potential in the design of electrocatalysts for overall water splitting.

In 2001, the U.S. government released a rule that allowed states to “opt-out” of the federal requirement that a physician supervise the administration of anesthesia by a nurse anesthetist. To date, 17 states have opted out. The majority of the opt-out states cited increased access to anesthesia care as the primary rationale for their decision. In this study, we assess the impact of state opt-out policy on access to and costs of surgeries and other procedures requiring anesthesia services. Our null hypothesis is that opt-out rule adoption had little or no effect on surgery access or costs. We estimate an inpatient model of surgeries and costs and an outpatient model of surgeries. Each model uses data from multiple years of U.S. inpatient hospital discharges and outpatient surgeries. For inpatient cost models, the coefficient of the opt-out variable was consistently positive and also statistically significant in most model specifications. In terms of access to inpatient surgical care, the opt-out rules did not increase or decrease access in opt-out states. The results for the outpatient access models are less consistent, with some model specifications indicating a reduction in access associated with opt-out status, while other model specifications suggesting no discernable change in access. Given the sensitivity of model findings to changes in model specification, the results do not provide support for the belief that opt-out policy improves access to outpatient surgical care, and may even reduce access to outpatient surgical care (among freestanding facilities).

In the United States, anesthesia care can be provided by anesthesiologists or nurse anesthetists. Since 2001, 17 states have exercised their right to "opt-out" of the federal requirement that a physician supervise the administration of anesthesia by a nurse anesthetist, with the majority citing increased access to anesthesia care as the rationale for their decision. By using Medicare data, we found that most (4 of 5) cohorts of "opt-out" states likely experienced smaller growth in anesthesia utilization rates compared with non-"opt-out" states, suggesting that opt-out was not associated with an increase in access to anesthesia care.

An estimated 12.8 million children in the United States need “health and related services of a type or amount beyond that required by children generally” (McPherson et al. 1998; van Dyck et al. 2004). These children are disproportionately represented in public assistance programs; poor and disadvantaged, often lacking access to routine and family-centered health care (Newacheck et al. 1998; Mayer, Cockrell Skinner, and Slifkin 2004; Strickland et al. 2004). Those with greater functional limitations often have worse access to care (van Dyck et al. 2004). Total annual health care expenditures for children with chronic illnesses or special health care needs (SHCN) are significantly higher than are those attributable to children without these conditions (Newacheck and Kim 2005). They are more likely than non-SHCN children to spend days in the hospital, visit an emergency room, have surgical procedures, and have visits with medical specialists (Newacheck, Inkelas, and Kim 2004; Boulet, Boyle, and Schieve 2009). Family members usually provide the majority of care, assistance, and coordination of services for all children with special needs. A recent survey conducted by the National Alliance for Caregiving (2009) indicates that these caregivers spend an average of 29.7 hours per week helping with activities of daily living (ADLs) and other supportive activities, which limits their ability to earn income outside the home (van Dyck et al. 2004; Okumura et al. 2009). These issues are particularly pronounced for family or informal caregivers who are single parents (Rupp and Ressler 2009). Among all caregiver scenarios, families with children with SHCN experience the most adverse financial and medical effects of caregiving (Altman, Cooper, and Cunningham 1999). The role of family caregivers across the life span has a long history as an important topic for researchers and policy makers (Levine et al. 2010). This interest in caregiving has involved a call for research on the population-based health outcomes of caregivers, the dynamics of caregiving across the life span, and the link of caregivers' health to the health and quality of life of care recipients. Talley and Crews (2007), in their discussion of caregiving and public health, indicate that informal caregiving is “… an enormous system of care in the United States and around the world.” Unfortunately, little attention has focused on the collaborative element of home care involving the two systems that serve those receiving care in the community, the formal and the informal system. For those in the community with impairments or activity limitations, care often involves collaboration between formal (paid) health service providers and informal (unpaid) caregivers (Shewchuk and Elliott 2000; Carter 2008). An integral part of understanding how children with chronic health problems receive care in the community involves understanding how informal and formal care systems interact to structure the delivery of necessary formal health services. In 2007, the Medicaid program supported medical care to almost 29 million children, and 19 cents of every Medicaid dollar went to pay for services to children (Kaiser Commission 2010). The vast majority of these expenditures were for standard medical services in families where informal caregiving was not an issue. However, a nontrivial portion of these Medicaid monies paid for home health services that complemented the efforts of unpaid caregivers helping children with SHCN living in low-income households. In Texas, for example, in the state fiscal year beginning September 1, 2008 and ending August 31, 2009 (SFY 2009), only 0.24 percent of the children in the Medicaid program received Medicaid Personal Care Services (PCS) in their homes, but these same children accounted for 4.46 percent of total Medicaid (nonmanaged care) expenditures for children's health care. The average Medicaid expenditure for a child in Texas was U.S.$1,834 in SFY 2009. For children receiving PCS to supplement assistance provided by informal caregivers, the average annual Medicaid expenditure was U.S.$33,628.1 In SFY 2010, children in the PCS program increased to 0.31 percent of children receiving Medicaid and the cost of services increased by over U.S.$100 million to 6.03 percent of the Texas Medicaid Program's expenditures for children (Miller et al. 2011). In the present study, we examined the degree to which the conditions, impairments, activity limitations, and problem behaviors of the child—as experienced and reported by the caregiver—were predictive of the amount of PCS authorized by Medicaid case managers. We also investigated the degree to which a case manager's discretion in translating a child's characteristics into a statement of need for care (hours) might account for unique variance in the hours authorized. The three specific research questions addressed were as follows: What factors affected caregivers' reports of activity limitations requiring formal personal care assistance? What impact did caregivers' input on activity (ADL) limitations have on decisions to provide Medicaid PCS resources? How much variance in PCS hours was attributable to variation in indicators of children's status versus differences among case managers performing assessments?

Objectives: This research investigated the relationship between a child’s reported intellectual disability (ID) level and caregivers’ reports of the child’s health status to predict Medicaid Personal Care Services (PCS) hours authorized for that child. We also investigated how activity limitations in the home varied with the level of ID. Design: The sample included 1,108 community-residing children with a reported level of ID in the Texas Medicaid system and who were assessed for the PCS program. All data were collected with the Personal Care Assessment Form (PCAF), an instrument developed by the authors for evaluating children’s PCS needs. Case managers completed the PCAF in the child’s home with the child and primary caregivers present. Structural equation modeling (SEM) was used to test a model reflecting the role of ID and other characteristics of the child in determining the number of PCS hours authorized. Additional analyses revealed the degree to which variation among the case managers affected the number of hours authorized. Results: ID level and other individual characteristics had a significant effect on reports of a child’s activity limitations (R 2 .67), which in turn affected the hours of PCS authorized (R 2 .27). We found no significant direct relationship between ID level and PCS hours: ID level had an indirect relationship on PCS hours through activity limitations. When the variance in hours authorized was decomposed, individual characteristics accounted for 20% of the variance and case managers accounted for 14%. Conclusions: Assessments of caregiver and child strengths and limitations in the home are critical in the allocation of Medicaid home-based services, above and beyond the information conveyed by demographic and diagnostic data. Implications for home-based assessments of functional limitations and needs for family caregivers and their children with ID are discussed.

SummaryObjective: Health information exchange (HIE) is the interorganizational sharing of patient information and is one of many health information technology initiatives expected to transform the U.S. healthcare system. Two outcomes expected to be improved by HIE are patient-provider communication and patient satisfaction . This analysis examined the relationship between the level of HIE engagement and these two factors in a sample of U.S. hospitals.Methods: Independent variables came from existing secondary sources and the dependent measures were from the Hospital Consumer Assessment of Healthcare Providers and Systems. The analysis included 3,278 hospitals. Using ordinary least squares regression, implemented HIE was positively associated with the percentage of patients reporting nurses communicated well and higher satisfaction. Due to the potential for selection bias, results were further explored using a propensity score analysis.Results: Hospitals that had adopted HIE, but not yet implemented saw no benefits. Hospitals’ level of HIE was not associated with the percentage of patients reporting doctors communicated well. According to propensity score corrected estimates, implemented HIE was associated with the percentage of patients who reported nurses always communicated well and who would definitely recommend the hospital.Conclusion: Few studies have examined the impact of HIE at the organizational level. This examination provides some evidence that hospitals engaging in HIE are associated with higher patient satisfaction.

The authors describe the customary tools used by health services researchers to conduct economic evaluations of health interventions. Recognizing the inherent challenges of these tools for utilization in contemporary public health practice, we recommend a practical cost-benefit analysis (PCBA) to allow public health practitioners to assess the economic merits of their existing public health programs. The PCBA estimates what health effects and corresponding medical cost avoidance would be required to support the costs associated with implementing a community-based prevention program. We apply the PCBA to evaluate a statewide evidence-based falls prevention program for seniors in Texas. We estimate a positive return on realized costs due to avoided direct and indirect medical expenses if the program averts 7 falls among 140 participants within the first year. While acknowledging the demonstrated health-related benefits of public health interventions, we provide a practical ex-post economic evaluation methodology to assess return on investment as a more simplistic yet effective alternative for public health practitioners versus contemporary analyses of health services researchers.

The medical home is a potentially transformative strategy to address issues of access, quality, and efficiency in the delivery of health care in the United States. While numerous organizations support a physician-driven definition, it is by no means the universally accepted definition. Several professional groups, payers, and researchers have offered differing, or nuanced, definitions of medical homes. This lack of consensus has contributed to uncertainty among providers about the medical home. We conducted a systematic review of the literature on the medical home and identified 29 professional, government, and academic sources offering definitions. While consensus appears to exist around a core of selected features, the medical home means different things to different people. The variation in definitions can be partly explained by the obligation of organizations to their members and whether the focus is on the patient or provider. Differences in definitions have implications at both the policy and practice levels.

The histamine H(4) receptor (H(4)R) is expressed primarily on cells involved in inflammation and immune responses. To determine the potential role of H(4)R in pain transmission, the effects of JNJ7777120, a potent and selective H(4) antagonist, were characterized in preclinical pain models. Administration of JNJ7777120 fully blocked neutrophil influx observed in a mouse zymosan-induced peritonitis model (ED(50)=17 mg/kg s.c., 95% CI=8.5-26) in a mast cell-dependent manner. JNJ7777120 potently reversed thermal hyperalgesia observed following intraplantar carrageenan injection of acute inflammatory pain (ED(50)=22 mg/kg i.p., 95% CI=10-35) in rats and significantly decreased the myeloperoxide activity in the carrageenan-injected paw. In contrast, no effects were produced by either H(1)R antagonist diphenhydramine, H(2)R antagonists ranitidine, or H(3)R antagonist ABT-239. JNJ7777120 also exhibited robust anti-nociceptive activity in persistent inflammatory (CFA) pain with an ED(50) of 29 mg/kg i.p. (95% CI=19-40) and effectively reversed monoiodoacetate (MIA)-induced osteoarthritic joint pain. This compound also produced dose-dependent anti-allodynic effects in the spinal nerve ligation (ED(50)=60 mg/kg) and sciatic nerve constriction injury (ED(50)=88 mg/kg) models of chronic neuropathic pain, as well as in a skin-incision model of acute post-operative pain (ED(50)=68 mg/kg). In addition, the analgesic effects of JNJ7777120 were maintained following repeated administration and were evident at the doses that did not cause neurologic deficits in rotarod test. Our results demonstrate that selective blockade of H(4) receptors in vivo produces significant anti-nociception in animal models of inflammatory and neuropathic pain.

We present the results of extensive multi-frequency monitoring of the radio galaxy 3C 120 between 2002 and 2007 at X-ray, optical, and radio wave bands, as well as imaging with the Very Long Baseline Array (VLBA). Over the 5 yr of observation, significant dips in the X-ray light curve are followed by ejections of bright superluminal knots in the VLBA images. Consistent with this, the X-ray flux and 37 GHz flux are anti-correlated with X-ray leading the radio variations. This implies that, in this radio galaxy, the radiative state of accretion disk plus corona system, where the X-rays are produced, has a direct effect on the events in the jet, where the radio emission originates. The X-ray power spectral density of 3C 120 shows a break, with steeper slope at shorter timescale and the break timescale is commensurate with the mass of the central black hole based on observations of Seyfert galaxies and black hole X-ray binaries. These findings provide support for the paradigm that black hole X-ray binaries and active galactic nuclei are fundamentally similar systems, with characteristic time and size scales linearly proportional to the mass of the central black hole. The X-ray and optical variations are strongly correlated in 3C 120, which implies that the optical emission in this object arises from the same general region as the X-rays, i.e., in the accretion disk-corona system. We numerically model multi-wavelength light curves of 3C 120 from such a system with the optical-UV emission produced in the disk and the X-rays generated by scattering of thermal photons by hot electrons in the corona. From the comparison of the temporal properties of the model light curves to that of the observed variability, we constrain the physical size of the corona and the distances of the emitting regions from the central BH., Accepted for publication in the Astrophysical Journal. 28 pages, 21 figures, 2 tables

Background: Theoretically, nursing homes should engage in advertising for the following two reasons: (a) to improve awareness of the services offered in a particular market and (b) to signal high-quality services. In this study, we build upon results from prior studies of nursing home advertising activity, market competition, and quality. Purpose: The purpose of this study was to examine the association between advertising expenses, price, and quality. We focused on answering the question: Do nursing homes use advertising and price to signal superior quality? Methodology: The Texas Nursing Facilities Medicaid Cost Report, the Texas Quality Reporting System, and the Area Resource File were merged for the year 2003. We used three alternative measures of quality to improve the robustness of this exploratory analysis. Quality measures were examined using Bonferroni correlation coefficient analysis. Associations between advertising expenses and quality were evaluated using three regression models predicting quality. We also examined the association of the price of a private bed per day with quality. Findings: Advertising expenses were not associated with better nursing home quality as measured by three quality scales. The average price customers pay for one private bed per day was associated with better quality only in one of the three quality regression models. The price of nursing home care might be a better indicator of quality and necessary to increase as quality of care is improved in the nursing homes sector. Because more advertising expenditures are not necessarily associated with better quality, consumers could be mislead by advertisements and choose poor quality nursing homes. Practice Implications: Nursing home administrators should focus on customer relationship management tools instead of expensive advertising. Relationship management tools are proven marketing techniques for the health services sector, usually less expensive than advertising, and help with staff retention and quality outcomes.

Background and purpose: The histamine H3 receptor antagonist radioligand [3H]-A-349821 was characterized as a radiotracer for assessing in vivo receptor occupancy by H3 receptor antagonists that affect behaviour. This model was established as an alternative to ex vivo binding methods, for relating antagonist H3 receptor occupancy to blood levels and efficacy in preclinical models. Experimental approach: In vivo cerebral cortical H3 receptor occupancy by [3H]-A-349821 was determined in rats from differences in [3H]-A-349821 levels in the isolated cortex and cerebellum, a brain region with low levels of H3 receptors. Comparisons were made to relate antagonist H3 receptor occupancy to blood levels and efficacy in a preclinical model of cognition, the five-trial inhibitory avoidance response in rat pups. Key results: In adult rats, [3H]-A-349821, 1.5 µg·kg−1, penetrated into the brain and cleared more rapidly from cerebellum than cortex; optimally, [3H]-A-349821 levels were twofold higher in the latter. With increasing [3H]-A-349821 doses, cortical H3 receptor occupancy was saturable with a binding capacity consistent with in vitro binding in cortex membranes. In studies using tracer [3H]-A-349821 doses, ABT-239 and other H3 receptor antagonists inhibited H3 receptor occupancy by [3H]-A-349821 in a dose-dependent manner. Blood levels of the antagonists corresponding to H3 receptor occupancy were consistent with blood levels associated with efficacy in the five-trial inhibitory avoidance response. Conclusions and implications: When employed as an occupancy radiotracer, [3H]-A-349821 provided valid measurements of in vivo H3 receptor occupancy, which may be helpful in guiding and interpreting clinical studies of H3 receptor antagonists.

Background and purpose: The histamine H4 receptor is widely expressed in cells of immune origin and has been shown to play a role in a variety of inflammatory processes mediated by histamine. In this report, we describe the in vitro and in vivo anti-inflammatory properties of a potent histamine H4 receptor antagonist, A-940894 (4-piperazin-1-yl-6,7-dihydro-5H-benzo[6,7]cyclohepta[1,2-d]pyrimidin-2-ylamine). Experimental approach: We have analysed the pharmacological profile of A-940894 at mouse native, rat recombinant and human recombinant and native, histamine H4 receptors by radioligand binding, calcium mobilization, mast cell shape change, eosinophil chemotaxis assays and in the mouse model of zymosan-induced peritonitis. Key results: A-940894 potently binds to both human and rat histamine H4 receptors and exhibits considerably lower affinity for the human histamine H1, H2 or H3 receptors. It potently blocked histamine-evoked calcium mobilization in the fluorometric imaging plate reader assays and inhibited histamine-induced shape change of mouse bone marrow-derived mast cells and chemotaxis of human eosinophils in vitro. In a mouse mast cell-dependent model of zymosan-induced peritonitis, A-940894 significantly blocked neutrophil influx and reduced intraperitoneal prostaglandin D2 levels. Finally, A-940894 has good pharmacokinetic properties, including half-life and oral bioavailability in rats and mice. Conclusions and Implications: These data suggest that A-940894 is a potent and selective histamine H4 receptor antagonist with pharmacokinetic properties suitable for long-term in vivo testing and could serve as a useful tool for the further characterization of histamine H4 receptor pharmacology.

Specialty hospitals, particularly those specializing in surgery and owned by physicians, have generated a relatively high degree of policy attention over the past several years. The main focus of policy debates has been in two areas: the extent to which specialty hospitals might compete unfairly with incumbent general hospitals and the extent to which physician ownership might be associated with higher usage. Largely absent from the debates, however, has been a discussion of the basic economic model of specialty hospitals. This article reviews existing literature, reports, and findings from site visits to explore the economic rationale for specialty hospitals. The discussion focuses on six factors associated with specialization: consumer demand, procedural operating margins, clinical efficiencies, procedural economies of scale, economies (and diseconomies) of scope, and competencies and learning. A better understanding of the economics of specialization will help policy makers evaluate the full spectrum of advantages and disadvantages of specialty hospitals.

We identified 4-year (2 years before and 2 years after the index [baseline] interview) ED use patterns in older adults and the factors associated with them.A secondary analysis of baseline interview data from the nationally representative Survey on Assets and Health Dynamics Among the Oldest Old linked to Medicare claims data. Participants were 4310 self-respondents 70 years old or older. Current Procedural Terminology (CPT) codes 99281 and 99282 identified low-intensity use, and CPT codes 99283-99285 identified high-intensity use. Exploratory factor analysis and multivariable multinomial logistic regression were used.The majority (56.6%) of participants had no ED visits during the 4-year period. Just 5.7% had only low-intensity ED use patterns, whereas 28.9% used the ED only for high-intensity visits, and 8.7% had a mixture of low-intensity and high-intensity use. Participants with lower immediate word recall scores and those who did not live in major metropolitan areas were more likely to be low-intensity-only ED users. Older individuals, those who did not live in rural counties, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to be high-intensity-only ED users. Participants who were older, did not live in major cities, had lower education levels, had greater morbidity and functional status burdens, and lower immediate word recall scores were more likely to have mixed ED use patterns.Nearly half of these older adults used the ED at least once over a 4-year period, with a mean annual ED use percentage of 18.4. Few, however, used the ED only for visits that may have been avoidable. This finding suggests that triaging Medicare patients would not decrease ED overcrowding, although continued surveillance is necessary to detect potential changes in ED use patterns among older adults.

Objective: Little is known about changes in self-rated health (SRH) among African Americans. Method: We examined SRH changes and trajectories among 998 African Americans 49 to 65 years old who we reinterviewed annually for 4 years, using multinomial logistic regression and mixed effect models. Results: Fifty-five percent had the same SRH at baseline and 4 years later, 25% improved, and 20% declined. Over time, men were more likely to report lower SRH levels, individuals with hypertension were less likely to report lower SRH levels, and those with congestive heart failure at baseline were more likely to report higher SRH levels. Lower SRH trajectory intercepts were observed for those with lower socioeconomic status, poorer health habits, disease history, and worse functional status. Those with better cognitive status had higher SRH trajectory intercepts. Discussion: The decline in SRH levels among 49- to 65-year-old African Americans is comparable to that of Whites.

In this article, we pharmacologically characterized two naturally occurring human histamine H3 receptor (hH3R) isoforms, hH3R(445) and hH3R(365). These abundantly expressed splice variants differ by a deletion of 80 amino acids in the intracellular loop 3. In this report, we show that the hH3R(365) is differentially expressed compared with the hH3R(445) and has a higher affinity and potency for H3R agonists and conversely a lower potency and affinity for H3R inverse agonists. Furthermore, we show a higher constitutive signaling of the hH3R(365) compared with the hH3R(445) in both guanosine-5'-O-(3-[35S]thio) triphosphate binding and cAMP assays, likely explaining the observed differences in hH3R pharmacology of the two isoforms. Because H3R ligands are beneficial in animal models of obesity, epilepsy, and cognitive diseases such as Alzheimer's disease and attention deficit hyperactivity disorder and currently entered clinical trails, these differences in H3R pharmacology of these two isoforms are of great importance for a detailed understanding of the action of H3R ligands.