A systematic review of maternal confidence for physiologic birth: characteristics of prenatal care and confidence measurement.

INTRODUCTION: Because a focus on physiologic labor and birth has reemerged in recent years, care providers have the opportunity in the prenatal period to help women increase confidence in their ability to give birth without unnecessary interventions. However, most research has only examined support for women during labor. The purpose of this systematic review was to examine the research literature for information about prenatal care approaches that increase women's confidence for physiologic labor and birth and tools to measure that confidence. METHODS: Studies were reviewed that explored any element of a pregnant woman's interaction with her prenatal care provider that helped build confidence in her ability to labor and give birth. Timing of interaction with pregnant women included during pregnancy, labor and birth, and the postpartum period. In addition, we looked for studies that developed a measure of women's confidence related to labor and birth. Outcome measures included confidence or similar concepts, descriptions of components of prenatal care contributing to maternal confidence for birth, and reliability and validity of tools measuring confidence. RESULTS: The search of MEDLINE, CINAHL, PsycINFO, and Scopus databases provided a total of 893 citations. After removing duplicates and articles that did not meet inclusion criteria, 6 articles were included in the review. Three relate to women's confidence for labor during the prenatal period, and 3 describe tools to measure women's confidence for birth. DISCUSSION: Research about enhancing women's confidence for labor and birth was limited to qualitative studies. Results suggest that women desire information during pregnancy and want to use that information to participate in care decisions in a relationship with a trusted provider. Further research is needed to develop interventions to help midwives and physicians enhance women's confidence in their ability to give birth and to develop a tool to measure confidence for use during prenatal care.

The rules of engagement: physician engagement strategies in intergroup contexts.

PURPOSE: Recognition of the importance and difficulty of engaging physicians in organisational change has sparked an explosion of literature. The social identity approach, by considering engagement in terms of underlying group identifications and intergroup dynamics, may provide a framework for choosing among the plethora of proposed engagement techniques. This paper seeks to address this issue. DESIGN/METHODOLOGY/APPROACH: The authors examined how four disparate organisations engaged physicians in change. Qualitative methods included interviews (109 managers and physicians), observation, and document review. FINDINGS: Beyond a universal focus on relationship-building, sites differed radically in their preferred strategies. Each emphasised or downplayed professional and/or organisational identity as befit the existing level of inter-group closeness between physicians and managers: an independent practice association sought to enhance members' identity as independent physicians; a hospital, engaging community physicians suspicious of integration, stressed collaboration among separate, equal partners; a developing integrated-delivery system promoted alignment among diverse groups by balancing "systemness" with subgroup uniqueness; a medical group established a strong common identity among employed physicians, but practised pragmatic co-operation with its affiliates. RESEARCH LIMITATIONS/IMPLICATIONS: The authors cannot confirm the accuracy of managers perceptions of the inter-group context or the efficacy of particular strategies. Nonetheless, the findings suggested the fruitfulness of social identity thinking in approaching physician engagement. PRACTICAL IMPLICATIONS: Attention to inter-group dynamics may help organisations engage physicians more effectively. ORIGINALITY/VALUE: This study illuminates and explains variation in the way different organisations engage physicians, and offers a theoretical basis for selecting engagement strategies.

Assertive women as expert witnesses: a study of assertive and defensive responses in male and female experts.

This investigation of expert witness gender used scenarios addressing threats to the expert, sexuality, parenting by the expert, and lying, and in which intrusive and non-intrusive gender cross-examinations were presented to 352 mock jurors. Male and female experts were matched carefully on attractiveness and other social desirability dimensions. In half of the situations the expert witnesses replied with defensive answers, and in the other half, they replied assertively. The assertive responses were found to be significantly more effective on a number of dependent measures, including perceived credibility. In results consistent with other studies, the male experts were evaluated more positively than the female experts. Sexism and other attitudes of the mock jurors were unrelated to credibility and expert gender. The results are discussed in the context of managing aggressive cross-examinations, role demands for women in the courtroom, and methodological approaches to the study of expert witness gender.

A framework for evaluating the formation, implementation, and performance of accountable care organizations.

The implementation of accountable care organizations (ACOs), a new health care payment and delivery model designed to improve care and lower costs, is proceeding rapidly. We build on our experience tracking early ACOs to identify the major factors-such as contract characteristics; structure, capabilities, and activities; and local context-that would be likely to influence ACO formation, implementation, and performance. We then propose how an ACO evaluation program could be structured to guide policy makers and payers in improving the design of ACO contracts, while providing insights for providers on approaches to care transformation that are most likely to be successful in different contexts. We also propose key activities to support evaluation of ACOs in the near term, including tracking their formation, developing a set of performance measures across all ACOs and payers, aggregating those performance data, conducting qualitative and quantitative research, and coordinating different evaluation activities.

Insights from transformations under way at four Brookings-Dartmouth accountable care organization pilot sites.

This cross-site comparison of the early experience of four provider organizations participating in the Brookings-Dartmouth Accountable Care Organization Collaborative identifies factors that sites perceived as enablers of successful ACO formation and performance. The four pilots varied in size, with between 7,000 and 50,000 attributed patients and 90 to 2,700 participating physicians. The sites had varying degrees of experience with performance-based payments; however, all formed collaborative new relationships with payers and created shared savings agreements linked to performance on quality measures. Each organization devoted major efforts to physician engagement. Policy makers now need to consider how to support and provide incentives for the successful formation of multipayer ACOs, and how to align private-sector and CMS performance measures. Linking providers to learning networks where payers and providers can address common technical issues could help. These sites' transitions to the new payment model constitutes an ongoing journey that will require continual adaptation in the structure of contracts and organizational attributes.

Interpretations of integration in early accountable care organizations.

CONTEXT: It is widely hoped that accountable care organizations (ACOs) will improve health care quality and reduce costs by fostering integration among diverse provider groups. But how do implementers actually envision integration, and what will integration mean in terms of managing the many social identities that ACOs bring together? METHODS: Using the lens of the social identity approach, this qualitative study examined how four nascent ACOs engaged with the concept of integration. During multiday site visits, we conducted interviews (114 managers and physicians), observations, and document reviews. FINDINGS: In no case was the ACO interpreted as a new, overarching entity uniting disparate groups; rather, each site offered a unique interpretation that flowed from its existing strategies for social-identity management: An independent practice association preserved members' cherished value of autonomy by emphasizing coordination, not "integration"; a medical group promoted integration within its employed core, but not with affiliates; a hospital, engaging community physicians who mistrusted integrated systems, reimagined integration as an equal partnership; an integrated delivery system advanced its careful journey towards intergroup consensus by presenting the ACO as a cultural, not structural, change. CONCLUSIONS: The ACO appears to be a model flexible enough to work in synchrony with whatever social strategies are most context appropriate, with the potential to promote alignment and functional integration without demanding common identification with a superordinate group. "Soft integration" may be a promising alternative to the vertically integrated model that, though widely assumed to be ideal, has remained unattainable for most organizations.

The promise and peril of accountable care for vulnerable populations: a framework for overcoming obstacles.

Accountable care organizations (ACOs) are a promising payment model aimed at reducing costs while also improving the quality of care. However, there is a risk that vulnerable populations may not be fully incorporated into this new model. We define two distinct vulnerable populations, clinically at-risk and socially disadvantaged, and we discuss how ACOs may benefit each group. We provide a framework to use in considering challenges for both vulnerable patients and health systems on the path to accountable care. We identify policies that can help overcome these obstacles: strategies that support ACO formation in diverse settings and that monitor, measure, and reward the performance of providers that reach all patients, including vulnerable populations.

Incidence of complications and early recurrence in 29 patients after facial rejuvenation with barbed suture lifting.

BACKGROUND: Barbed suture lifting is a minimally invasive procedure for rejuvenation of the aging face. Few studies have examined its efficacy and associated risks. OBJECTIVES: To evaluate the morbidity associated with this procedure and its long-term effects. METHODS AND MATERIALS: A retrospective review of 29 cosmetic patients who underwent thread lifting was conducted. A chart review provided information on patient demographics, surgical technique, and postoperative course. RESULTS: Analysis demonstrated that adverse events occurred in 69% and early recurrence in 45% of the patients in the study group. The incidence remained high upon extraction of independent variables, including technique used, location of thread placement, and number of threads placed. CONCLUSIONS: Indications for performing minimally invasive cosmetic surgery include obtaining outcomes comparable with those of an established widely used criterion standard. The goal for new procedures should be to deliver predictable long-term results while providing less morbidity, less downtime, and greater patient satisfaction. The results of this study indicate that the barbed suture lift was unable to accomplish these goals. This study also reflects the importance of a critical review of the ever-expanding options available to aesthetic surgeons.

Emulsan quantitation by Nile red quenching fluorescence assay.

A Nile red fluorescent technique to quantify 20-200 microg ml(-1) of emulsan was developed. Nile red dissolved in DMSO showed an adsorption peak at 552 nm, and emission peak at 636 nm, with molar extinction coefficient of 19,600 cm(-1) M(-1). Nile red fluorescence in DMSO was proportionally quenched by emulsan and the quenching was time-dependent. The assay was used to follow the production of emulsan by cultures of Acinetobacter venetianus RAG-1.