Why did this happen to me? Causal attributions of illness and cultural health capital.

This study examines how conversations between patients and clinicians about the causes of their health conditions relate to patient engagement in care. Leveraging cultural health capital (CHC) theory, we find that patient-physician discussions of health attributions are one mechanism to build patient understanding and activate engagement. We present a qualitative interpretive analysis of data collected in three phases with adult home health care patients: phone interviews (n = 28), field observations (n = 61), and semi-structured field interviews (n = 38). We find that engaging in discussions of causal health attributions with clinicians enables patients to overcome uncertainty, envision preventive actions, and engage in setting future goals. Such discussions must be supported by acknowledgement of the co-responsibility of individual factors and structural factors such as social determinants of health. These discussions are not easy to navigate but they can potentially help patients transition from a mindset of treating the disease (pathogenic approach) to an awareness of their available capabilities to improve health (salutogenic approach). This study contributes to research on attribution theory and cultural health capital theory by demonstrating how discussing causes for poor health can enable patients resolve doubts and accrue instrumental and symbolic resources that facilitate healing.

Implementation and 12-Month Health Service Utilization and Cost Outcomes from a Managed Care Health Plan's Permanent Supportive Housing Program.

Homelessness, which refers to the lack of a fixed, regular, and adequate nighttime residence, is a pervasive public health issue. This article presents results from an implementation and outcome study of an ongoing permanent supportive housing (PSH) program-including service utilization and associated costs review-operated by a large not-for-profit Medicaid and Medicare managed care plan serving more than 1 million members in the Inland Empire area of Southern California. This PSH program combines a long-term housing subsidy with intensive case management services for adult plan members experiencing homelessness who have one or more chronic physical or behavioral health conditions and represent high utilizers of inpatient health care. The aim of this research was to determine whether programmatic costs incurred by the health plan supporting the PSH program were partially or fully offset by decreased costs attributable to health care utilization within the health system. The evaluation used a quasi-experimental research design with an observational control group. The authors differentiated the program's effect during the transitional period-that is, after program enrollment and prior to housing placement-from its effect during the period after members were housed. In addition, the authors present participant flow through the key program milestones (e.g., referral, enrollment, housing placement, program exit) and describe health care utilization and associated costs for members who exited the program. Finally, they report the PSH programmatic expenditures relative to the changes in health care costs to provide an overall picture of the intervention's benefits and costs to the health plan.

Social Networks and Cognitive Function: An Evaluation of Social Bridging and Bonding Mechanisms.

BACKGROUND AND OBJECTIVES: Social connectedness has been linked prospectively to cognitive aging, but there is little agreement about the social mechanisms driving this relationship. This study evaluated 9 measures of social connectedness, focusing on 2 forms of social enrichment-access to an expansive and diverse set of loosely connected individuals (i.e., social bridging) and integration in a supportive network of close ties (i.e., social bonding). RESEARCH DESIGN AND METHODS: This study used egocentric network and cognitive data from 311 older adults in the Social Networks in Alzheimer Disease study. Linear regressions were used to estimate the association between social connectedness and global cognitive function, episodic memory, and executive function. RESULTS: Measures indicative of social bridging (larger network size, lower density, presence of weak ties, and proportion of non-kin) were consistently associated with better cognitive outcomes, while measures of social bonding (close ties, multiplex support, higher frequency of contact, better relationship quality, and being married) largely produced null effects. DISCUSSION AND IMPLICATIONS: These findings suggest that the protective benefits of social connectedness for cognitive function and memory may operate primarily through a cognitive reserve mechanism that is driven by irregular contact with a larger and more diverse group of peripheral others.

Predicting potential palliative care beneficiaries for health plans: A generalized machine learning pipeline.

Recognizing that palliative care improves the care quality and reduces the healthcare costs for individuals in their end of life, health plan providers strive to better enroll the appropriate target population for palliative care. Current research has not adequately addressed challenges related to proactively select potential palliative care beneficiaries from a population health perspective. This study presents a Generalized Machine Learning Pipeline (GMLP) to predict palliative needs in patients using administrative claims data. The GMLP has five steps: data cohort creation, feature engineering, predictive modeling, scoring beneficiaries, and model maintenance. It encapsulates principles of population health management, business domain knowledge, and machine learning (ML) process knowledge with an innovative data pull strategy. The GMLP was applied in a regional health plan using a data cohort of 17,197 patients. Multiple ML models were turned and evaluated against a custom performance metric based on the business requirement. The best model was an AdaBoost model with a precision of 71.43% and a recall of 67.98%. The post-implementation evaluation of the GMLP showed that it increased the recall of high mortality risk patients, improved their quality of life, and reduced the overall cost. The GMLP is a novel approach that can be applied agnostically to the data and specific ML algorithms. To the best of our knowledge, it is the first attempt to continuously score palliative care beneficiaries using administrative data. The GMLP and its use case example presented in the paper can serve as a methodological guide for different health plans and healthcare policymakers to apply ML in solving real-world clinical challenges, such as palliative care management and other similar risk-stratified care management workflows.

Provider Bias in prescribing opioid analgesics: a study of electronic medical Records at a Hospital Emergency Department.

BACKGROUND: Physicians do not prescribe opioid analgesics for pain treatment equally across groups, and such disparities may pose significant public health concerns. Although research suggests that institutional constraints and cultural stereotypes influence doctors' treatment of pain, prior quantitative evidence is mixed. The objective of this secondary analysis is therefore to clarify which institutional constraints and patient demographics bias provider prescribing of opioid analgesics. METHODS: We used electronic medical record data from an emergency department of a large U.S hospital during years 2008-2014. We ran multi-level logistic regression models to estimate factors associated with providing an opioid prescription during a given visit while controlling for ICD-9 diagnosis codes and between-patient heterogeneity. RESULTS: A total of 180,829 patient visits for 63,513 unique patients were recorded during the period of analysis. Overall, providers were significantly less likely to prescribe opioids to the same individual patient when the visit occurred during higher rates of emergency department crowding, later times of day, earlier in the week, later years in our sample, and when the patient had received fewer previous opioid prescriptions. Across all patients, providers were significantly more likely to prescribe opioids to patients who were middle-aged, white, and married. We found no bias towards women and no interaction effects between race and crowding or between race and sex. CONCLUSIONS: Providers tend to prescribe fewer opioids during constrained diagnostic situations and undertreat pain for patients from high-risk and marginalized demographic groups. Potential harms resulting from previous treatment decisions may accumulate by informing future treatment decisions.

Physician dominance in the 21st century: Examining the rise of non-physician autonomy through prevailing theoretical lenses.

Theories of physician dominance are a foundational contribution of medical sociology to the study of health care, but must be revisited in the light of ongoing changes in medicine. As non-physician specialists like nurse practitioners grow in number and acquire more autonomy, increasing medical profession differentiation presents a challenge for traditional physician dominance theories. After evaluating potential theoretical explanations for subordinate occupations' autonomy gains, we conduct a state-level quantitative analysis of variation in nursing policies across U.S. states. We construct our dependent variable, nursing autonomy, using seven state-level advanced practice nursing policies adopted from 2001-2017. Using an ordered scale, we code nurse practitioner, nurse anaesthetist, nurse midwife and clinical-nurse-specialist practice and prescription polices according to each policy's autonomy level. We then use time-series regression to examine theory-driven propositions regarding nursing autonomy change. Nursing autonomy has increased over time, signalling a general erosion of physician dominance. However, we find differential patterns of policy adoption, indicating that erosion is not uniform. Physicians have maintained dominance in relatively prestigious specialties (e.g. anaesthesiology) while dominance declined in others (e.g. obstetrician). Factors external to the profession, such as consumer power, continue to influence within-profession dynamics. Examining ongoing professional differentiation in medicine illustrates how physician dominance depends on shifting social and professional contexts.

A new kind of gatekeeper: The increasing prevalence of Advanced Practice Nurses as case managers in US hospitals.

Case management is a representation of managed care, cost-containment organizational practices in healthcare, where managed care and its constitutive parts are situated against physician autonomy and decision-making. As a professional field, case management has evolved considerably, with the role recently taken up increasingly by Advanced Practice Nurses in various health care settings. We look at this evolution of a relatively new work task for Advanced Practice Nurses using a countervailing powers perspective, which allows us to move beyond discussions of case management effectiveness and best practices, and draw connections to trends in the social organization of healthcare, especially hospitals. We evaluated organizational (hospital-level) and environmental (county and state-level) characteristics associated with hospitals' use of Advanced Practice Nurses as case managers, using data from U.S. community acute care hospitals for 2016-2018, collected from three data sources: American Hospital Association annual survey (AHA), Centers for Medicare and Medicaid Services (CMS), and Area Resource File. Among organizational characteristics, we found that hospitals that are a part of established Accountable Care Organizations (OR = 2.55, p = 0.009; 95% CI = 1.26-5.14) and those that serve higher acuity patients, as indicated by possessing a higher Case Mix Index (OR = 1.32, p = 0.001; 95% CI = 1.13-1.55), were more likely to use Advanced Practice Nurses as case managers. Among environmental characteristics, having higher local Advanced Practice Nurses concentrations (OR = 1.24, p < 0.001; 95% CI = 1.11-1.39) was associated with hospital Advanced Practice Nurses case management service provision. Beyond the health impacts of Covid-19, its associated recession is placing families, governments and insurers under unprecedented financial stress. Governments and insurers alike are looking to reduce costs anywhere possible. This will inevitably result in increasing amounts of managed care, and decreasing reimbursements to hospitals, likely resulting in higher demand for APRN patient navigators.

Addressing Provider Shortages in Rural America: The Role of State Opt-Out Policy Adoptions in Promoting Hospital Anesthesia Provision.

BACKGROUND: Shortages of anesthesia providers in rural areas have long resulted in access limitations in many US states. This situation prompted federal legislation designed to promote increased usage of certified registered nurse anesthetists (CRNAs) in hospitals. Starting in 2001, state governors were afforded the option to adopt "opt-out" provisions, giving facilities in their states flexibility in utilizing CRNAs; specifically, adopting the opt-out policy removes physician oversight requirements for Medicare billing purposes. METHODS: We used mixed effects generalized linear models to identify predictors of CRNA service provision in hospitals from 2011-2015. RESULTS: We found that being located in an opt-out state does not result in increased odds of CRNA service provision in US hospitals. Higher levels of deprivation in counties, being located in rural geographic areas, and being a teaching hospital all influenced CRNA service provision. CONCLUSIONS: Given that we found no evidence that being in an opt-out state increases the odds of using CRNAs in hospitals, we contribute to the growing literature suggesting that states adopting the opt-out policy have not realized increased health care access or reduced health care costs. As a result of other contextual restrictions on hospitals' decision-making, simply adopting the opt-out policy has not been enough to address anesthesia provider shortages.

Change in Psychotropic Prescribing Patterns Among Youths in Foster Care Associated With a Peer-to-Peer Physician Consultation Program.

There has been growing concern about the safety and efficacy of psychotropic prescribing practices for children enrolled in Medicaid and in foster care.1 In response, accreditation organizations and policymakers have developed standards for optimal use of psychotropic medications among children.2 In addition, federal legislation has prompted states to implement monitoring programs to address quality and safety issues among vulnerable pediatric subpopulations.3,4 Here, we report findings from an evaluation of Indiana's program for foster youth, which used outlier case review followed by peer-to-peer consultation between prescribing physicians and child and adolescent psychiatrists. We observed clinically and statistically significant reductions in polypharmacy, off-label prescribing, inpatient hospitalizations, health care costs, and related outcomes among youths randomized to an immediate intervention group compared to no improvements in a waitlist control group.

Cultural Guides, Cultural Critics: Distrust of Doctors and Social Support during Mental Health Treatment.

Research on relationships and health often interprets culture as the passively transmitted "content" of social ties, an approach that overlooks the influence of cultural resources on relationships themselves. I propose that mental health patients seek social support partly based on cultural resources held by their network members, including members' medical knowledge and beliefs. I test hypotheses using data from the Indianapolis Network Mental Health Study, an egocentric network survey of new mental health patients ( N = 152) and their personal relationships ( N = 1,868). Results from random-intercept regressions show that patients obtain support from network members who trust doctors and who have experience with mental problems. In contrast, network members who distrust doctors disproportionately cause problems for patients. I discuss how cultural resources can categorize network members as supportive cultural guides or disruptive cultural critics. Reconsidering how culture shapes relationships clarifies the role of networks during illness management and illustrates their potentially harmful effects.

Effects of conservation policy on China's forest recovery.

Forest loss is one of the most pervasive land surface transformations on Earth, with drastic effects on global climate, ecosystems, and human well-being. As part of biodiversity conservation and climate change mitigation efforts, many countries, including China, have been implementing large-scale policies to conserve and restore forests. However, little is known about the effectiveness of these policies, and information on China's forest dynamics at the national level has mainly relied on official statistics. In response to international calls for improved reliability and transparency of information on biodiversity conservation and climate change mitigation efforts, it is crucial to independently verify government statistics. Furthermore, if forest recovery is verified, it is essential to assess the degree to which this recovery is attributable to policy, within the context of other relevant factors. We assess the dynamics of forest cover in China between 2000 and 2010 and evaluate the effectiveness of one of the largest forest conservation programs in the world-the Natural Forest Conservation Program (NFCP). Results indicate that forest cover has significantly increased in around 1.6% of China's territory and that the areas exhibiting forest gain experienced a combined increase in net primary productivity (ca. 0.9 Tg of carbon). Among the variables evaluated at county level, the NFCP exhibited a significantly positive relation with forest gain, whereas reduction in rural labor showed a negative relationship with both forest loss and gain. Findings such as these have global implications for forest conservation and climate change mitigation efforts.

Synthesis in land change science: methodological patterns, challenges, and guidelines.

Global and regional economic and environmental changes are increasingly influencing local land-use, livelihoods, and ecosystems. At the same time, cumulative local land changes are driving global and regional changes in biodiversity and the environment. To understand the causes and consequences of these changes, land change science (LCS) draws on a wide array synthetic and meta-study techniques to generate global and regional knowledge from local case studies of land change. Here, we review the characteristics and applications of synthesis methods in LCS and assess the current state of synthetic research based on a meta-analysis of synthesis studies from 1995 to 2012. Publication of synthesis research is accelerating, with a clear trend toward increasingly sophisticated and quantitative methods, including meta-analysis. Detailed trends in synthesis objectives, methods, and land change phenomena and world regions most commonly studied are presented. Significant challenges to successful synthesis research in LCS are also identified, including issues of interpretability and comparability across case-studies and the limits of and biases in the geographic coverage of case studies. Nevertheless, synthesis methods based on local case studies will remain essential for generating systematic global and regional understanding of local land change for the foreseeable future, and multiple opportunities exist to accelerate and enhance the reliability of synthetic LCS research in the future. Demand for global and regional knowledge generation will continue to grow to support adaptation and mitigation policies consistent with both the local realities and regional and global environmental and economic contexts of land change.

Effects of natural disasters on conservation policies: the case of the 2008 Wenchuan earthquake, China.

Conservation policies are increasing in response to human-induced ecosystem degradation, but little is known about their interplay with natural disasters. Through an analysis of satellite imagery and field data we evaluated the impacts of a devastating earthquake on forest recovery and avoided forest loss estimated to have been obtained by two of the largest conservation programs in the world. Results show that more than 10% of the forests in Wenchuan County, Sichuan province, China were immediately affected by the 2008 earthquake, offsetting some gains in forest cover observed since the enactment of the conservation programs. But without the enactment of these conservation programs, the combined effects of human disturbance and earthquake-induced landslides could have severely reduced the region's forest cover. The continuation--and enhancement--of incentives for participation in conservation programs will be important for reducing the environmental impacts of the combined effects of human disturbance and natural hazards not only in the study area but also in many disaster-prone regions around the world.

Effect of racial and ethnic composition of neighborhoods in San Francisco on rates of mental health-related 911 calls.

OBJECTIVE: This study investigated the association between the racial and ethnic residential composition of San Francisco neighborhoods and the rate of mental health-related 911 calls. METHODS: A total of 1,341,608 emergency calls (28,197 calls related to mental health) to San Francisco's 911 system were made from January 2001 through June 2003. Police sector data in the call records were overlaid onto U.S. census tracts to estimate sector demographic and socioeconomic characteristics. Negative binomial regression was used to estimate the association between the percentage of black, Asian, Latino, and white residents and rates of mental health-related calls. RESULTS: A one-point increase in a sector's percentage of black residents was associated with a lower rate of mental health-related calls (incidence rate ratio=.99, p<.05). A sector's percentage of Asian and Latino residents had no significant effect. CONCLUSIONS: The observed relationship between the percentage of black residents and mental health-related calls is not consistent with known emergency mental health service utilization patterns.

Highly efficient transgenesis in Xenopus tropicalis using I-SceI meganuclease.

In this study, we report a highly efficient transgenesis technique for Xenopus tropicalis based on a method described first for Medaka. This simple procedure entails co-injection of meganuclease I-SceI and a transgene construct flanked by two I-SceI sites into fertilized eggs. Approximately 30% of injected embryos express transgenes in a promoter-dependent manner. About 1/3 of such embryos show incorporation of the transgene at the one-cell stage and the remainder are 'half-transgenics' suggesting incorporation at the two-cell stage. Transgenes from both classes of embryos are shown to be transmitted and expressed in offspring. The procedure also works efficiently in Xenopus laevis. Because the needle injection procedure does not significantly damage embryos, a high fraction develop normally and can, as well, be injected with a second reagent, for example an mRNA or antisense morpholino oligonucleotide, thus allowing one to perform several genetic manipulations on embryos at one time. This simple and efficient technique will be a powerful tool for high-throughput transgenesis assays in founder animals, and for facilitating genetic studies in the fast-breeding diploid frog, X. tropicalis.

High-throughput transgenesis in Xenopus using I-SceI meganuclease.

In this report we describe an easy, highly efficient transgenesis method for Xenopus. The method is very simple; a commercially available meganuclease, I-SceI, is incubated with a transgene construct carrying its recognition sites, and is subsequently microinjected into fertilized eggs. Approximately 30% (in Xenopus tropicalis) or 20% (in Xenopus laevis) of injected embryos exhibit non-mosaic, promoter-dependent transgene expression, and transgenes from the founder animals are transmitted to offspring. The method is compatible with mRNA or antisense morpholino oligonucleotide injection, and these secondary reagents can be introduced simultaneously or sequentially with a transgene to test their interaction. This high-throughput transgenic technique will be a powerful tool for studying the complex wiring of regulatory networks at the genome-wide level, as well as for facilitating genetic studies in the rapidly breeding diploid frog, X. tropicalis.

Measuring community preferences for public mental health services: pilot test of a mail survey method.

This study tested the feasibility of a simple mail survey approach to measuring community preferences for mental health services. A 38 item survey detected statistically significant differences in preferences for four central goals, finding that community members most value Focus on the Severely Mentally Ill, followed by Community Safety and Environment, Service Quality and Original Community Mental Health Goals. Some procedural problems were encountered that reduced the response rates, however, the study yielded information that suggests improved procedures for future surveys. Simple mail surveys appear to offer a potentially affordable, efficient way to assess community service priorities.

Psychiatric emergencies after the terrorist attacks of September 11, 2001.

OBJECTIVE: Population surveys suggest that the events of September 11, 2001, resulted in psychiatric emergencies in U.S. communities. This study tested the extent of such emergencies in San Francisco. METHOD: S: Interrupted time-series designs were applied to counts of emergency calls to the police during the 424-day period beginning January 1, 2001, and of voluntary and coerced admissions to psychiatric emergency services during the 1620-day period beginning July 1, 1997. RESULTS: The number of men and women who were coerced into treatment increased significantly on Thursday, September 13, but the number of voluntary admissions was as expected. The number of telephone calls from citizens that police dispatchers judged to be mental health related increased significantly on Wednesday, September 12, and remained elevated through September 13. Several additional analyses were conducted to test the stability of the findings, and the results were essentially unchanged. CONCLUSIONS: The events of September 11 may not have induced emergent mental illness in U.S. communities at relatively great distance from the attacks. However, it is possible that persons with severe mental illness were either more evident to or less tolerated by the community.