Has the Expansion of Health Insurance Coverage via the Implementation of the Affordable Care Act Influenced Inequities in Coronary Revascularization in New York City?

BACKGROUND/PURPOSE: In 2014, New York City implemented the Affordable Care Act (ACA) leading to insurance coverage gains intended to reduce inequities in healthcare services use. The paper documents inequalities in coronary revascularization procedures (percutaneous coronary intervention and coronary artery bypass grafting) usage by race/ethnicity, gender, insurance type, and income before and after the implementation of the ACA. METHODS: We used data from the Healthcare Cost and Utilization Project to identify NYC patients hospitalized with the diagnosis of coronary artery disease (CAD) and/or congestive heart failure (CHF) in 2011-2013 (pre-ACA) and 2014-2017 (post-ACA). Next, we calculated age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization. Logistic regression models were used to identify the variables associated with receiving a coronary revascularization in each period. RESULTS: Age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization in patients 45-64 years of age and 65 years of age and older declined in the post-ACA period. Disparities by gender, race/ethnicity, insurance type, and income in the use of coronary revascularization persist in the post-ACA period. CONCLUSIONS: Although this health care reform law led to the narrowing of inequities in the use of coronary revascularization, disparities persist in NYC in the post-ACA period.

Access to outpatient care in Manhattan and Paris: A tale of real change in two world cities.

France's system of universal health insurance (UHI) offers more equitable access to outpatient care than the patchwork system in the U.S., which does not have a UHI system. We investigate the degree to which the implementation of the Patient Protection and Affordable Care Act (ACA) has narrowed the gap in access to outpatient care between France and the U.S. To do so, we update a previous comparison of access to outpatient care in Manhattan and Paris as measured by age-adjusted rates of hospital discharge for avoidable hospital conditions (AHCs). We compare these rates immediately before and after the implementation of the ACA in 2014. We find that AHC rates in Manhattan declined by about 25% and are now lower than those in Paris. Despite evidence that access to outpatient care in Manhattan has improved, Manhattanites continue to experience greater residence-based neighborhood inequalities in AHC rates than Parisians. In Paris, there was a 3% increase in AHC rates and neighborhood-level inequalities increased significantly. Our analysis highlights the persistence of access barriers to outpatient care in Manhattan, particularly among racial and ethnic minorities, even following the expansion of health insurance coverage.

Neighborhood inequalities and the decline of infant mortality in São Paulo.

This paper documents changes in infant mortality (IM) rates in São Paulo, Brazil, between 2003 and 2013 and examines the association among neighborhood characteristics and IM. We investigate the extent to which increased use of health care services and improvements in economic and social conditions are associated with reductions in IM. Using data from the Brazilian Census and the São Paulo Secretaria Municipal da Saúde/SMS, we conducted a longitudinal analysis of panel data in all 96 districts of São Paulo for every year between 2003 and 2013. Our regression model includes district level measures that reflect economic, health care and social determinants of IM. We find that investments in health care have contributed to lower IM rates in the city, but the direct effect of increased spending is most evident for people living in São Paulo's middle- and high-income neighborhoods. Improvements in social conditions were more strongly associated with IM declines than increases in the use of health care among São Paulo's low-income neighborhoods. To reduce health inequalities, policies should target benefits to lower-income neighborhoods. Subsequent research should document the consequences of recent changes in Brazil's economic capacity and commitment to public health spending for population health.

The evolution of infant mortality and neighbourhood inequalities in four world cities: 1988-2016.

OBJECTIVES: To determine the level of neighbourhood inequalities in infant mortality (IM) rates in the urban core of four world cities and to examine the association between neighbourhood-level income and IM. We compare our findings with those published in 2004 to better understand how these city health systems have evolved. METHODS: We compare IM rates among and within the four cities using data from four periods: 1988-1992; 1993-1997; 2003-2008 and 2012-2016. Using a maximum-likelihood negative binomial regression model that controls for births, we predict the relationship between neighbourhood-level income and IM. RESULTS: IM rates have declined in all four cities. Neighbourhood-level income is statistically significant for New York and, for the two most recent periods, in Paris. In contrast, there is no significant relationship between neighbourhood income and IM in London or Tokyo. CONCLUSIONS: Despite programmes to reduce IM inequalities at national and local levels, these persist in New York. Until the early part of this century, none of the other cities experienced a relationship between neighbourhood income and IM, but growing income inequalities within Paris have changed this situation. POLICY IMPLICATIONS: Policy-makers in these cities should focus on better understanding the social and economic factors associated with neighbourhood inequalities in IM.

Variation in end-of-life care and hospital palliative care among hospitals and local authorities: A preliminary contribution of big data.

BACKGROUND: Many studies explore the clinical and ethical dimensions of care at the end-of-life, but fewer use administrative data to examine individual and geographic differences, including the use of palliative care. AIM: Provide a population-based perspective on end-of-life and hospital palliative care among local authorities and hospitals in France. DESIGN: Retrospective cohort study of care received by 17,928 decedents 65 and over (last 6 months of life), using the French national health insurance database. RESULTS: 55.7% of decedents died in acute-care hospitals; 79% were hospitalized in them at least once; 11.7% were admitted at least once for hospital palliative care. Among 31 academic medical centers, intensive care unit admissions ranged from 12% to 67.4%; hospital palliative care admissions, from 2% to 30.6%. Across local authorities, for intensive care unit days and hospital palliative care admissions, the ratios between the values at the third and the first quartile were 2.4 and 1.5. The odds of admission for hospital palliative care or to an intensive care unit for more than 7 days were more than twice as high among people ⩽85 years (aOR = 2.11 (1.84-2.43) and aOR = 2.59 (2.12-3.17), respectively). The odds of admission for hospital palliative care were about 25% lower (p = 0.04) among decedents living in local authorities with the lowest levels of education than those with the highest levels. CONCLUSION: The variation we document in end-of-life and hospital palliative care across different categories of hospitals and 95 local authorities raises important questions as to what constitutes appropriate hospital use and intensity at the end-of-life.

Structure of cyanobacterial phycobilisome core revealed by structural modeling and chemical cross-linking.

In cyanobacteria and red algae, the structural basis dictating efficient excitation energy transfer from the phycobilisome (PBS) antenna complex to the reaction centers remains unclear. The PBS has several peripheral rods and a central core that binds to the thylakoid membrane, allowing energy coupling with photosystem II (PSII) and PSI. Here, we have combined chemical cross-linking mass spectrometry with homology modeling to propose a tricylindrical cyanobacterial PBS core structure. Our model reveals a side-view crossover configuration of the two basal cylinders, consolidating the essential roles of the anchoring domains composed of the ApcE PB loop and ApcD, which facilitate the energy transfer to PSII and PSI, respectively. The uneven bottom surface of the PBS core contrasts with the flat reducing side of PSII. The extra space between two basal cylinders and PSII provides increased accessibility for regulatory elements, e.g., orange carotenoid protein, which are required for modulating photochemical activity.

Alcohol Consumption by Older New York City Residents: The Need for New Policies to Address Misuse.

AIMS: The aim of this study is to assess risk factors for alcohol misuse among older New York City residents and examine the effect of local public health efforts to address alcohol misuse. METHODS: The Community Health Survey, a cross-sectional telephone survey of 8500 randomly selected adult New Yorkers, records the frequency of alcohol use. We examine these results among 65 and older subjects by sociodemographic status using logistic regression modeling and compare trends in smoking and alcohol consumption between 2002 and 2016. RESULTS: Those with unhealthy drinking habits, combining binge drinking and excessive consumption, constituted 5.7% of 65 plus population and were more likely to be White, US born, healthy, better educated and wealthier. The percentage of older smokers in New York City has decreased while unhealthy drinking is nearly flat since 2002. CONCLUSIONS: Our findings reinforce the importance of screening geriatric populations for alcohol use disorders and support the development of new public health efforts to address alcohol misuse if the city is to achieve results similar to those obtained in decreasing tobacco consumption.

A novel chlorophyll protein complex in the repair cycle of photosystem II.

In oxygenic photosynthetic organisms, photosystem II (PSII) is a unique membrane protein complex that catalyzes light-driven oxidation of water. PSII undergoes frequent damage due to its demanding photochemistry. It must undergo a repair and reassembly process following photodamage, many facets of which remain unknown. We have discovered a PSII subcomplex that lacks 5 key PSII core reaction center polypeptides: D1, D2, PsbE, PsbF, and PsbI. This pigment-protein complex does contain the PSII core antenna proteins CP47 and CP43, as well as most of their associated low molecular mass subunits, and the assembly factor Psb27. Immunoblotting, mass spectrometry, and ultrafast spectroscopic results support the absence of a functional reaction center in this complex, which we call the "no reaction center" complex (NRC). Analytical ultracentrifugation and clear native PAGE analysis show that NRC is a stable pigment-protein complex and not a mixture of free CP47 and CP43 proteins. NRC appears in higher abundance in cells exposed to high light and impaired protein synthesis, and genetic deletion of PsbO on the PSII luminal side results in an increased NRC population, indicative that NRC forms in response to photodamage as part of the PSII repair process. Our finding challenges the current model of the PSII repair cycle and implies an alternative PSII repair strategy. Formation of this complex may maximize PSII repair economy by preserving intact PSII core antennas in a single complex available for PSII reassembly, minimizing the risk of randomly diluting multiple recycling components in the thylakoid membrane following a photodamage event.

Disparities in Access to Revascularization: Evidence from New York.

Purpose: To quantify and compare citywide disparities in the performance of coronary revascularization procedures in New York residents diagnosed with ischemic heart disease (IHD) by the characteristics of the patients and their neighborhood of residence in 2000-2002 and 2011-2013. Methods: We identify the number of hospitalizations for patients with diagnoses of IHD and/or congestive heart failure (CHF) and the number of revascularization procedures performed on the population 45 years and older, relying on hospital administrative data for New York City, by area of residence, from the Statewide Planning and Research Cooperative System (SPARCS). We conduct multiple logistic regressions to analyze the factors associated with revascularization for hospitalized patients admitted with IHD and CHF over the two time periods. Results: Despite any decline in population health status, both the age-adjusted rates of inpatient hospital discharges for acute myocardial infarction, for IHD and for CHF, decreased as did the rates of revascularization procedures. Racial and ethnic disparities were much smaller in the later period than those documented earlier. However, there were persistent gender, insurance status, and neighborhood-level disparities in the treatment of heart disease. Conclusions: With the declines in rates of heart disease, our findings point to the need for more clinical and population-based research to improve the understanding of why race/ethnicity, gender, insurance status, and neighborhood-level disparities persist in the treatment of heart disease.

Infant Mortality in Moscow: the Perils of Progress in Russia's World City.

This paper examines changes in infant mortality (IM) in Moscow, Russia's largest and most affluent city. Along with some remarkable improvements in Moscow's health system over the period between 2000 and 2014, the overall IM rate for Moscow's residents decreased substantially between 2000 and 2014. There remains, however, substantial intra-city variation across Moscow's 125 neighborhoods. Our regression models suggest that in higher-income neighborhoods measured by percent of population with rental income as a primary source, the IM rate is significantly lower than in lower-income neighborhoods measured by percent of population with transfer income as primary source (housing and utility subsidies and payments to working and low-income mothers, single mothers and foster parents). We also find that the density of physicians in a neighborhood is negatively correlated with the IM rate, but the effect is small. The density of nurses and hospital beds has no effect. We conclude that overall progress on health outcomes and measures of access does not, in itself, solve the challenge of intra-urban inequalities.

Phycobilisomes Harbor FNRL in Cyanobacteria.

Cyanobacterial phycobilisomes (PBSs) are photosynthetic antenna complexes that harvest light energy and supply it to two reaction centers (RCs) where photochemistry starts. PBSs can be classified into two types, depending on the presence of allophycocyanin (APC): CpcG-PBS and CpcL-PBS. Because the accurate protein composition of CpcL-PBS remains unclear, we describe here its isolation and characterization from the cyanobacterium Synechocystis sp. strain 6803. We found that ferredoxin-NADP+ oxidoreductase (or FNRL), an enzyme involved in both cyclic electron transport and the terminal step of the electron transport chain in oxygenic photosynthesis, is tightly associated with CpcL-PBS as well as with CpcG-PBS. Room temperature and low-temperature fluorescence analyses show a red-shifted emission at 669 nm in CpcL-PBS as a terminal energy emitter without APC. SDS-PAGE and quantitative mass spectrometry reveal an increased content of FNRL and CpcC2, a rod linker protein, in CpcL-PBS compared to that of CpcG-PBS rods, indicative of an elongated CpcL-PBS rod length and its potential functional differences from CpcG-PBS. Furthermore, we combined isotope-encoded cross-linking mass spectrometry with computational protein structure predictions and structural modeling to produce an FNRL-PBS binding model that is supported by two cross-links between K69 of FNRL and the N terminus of CpcB, one component in PBS, in both CpcG-PBS and CpcL-PBS (cross-link 1), and between the N termini of FNRL and CpcB (cross-link 2). Our data provide a novel functional assembly form of phycobiliproteins and a molecular-level description of the close association of FNRL with phycocyanin in both CpcG-PBS and CpcL-PBS.IMPORTANCE Cyanobacterial light-harvesting complex PBSs are essential for photochemistry in light reactions and for balancing energy flow to carbon fixation in the form of ATP and NADPH. We isolated a new type of PBS without an allophycocyanin core (i.e., CpcL-PBS). CpcL-PBS contains both a spectral red-shifted chromophore, enabling efficient energy transfer to chlorophyll molecules in the reaction centers, and an increased FNRL content with various rod lengths. Identification of a close association of FNRL with both CpcG-PBS and CpcL-PBS brings new insight to its regulatory role for fine-tuning light energy transfer and carbon fixation through both noncyclic and cyclic electron transport.

Comparative analysis of health system performance in Montreal and New York: the importance of context for interpreting indicators.

Although eliminating financial barriers to care is a necessary condition for improving access to health services, it is not sufficient. Given the contrasting health systems with regard to financing and organization of health insurance in the United States and Canada, there is a long history of comparing these countries. We extend the empirical studies on the Canadian and US health systems by comparing access to ambulatory care as measured by hospitalization rates for ambulatory care sensitive conditions (ACSC) in Montreal and New York City. We find that, in New York, ACSC rates were more than twice as high (12.6 per 1000 population) as in Montreal (4.8 per 1000 population). After controlling for age, sex, and number of diagnoses, significant differences in ACSC rates are present in both cities, but are more pronounced in New York. Our findings are consistent with the hypothesis that universal, first-dollar health insurance coverage has contributed to lower ACSC rates in Montreal than New York. However, Montreal's surprisingly low ACSC rate calls for further research.

Disparities in Statin Use in New York City: Implications for Health Reform.

Heart disease is the leading cause of death in the USA, and there is an extensive literature describing disparities in the treatment of the disease. Cholesterol-lowering medications are an effective strategy for reducing the risk of cardiovascular diseases for many patients, but some who are prescribed these medications fail to take them. We examine data from the 2014 New York City Community Health Survey to investigate the factors that influence why patients are not compliant in following the prescribed regimen. We focus on adults age 45 and older who report that they are diagnosed with elevated cholesterol levels and were told by a health professional they needed to take cholesterol-lowering medication. We find that evident disparities: individuals with low incomes, those who rely on emergency departments for their healthcare, have not received medical care within the past year, are depressed, and identify as black non-Hispanic and Hispanic are less likely to adhere to a cholesterol-lowering medication program. Although Medicare beneficiaries are less likely to take cholesterol-lowering medication than those with private insurance, those who were on Medicaid or were uninsured did not report lower rates of adherence.

Where are the most ancient stars in the Milky Way?

The oldest stars in the Milky Way (MW) bear imprints of the Galaxy's early assembly history. We use FIRE cosmological zoom-in simulations of three MW-mass disc galaxies to study the spatial distribution, chemistry, and kinematics of the oldest surviving stars (z form ≳ 5) in MW-like galaxies. We predict the oldest stars to be less centrally concentrated at z = 0 than stars formed at later times as a result of two processes. First, the majority of the oldest stars are not formed in situ but are accreted during hierarchical assembly. These ex situ stars are deposited on dispersion-supported, halo-like orbits but dominate over old stars formed in situ in the solar neighbourhood, and in some simulations, even in the galactic centre. Secondly, old stars formed in situ are driven outwards by bursty star formation and energetic feedback processes that create a time-varying gravitational potential at z ≳ 2, similar to the process that creates dark matter cores and expands stellar orbits in bursty dwarf galaxies. The total fraction of stars that are ancient is more than an order of magnitude higher for sight lines away from the bulge and inner halo than for inward-looking sight lines. Although the task of identifying specific stars as ancient remains challenging, we anticipate that million-star spectral surveys and photometric surveys targeting metal-poor stars already include hundreds of stars formed before z = 5. We predict most of these targets to have higher metallicity (-3 < [Fe/H] < -2) than the most extreme metal-poor stars.

Medicare Beneficiaries Living In Housing With Supportive Services Experienced Lower Hospital Use Than Others.

There is strong evidence that housing conditions affect population health, but evidence is limited on the extent to which housing with supportive social services can maintain population health and reduce the use of expensive hospital services. We examined a nonprofit, community-based program in Queens, New York, that supplied affordable housing with supportive social services to elderly Medicare beneficiaries. We evaluated whether this program reduced hospital use, including hospital discharges for ambulatory care-sensitive conditions (ACSCs). We compared hospital use among an intervention group residing in six high-rise buildings in two neighborhoods to that among their Medicare counterparts living in the same neighborhoods but in different buildings. We found that hospital discharge rates were 32 percent lower, hospital lengths-of-stay one day shorter, and ACSC rates 30 percent lower among residents in the intervention group than among people in the comparison group. This suggests that investments in housing with supportive social services have the potential to reduce hospital use and thereby decrease spending for vulnerable older patients.

Globular clusters in high-redshift dwarf galaxies: a case study from the Local Group.

We present the reconstructed evolution of rest-frame ultraviolet (UV) luminosities of the most massive Milky Way dwarf spheroidal satellite galaxy, Fornax, and its five globular clusters (GCs) across redshift, based on analysis of the stellar fossil record and stellar population synthesis modelling. We find that (1) Fornax's (proto-)GCs can generate 10-100 times more UV flux than the field population, despite comprising <~ 5 per cent of the stellar mass at the relevant redshifts; (2) due to their respective surface brightnesses, it is more likely that faint, compact sources in the Hubble Frontier Fields (HFFs) are GCs hosted by faint galaxies, than faint galaxies themselves. This may significantly complicate the construction of a galaxy UV luminosity function at z > 3. (3) GC formation can introduce order-of-magnitude errors in abundance matching. We also find that some compact HFF objects are consistent with the reconstructed properties of Fornax's GCs at the same redshifts (e.g. surface brightness, star formation rate), suggesting we may have already detected proto-GCs in the early Universe. Finally, we discuss the prospects for improving the connections between local GCs and proto-GCs detected in the early Universe.

Gas kinematics in FIRE simulated galaxies compared to spatially unresolved HI observations.

The shape of a galaxy's spatially unresolved, globally integrated 21-cm emission line depends on its internal gas kinematics: galaxies with rotationally supported gas discs produce double-horned profiles with steep wings, while galaxies with dispersion-supported gas produce Gaussian-like profiles with sloped wings. Using mock observations of simulated galaxies from the FIRE project, we show that one can therefore constrain a galaxy's gas kinematics from its unresolved 21-cm line profile. In particular, we find that the kurtosis of the 21-cm line increases with decreasing V/σ and that this trend is robust across a wide range of masses, signal-to-noise ratios, and inclinations. We then quantify the shapes of 21-cm line profiles from a morphologically unbiased sample of ~2000 low-redshift, HI-detected galaxies with Mstar = 107-11 M☉ and compare to the simulated galaxies. At Mstar ≳ 1010 M☉, both the observed and simulated galaxies produce double-horned profiles with low kurtosis and steep wings, consistent with rotationally supported discs. Both the observed and simulated line profiles become more Gaussian like (higher kurtosis and less-steep wings) at lower masses, indicating increased dispersion support. However, the simulated galaxies transition from rotational to dispersion support more strongly: at Mstar 108-10 M, most of the simulations produce more Gaussian-like profiles than typical observed galaxies with similar mass, indicating that gas in the low-mass simulated galaxies is, on average, overly dispersion supported. Most of the lower-mass-simulated galaxies also have somewhat lower gas fractions than the median of the observed population. The simulations nevertheless reproduce the observed line-width baryonic Tully-Fisher relation, which is insensitive to rotational versus dispersion support.

Reactive oxygen species leave a damage trail that reveals water channels in Photosystem II.

Photosystem II (PSII), a unique membrane-bound oxidoreductase, catalyzes light-driven oxidation of water to molecular oxygen. Although high-resolution structures of PSII are known, the exact path of the substrate water molecules to the catalytic Mn4CaO5 center within the PSII complex remains poorly understood. PSII produces reactive oxygen species (ROS), responsible for the frequent damage and turnover of this megacomplex that occur under physiological conditions. Such ROS are known to specifically modify PSII proteins. Using high-resolution tandem mass spectrometry, we identified oxidative modifications on 36 amino acid residues on the lumenal side of PSII, in the core PSII proteins D1, D2, and CP43 of the cyanobacterium Synechocystis sp. PCC 6803. Remarkably, these oxidized residues clustered into three nearly continuous formations, tracking the pathways of ROS diffusion from the manganese center all the way out to the surface of PSII. We suggest that these profiles of oxidized residues reveal the locations of water channels within PSII. Our results provide the most comprehensive experimental evidence to date of physiologically relevant oxidized residues in PSII and illuminate three possible channels for water between the catalytic Mn cluster in the PSII complex and the bulk medium around it.

Mass spectrometry-based cross-linking study shows that the Psb28 protein binds to cytochrome b559 in Photosystem II.

Photosystem II (PSII), a large pigment protein complex, undergoes rapid turnover under natural conditions. During assembly of PSII, oxidative damage to vulnerable assembly intermediate complexes must be prevented. Psb28, the only cytoplasmic extrinsic protein in PSII, protects the RC47 assembly intermediate of PSII and assists its efficient conversion into functional PSII. Its role is particularly important under stress conditions when PSII damage occurs frequently. Psb28 is not found, however, in any PSII crystal structure, and its structural location has remained unknown. In this study, we used chemical cross-linking combined with mass spectrometry to capture the transient interaction of Psb28 with PSII. We detected three cross-links between Psb28 and the α- and ß-subunits of cytochrome b559, an essential component of the PSII reaction-center complex. These distance restraints enable us to position Psb28 on the cytosolic surface of PSII directly above cytochrome b559, in close proximity to the QB site. Protein-protein docking results also support Psb28 binding in this region. Determination of the Psb28 binding site and other biochemical evidence allow us to propose a mechanism by which Psb28 exerts its protective effect on the RC47 intermediate. This study also shows that isotope-encoded cross-linking with the "mass tags" selection criteria allows confident identification of more cross-linked peptides in PSII than has been previously reported. This approach thus holds promise to identify other transient protein-protein interactions in membrane protein complexes.

The proteolysis adaptor, NblA, binds to the N-terminus of ß-phycocyanin: Implications for the mechanism of phycobilisome degradation.

Phycobilisome (PBS) complexes are massive light-harvesting apparati in cyanobacteria that capture and funnel light energy to the photosystem. PBS complexes are dynamically degraded during nutrient deprivation, which causes severe chlorosis, and resynthesized during nutrient repletion. PBS degradation occurs rapidly after nutrient step down, and is specifically triggered by non-bleaching protein A (NblA), a small proteolysis adaptor that facilitates interactions between a Clp chaperone and phycobiliproteins. Little is known about the mode of action of NblA during PBS degradation. In this study, we used chemical cross-linking coupled with LC-MS/MS to investigate the interactions between NblA and phycobiliproteins. An isotopically coded BS3 cross-linker captured a protein interaction between NblA and ß-phycocyanin (PC). LC-MS/MS analysis identified the amino acid residues participating in the binding reaction, and demonstrated that K52 in NblA is cross-linked to T2 in ß-PC. These results were modeled onto the existing crystal structures of NblA and PC by protein docking simulations. Our data indicate that the C-terminus of NblA fits in an open groove of ß-PC, a region located inside the central hollow cavity of a PC rod. NblA may mediate PBS degradation by disrupting the structural integrity of the PC rod from within the rod. In addition, M1-K44 and M1-K52 cross-links between the N-terminus of NblA and the C-terminus of NblA are consistent with the NblA crystal structure, confirming that the purified NblA is structurally and biologically relevant. These findings provide direct evidence that NblA physically interacts with ß-PC.