Joint AGS-CCEHI Survey Offers Insights into Patient Engagement in Geriatric Clinical Settings.

OBJECTIVES: Many clinical practices and health systems are increasingly interested in adopting structures for consumer engagement to inform organizational policies and programs. These structures can include patient and family advisory committees, patient representation on an organization's board of directors, or inclusion of patients and family members in quality improvement activities. However, to date only limited information has been available on the uptake of patient engagement strategies and structures, and none specific to geriatrics. We surveyed American Geriatrics Society (AGS) members to ascertain how and when consumer engagement is occurring in the clinical settings where AGS members provide care, and to identify opportunities to improve engagement. DESIGN: Descriptive survey. PARTICIPANTS: A total of 20% (829) of eligible AGS members responded to this section of the survey. MEASUREMENTS: Respondents' primary work site, methods and staffing of patient and family engagement, barriers to engagement, and strategies to improve engagement. RESULTS: The most common methods of engagement were through advisory committees (28%), quality improvement and program evaluations (27%), and focus groups (21%). However, more than one-third of respondents (35%) said they were not sure whether their clinical setting had any structures or strategies in place for consumer engagement. Respondents identified barriers to engagement as well as the tools and information that would help improve engagement. CONCLUSION: The survey findings provide insight into what patient engagement looks like in the hospitals, health systems, and other clinical settings where geriatrics health professionals work. Making structures for patient and family engagement more widespread in geriatric practice settings will require addressing the barriers identified by survey respondents including the need for funding and staff time, transportation, and training and supports for participating patients and caregivers. J Am Geriatr Soc 67:1791-1794, 2019.

Will 2019 kick off a new era in person-centered care?

Medicare's star rating system for Medicare Advantage health plans is a powerful tool for driving plan behavior and, beginning in 2019, CMS is providing new weight to patient access and experience measures. As the shift begins, a recent analysis of person-centered care measures in the star rating system conducted by the Center for Consumer Engagement in Health Innovation found ample room for improving both plan performance and how the ratings measure patient-centeredness. Although from 2010 to 2017, plans performed better on person-centered measures compared with the other measures in the star rating set (3.4 vs 3.0), our analysis also shows that performance on patient-centered measures has not comparatively budged appreciably over time. This may indicate that improvement initiatives focused on non-person-centered star measures have not had a spillover effect on the person-centered measures, or that plans may feel that once a minimum threshold on person-centered measures is met, they need not focus attention on further improvements. At the same time, we need a more comprehensive assessment of person-centeredness. The CMS star measures classified as person-centered are limited in scope and do not constitute a comprehensive view of what it actually means to be person-centered. The new weighting of patient access and experience measures in the CMS star rating system will press plans to refocus their managerial attention, allocate internal assets, and improve their performance, but we also need new measures that are more closely aligned with the domains that describe person-centered care.

Competing Visions for Consumer Engagement in the Dawn of the Trump Administration.

Two different models of consumer engagement use largely the same language but represent 2 distinct paradigms: the first focuses on patients as partners in health care decision making and the second focuses on financial incentives/penalties for patients. While the 2 paradigms coexist to some degree, they have different implications particularly for populations with complex health and social needs. For these populations, financial barriers can undermine the ability to recognize and promote patients as partners in a system of integrated, coordinated care. We describe these 2 competing visions and their adoption to date and offer our assessment of future directions for consumer engagement.

Perspectives on How to Engage Consumers in Health System Transformation.

While health care organizations and public programs have recently demonstrated an increased interest in engaging patients and consumers as part of the implementation of new programs and policies, there is little published to date to guide these organizations in how to best engage consumers. We turn to an unconventional source-health care consumer advocates-who have developed experience in the type of consumer outreach, engagement, and activation that could help inform health care organizations and policy makers in further defining and studying engagement. We share perspectives from the field of advocacy that we believe could be applicable to health care organizations and policy makers working to build patient and family engagement, particularly in organizational governance and policy.

Creation of state basic health programs would lead to 4 percent fewer people churning between Medicaid and exchanges.

The Affordable Care Act gives states the option of creating a so-called Basic Health Program to provide health insurance coverage for individuals and families whose incomes are low but who do not qualify for Medicaid. The Basic Health Program is intended, in part, to decrease churning, or frequent movement between Medicaid and state-run health insurance exchanges, by increasing the income-based eligibility transition point between the two programs to 200 percent of the federal poverty level. We analyzed data from the 2008 panel of the Survey of Income and Program Participation and found that among adults likely to participate in Medicaid and exchanges, only somewhat fewer experienced a change in eligibility with a 200 percent federal poverty level eligibility threshold compared with the previous threshold of 138 percent. As a result, we found that a Basic Health Program would prevent churning for 1.8 million adults nationally each year-reducing by about 4 percent the expected churning of low-income Americans between Medicaid and exchanges within a year. Such programs would also decrease the risk that lower-income families would be subject to recouping of premium tax credits. But churning rates would remain very high, and additional policy steps would be required to minimize the effect of coverage disruptions.

Purification and characterization of a fish scale-degrading enzyme from a newly identified Vogesella sp.

The objective of the present study is to purify and characterize the fish scale-degrading enzyme from Vogesella sp.7307-1, which was newly identified and isolated from fish scales. The enzyme from Vogesella sp.7307-1 was assayed with casein and confirmed as a protease. Crude protease was extracted, isolated, and purified 35.7-fold with 19.6% recovery using 20-80% saturation of ammonium sulfate fractionation, Q FF ion exchange chromatography, and Superdex 200 gelfiltration. The molecular weight of the purified enzyme was 119 kDa. The Km and Vmax were 0.067 mM and 425.5 U/mg-min, respectively using azo-casein as substrate. The optimum pH of the purified enzyme was 7.5, and the optimum temperature was 50 °C. The enzyme was stable at temperatures below 55 °C and pH range 7.5 to 9.0. The enzyme activity of the purified protease was completely inhibited by EDTA (ethylene diamine teraacetates), indicating the enzyme was a metalloprotease. Hydrolysates from fish scales treated with protease 7307-1 were found having low molecular weight peptides (<1 kDa). The protease 7307-1 is a promising enzyme for preparing smaller peptides from fish scales.

Synthesis of UV-absorbing and fluorescent carrier ampholyte mixtures and their application for the determination of the operational pH values of buffering membranes used in isoelectric trapping separations.

Success in isoelectric trapping separations critically depends on the knowledge of the accurate operational pH value of the buffering membranes used. Currently, due to a lack of easy, rapid, accurate methods that can be used for the post-synthesis determination of the operational pH value of a buffering membrane, only nominal pH values calculated from the amounts of the reagents used in the synthesis of the membranes and their acid-base dissociation constants are available. To rectify this problem, UV-absorbing and fluorescent carrier ampholyte mixtures were prepared by alkylating pentaethylenehexamine with a chromophore and a fluorophore, followed by Michael addition of acrylic acid and itaconic acid to the resulting oligoamine. Carrier ampholyte mixtures, with evenly distributed absorbance values across the 3

Lipoxygenase from banana leaf: purification and characterization of an enzyme that catalyzes linoleic acid oxygenation at the 9-position.

The objective of the present study was to purify and characterize the lipoxygenase (LOX) from banana leaf (Giant Cavendishii, AAA), an unutilized bioresource. LOX was extracted, isolated, and purified 327-fold using 25-50% saturation of ammonium sulfate fractionation, hydroxyapatite column separation, and gel filtration on Superdex 200. The molecular mass of the purified LOX was 85 kDa, K(m) was 0.15 mM, and V(max) was 2.4 microM/min.mg using linoleic acid as substrate. Triton X-100 was required in the extraction medium; otherwise, no LOX activity was detected. LOX activity increased with the concentration of Triton X-100 with an optimum at 0.1%. The optimal pH of the purified LOX from banana leaf was 6.2, and optimal temperature was 40 degrees C. The LOX showed the highest reactivity toward 18:2 followed by 18:3 and 20:4. A very low reaction rate was observed toward 20:5 and 22:6. On the basis of retention time in normal phase HPLC, the products of 18:2 or 18:3 catalyzed by purified LOX were hydroperoxyoctadecadienoic acid or hydroperoxyoctadecatrienoic acid. It seems that 9-LOX is the predominant enzyme in banana leaf. Banada leaf dried at 110 degrees C for 2 h developed algal aroma. Banana leaf extract stored at 10 degrees C for 12 h formed an oolong tea-like flavor. Banana leaf extract reacted with 18:2 or soybean oil pretreated with bacterial lipase produced green and melon-like aroma, whereas the same reaction with 18:3 produced a sweet, fruity, cucumber-like flavor note.

Safety of mifepristone abortions in clinical use.

OBJECTIVES: Extensive data from clinical trials document mifepristone's safety and efficacy for induced abortion, but less information is available about its safety in routine clinical use. METHODS: Data on mifepristone abortion use from the Planned Parenthood Federation of America, the largest provider of mifepristone abortion in the United States, from 2001 through the first quarter of 2004 were collected using a centralized reporting system. Over the study period, 95,163 mifepristone abortions were provided. Reportable events are complications requiring inpatient or outpatient hospital treatment. RESULTS: Overall, 2.2 per 1000 women (95% CI 1.9-2.5) experienced a complication, most commonly, heavy bleeding. Mifepristone abortion mortality is estimated to be 1.1 per 100,000 based on one death (95% CI 0.3-5.9). CONCLUSIONS: The safety of mifepristone is high; few serious medical complications occur in routine clinical use.

Advanced practice clinicians' interest in providing medical abortion: results of a California survey.

CONTEXT: California's Reproductive Health Privacy Act, which became law in January 2003, clarified that advanced practice clinicians could legally provide medical abortion. Little is known about the characteristics associated with nonphysician clinicians' interest in receiving medical abortion training or their perceptions of barriers to medical abortion provision. METHODS: In early 2003, a total of 1,176 licensed advanced practice clinicians in California-nurse practitioners, physician assistants and certified nurse-midwives-completed a mail-in survey assessing their personal characteristics, beliefs and clinical practices. Weighted univariate and bivariate analyses were conducted to describe the respondents, their interest in receiving medical abortion training and their perceptions of barriers to providing such care. RESULTS: One-quarter of respondents desired training in medical abortion. A higher proportion of nurse-midwives than of nurse practitioners or physician assistants desired training (42% vs. 24% and 23%, respectively). The proportion of respondents desiring training also was elevated among clinicians who have prochoice attitudes, those who are familiar with medical abortion and those who spend at least one-third of their time providing care to women of reproductive age. Lack of training opportunities, legal uncertainties and clinical facility constraints were the most frequently reported perceived barriers to provision of medical abortion. CONCLUSIONS: Considerable proportions of advanced practice clinicians-especially of nurse-midwives-may be interested in receiving medical abortion training. Perceived barriers to providing medical abortion are amenable to change. Policies and programs are needed to ensure that interested, committed clinicians can overcome barriers to providing medical abortion for their patients.