Modeling the GABAergic action of etomidate on the thalamocortical system.

BACKGROUND: We have used a computational model of the thalamocortical system to investigate the effects of a GABAergic anesthetic (etomidate) on cerebral cortical and thalamic neuronal function. We examined the effects of phasic and tonic inhibition, as well as the relative importance of anesthetic action in the thalamus and cortex. METHODS: The amount of phasic GABAergic inhibition was adjusted in the model to simulate etomidate concentrations of between 0.25 and 2 microM, with the concentration range producing unconsciousness assumed to be between 0.25 and 0.5 microM. In addition, we modeled tonic inhibition separately, and then phasic and tonic inhibition together. We also introduced phasic and tonic inhibition into the cerebral cortex and thalamus separately to determine the relative importance of each of these structures to anesthetic-induced depression of the thalamocortical system. RESULTS: Phasic inhibition decreased cortical neuronal firing by 11%-18% in the 0.25-0.5 microM range and by 38% at 2 microM. Tonic inhibition produced similar depression (11%-21%) in the 0.25-0.5 microM range but 65% depression at 2 microM; phasic and tonic inhibition combined produced the most inhibition (76% depression at 2 microM). When the thalamus and cortex were separately subjected to phasic and tonic inhibition, cortical firing rates decreased less compared to when both structures were targeted. In the 0.25-0.5 microM range, cortical firing rate was minimally affected when etomidate action was simulated in the thalamus only. CONCLUSIONS: This computational model of the thalamocortical system indicated that tonic GABAergic inhibition seems to be more important than phasic GABAergic inhibition (especially at larger etomidate concentrations), although both combined had the most effect on cerebral cortical firing rates. Furthermore, etomidate action in the thalamus, by itself, does not likely explain etomidate-induced unconsciousness.

Public reporting and pay-for-performance: safety-net hospital executives' concerns and policy suggestions.

Safety-net hospitals (SNHs) may gain little financial benefit from the rapidly spreading adoption of public reporting and pay-for-performance, but may feel compelled to participate (and bear the costs of data collection) to meet public expectations of transparency and accountability. To better understand the concerns that SNH administrators have regarding public reporting and pay-for-performance, we interviewed 37 executives at randomly selected California SNHs. The main concerns noted by SNH executives were that human and financial resource constraints made it difficult for SNHs to accurately measure their performance. Additionally, some executives felt that market-driven public reporting and pay-for-performance may focus on clinical areas and incentive structures that may not be high-priority clinical areas for SNHs. Executives at SNHs suggested several policy responses to these concerns-such as offering training programs for SNH data collectors-that could be relatively inexpensive and might improve the cost-benefit ratio of public reporting and pay-for-performance programs.

A behavioral model of clinician responses to incentives to improve quality.

The use of pay for performance (P4P) and public reporting of performance (PR) in health care is increasing rapidly worldwide. The rationale for P4P and PR comes from experience in other industries and from theories about incentive use from psychology, economics, and organizational behavior. This paper reviews the major themes from this prior research and considers how they might be applied to health care. The resulting conceptual model addresses the dual nature (combining direct financial and reputational incentives) of the initiatives many policymakers are pursuing. It also includes explicit recognition of the key contextual factors (at the levels of the markets and the provider organization) and provider and patient characteristics that can enhance or mitigate response to incentives. Evaluation of the existing literature (through June 2005) about incentive use in health care in light of the conceptual model highlights important weaknesses in the way that trials have been reported to date and suggests future research topics.