RESUMEN
Importance: Medicare Advantage is associated with improved health outcomes, increased care efficiency, and lower out-of-pocket costs compared with fee-for-service (FFS) Medicare. When engaged in 2-sided risk arrangements, physicians are incented to offer high value for patients; however, no studies have explored the quality and efficiency outcomes in 2-sided risk Medicare Advantage models compared with FFS Medicare. Objective: To compare quality and efficiency of care between physicians using a Medicare Advantage 2-sided risk model and FFS Medicare. Design, Setting, and Participants: This retrospective cohort analysis with exact and propensity score-matched design used claims data from January 1, 2018, to December 31, 2019. Participants included beneficiaries enrolled in a Medicare Advantage 2-sided risk model (ie, physicians assumed the financial risk of total costs of care) and those in an FFS Medicare program in a 5% limited data set with part A and B coverage residing in 6 states (Arizona, California, Florida, Nevada, Texas, and Utah). Data were analyzed from February 1 to June 15, 2022. Exposures: Medicare Advantage 2-sided risk model seen in practices that are part of a nationwide health care delivery organization compared with traditional FFS Medicare. Main Outcomes and Measures: Comparative analysis of 8 quality and efficiency metrics in populations enrolled in a 2-sided risk-model Medicare Advantage program and 5% FFS Medicare. Results: In this analytic cohort of 316â¯312 individuals (158â¯156 in each group), 46.11% were men and 53.89% were women; 32.72% were aged 65-69 years, 29.44% were aged 70-74 years, 19.05% were aged 75-79 years, 10.84% were aged 80-85 years, and 7.95% were 85 years or older. The Medicare Advantage model was associated with care of higher quality and efficiency in all 8 metrics compared with the FFS model. This included lower odds of inpatient admission (-18%; odds ratio [OR], 0.82 [95% CI, 0.79-0.84]), inpatient admission through the emergency department (ED) (-6%; OR, 0.94 [95% CI, 0.91-0.97]), ED visits (-11%; OR, 0.89 [95% CI, 0.86-0.91]), avoidable ED visits (-14%; OR, 0.86 [95% CI, 0.82-0.89]), 30-day inpatient readmission (-9%; rate ratio, 0.91 [95% CI, 0.86-0.98]), admission for stroke or myocardial infarction (-10%; OR, 0.90 [95% CI, 0.83-0.98]), and hospitalization for chronic obstructive pulmonary disease or asthma exacerbation (-44%; OR, 0.56 [95% CI, 0.50-0.62]). Conclusions and Relevance: The improvements observed in this study may be partly or fully attributed to the Medicare Advantage model. The Medicare Advantage risk adjustment system appears to be meeting its intended goal by aligning the capitation payments to the health care burden of the individual beneficiary and aggregate population served, thus providing revenue to develop infrastructure that supports improvements in quality and efficiency for the patients enrolled in Medicare Advantage models with 2-sided risk.
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Planes de Aranceles por Servicios , Medicare Part C , Masculino , Anciano , Humanos , Femenino , Estados Unidos , Estudios Retrospectivos , Calidad de la Atención de Salud , HospitalizaciónRESUMEN
The concept of a Health Promoting School has been found to be effective to improve health and well-being of students as well as a help with teaching and learning in school. Effective implementation of Health Promoting School is a complex intervention involving multi-factorial and innovative activity in many domains such as curriculum, school environment and community. Many studies evaluating Health Promoting School do not include outcomes reflecting the organisational or structural change as many of those studies are quantitative in nature and the statistical assumptions are not valid reflecting the organisational structure changes. Recent global meetings of experts have reviewed the impact on student health from the perspectives of school environment, school policies on health, action competencies on healthy living and community linkage. The English Wessex Healthy School Award Scheme and the Hong Kong Healthy School Awards Scheme have developed detailed systems to analyse whether each individual school has reached the standard of a model Health Promoting School reflecting a more holistic appreciation and understanding of all the effects of school-based health promotion with positive award-related changes. However, not many schools are able to implement Health Promoting School in its entirety, so cores indicators are needed as a starting point for wider implementation. Hong Kong Healthy School Awards Scheme is still ongoing with data for analysis of indicators with significant correlation with better health and well-being. We identified the core indicators and substantiated the requirements for successful outcomes by supplementing the established award-scheme framework with a review of recent literature and documents. Framework of Health Promoting School would go beyond improvement of health literacy to enable a more efficient system for education and health on children, hence a good investment in children.
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Promoción de la Salud/organización & administración , Instituciones Académicas , Promoción de la Salud/normas , Hong KongRESUMEN
The Arabidopsis receptor kinase FERONIA (FER) is a multifunctional regulator for plant growth and reproduction. Here we report that the female gametophyte-expressed glycosylphosphatidylinositol-anchored protein (GPI-AP) LORELEI and the seedling-expressed LRE-like GPI-AP1 (LLG1) bind to the extracellular juxtamembrane region of FER and show that this interaction is pivotal for FER function. LLG1 interacts with FER in the endoplasmic reticulum and on the cell surface, and loss of LLG1 function induces cytoplasmic retention of FER, consistent with transport of FER from the endoplasmic reticulum to the plasma membrane in a complex with LLG1. We further demonstrate that LLG1 is a component of the FER-regulated RHO GTPase signaling complex and that fer and llg1 mutants display indistinguishable growth, developmental and signaling phenotypes, analogous to how lre and fer share similar reproductive defects. Together our results support LLG1/LRE acting as a chaperone and co-receptor for FER and elucidate a mechanism by which GPI-APs enable the signaling capacity of a cell surface receptor.
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Proteínas de Arabidopsis/metabolismo , Arabidopsis/fisiología , Proteínas Ligadas a GPI/metabolismo , Glicosilfosfatidilinositoles/metabolismo , Glicoproteínas de Membrana/metabolismo , Chaperonas Moleculares/metabolismo , Fosfotransferasas/metabolismo , Transducción de Señal/fisiología , Proteínas de Arabidopsis/genética , Cartilla de ADN , Electroforesis en Gel de Poliacrilamida , Proteínas Ligadas a GPI/genética , Immunoblotting , Inmunoprecipitación , Glicoproteínas de Membrana/genética , Microscopía Fluorescente , Hormonas Peptídicas/metabolismo , Especies Reactivas de Oxígeno/metabolismo , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Técnicas del Sistema de Dos Híbridos , Proteínas de Unión al GTP rho/metabolismoRESUMEN
BACKGROUND: Home and school environments conducive for unhealthy eating and physical inactivity are precursors of obesity. The aim of this study is evaluation of the effectiveness of a multi-component school-based weight management programme for overweight and obese primary school children via a home-school joint venture. METHODS: This study made use of variety of behavioural modification strategies integrating into the Health Promoting School approach to promote healthy lifestyles. The participants were overweight and obese students aged between 8 and 12 from six participating schools. The interventions involved students attending ten 75 minutes after-school sessions and one 3-hour week-end session of practical interactive and fun activities on healthy eating and exercise, and meal plan together with parents and printed tailor-made management advices. Parents received an introductory seminar with 2 sets of specially designed exercise for their overweight children. The tools to measure bodyweight and fat percentage and standing height were bio-impedance body fat scale and a portable stadiometer. Self-administered questionnaire was used to measure knowledge, attitudes and behaviours. McNemar test was utilized to compare the proportions of behaviour changes within the same group to assess for the trends of changes. BMI z-score and body fat percentage of intervention participants at baseline, 4 month and 8 month were compared pair-wisely using tests of within subject contrasts in repeated measures ANOVA to assess for programme sustainability. RESULTS: Those students in the intervention group reduced their BMI z-score (-0.21, 95% CI -0.34 to -0.07, P = 0.003) and body fat (-2.67%, 95% CI -5.12 to -0.22, P = 0.033) compared to wait list control group with statistical significant, and the intervention group also had a significant reduction in BMI z-score (-0.06, 95% CI -0.11, -0.007, P = 0.028) and body fat (-1.71%, 95% CI, -3.44 to 0.02, P = 0.052) after a 4 month maintenance period. Improvement of dietary habits and positive attitudes towards exercise were observed among the intervention group. CONCLUSION: School based weight management programme integrated into a Health Promoting School approach with improved school policies and environment in supporting individual skills of obese students and their parents appears to be a promising practice for sustaining weight control. TRIAL REGISTRATION: ISRCTN58795797.