Health care organizations and systems can have a large impact on how extensively telemedicine and virtual visits are used by medical practices and individual clinicians. This supplemental issue of ...medical care aims to advance evidence about how health care organizations and systems can best support telemedicine and virtual visit implementation. This issue includes 10 empirical studies examining the impact of telemedicine on quality of care, utilization, and/or patient care experiences, of which 6 are studies of Kaiser Permanente patients; 3 are studies of Medicaid, Medicare, and community health center patients; and 1 is a study of PCORnet primary care practices. The Kaiser Permanente studies find that ancillary service orders resulting from telemedicine encounters were not placed as often as in-person encounters for urinary tract infections, neck, and back pain, but there were no significant changes in patient fulfillment of ordered antidepressant medications. Studies focused on diabetes care quality among community health center patients and Medicare and Medicaid beneficiaries highlight that telemedicine helped maintain continuity of primary care and diabetes care quality during the COVID-19 pandemic. The research findings collectively demonstrate high variation in telemedicine implementation across systems and the important role that telemedicine had in maintaining the quality of care and utilization for adults with chronic conditions when in-person care was less accessible.
Abstract
Summary
NanoCLUST is an analysis pipeline for the classification of amplicon-based full-length 16S rRNA nanopore reads. It is characterized by an unsupervised read clustering step, based on ...Uniform Manifold Approximation and Projection (UMAP), followed by the construction of a polished read and subsequent Blast classification. Here, we demonstrate that NanoCLUST performs better than other state-of-the-art software in the characterization of two commercial mock communities, enabling accurate bacterial identification and abundance profile estimation at species-level resolution.
Availability and implementation
Source code, test data and documentation of NanoCLUST are freely available at https://github.com/genomicsITER/NanoCLUST under MIT License.
Supplementary information
Supplementary data are available at Bioinformatics online.
Mavacamten, formerly known as MYK-461 is a recently discovered novel small-molecule modulator of cardiac myosin that targets the underlying sarcomere hypercontractility of hypertrophic ...cardiomyopathy, one of the most prevalent heritable cardiovascular disorders. Studies on isolated cells and muscle fibers as well as intact animals have shown that mavacamten inhibits sarcomere force production, thereby reducing cardiac contractility. Initial mechanistic studies have suggested that mavacamten primarily reduces the steady-state ATPase activity by inhibiting the rate of phosphate release of β-cardiac myosin-S1, but the molecular mechanism of action of mavacamten has not been described. Here we used steady-state and presteady-state kinetic analyses to investigate the mechanism of action of mavacamten. Transient kinetic analyses revealed that mavacamten modulates multiple steps of the myosin chemomechanical cycle. In addition to decreasing the rate-limiting step of the cycle (phosphate release), mavacamten reduced the number of myosin-S1 heads that can interact with the actin thin filament during transition from the weakly to the strongly bound state without affecting the intrinsic rate. Mavacamten also decreased the rate of myosin binding to actin in the ADP-bound state and the ADP-release rate from myosin-S1 alone. We, therefore, conclude that mavacamten acts on multiple stages of the myosin chemomechanical cycle. Although the primary mechanism of mavacamten-mediated inhibition of cardiac myosin is the decrease of phosphate release from β-cardiac myosin-S1, a secondary mechanism decreases the number of actin-binding heads transitioning from the weakly to the strongly bound state, which occurs before phosphate release and may provide an additional method to modulate myosin function.
Hypertrophic cardiomyopathy (HCM) is an inherited disease of heart muscle that can be caused by mutations in sarcomere proteins. Clinical diagnosis depends on an abnormal thickening of the heart, but ...the earliest signs of disease are hyperdynamic contraction and impaired relaxation. Whereas some in vitro studies of power generation by mutant and wild-type sarcomere proteins are consistent with mutant sarcomeres exhibiting enhanced contractile power, others are not. We identified a small molecule, MYK-461, that reduces contractility by decreasing the adenosine triphosphatase activity of the cardiac myosin heavy chain. Here we demonstrate that early, chronic administration of MYK-461 suppresses the development of ventricular hypertrophy, cardiomyocyte disarray, and myocardial fibrosis and attenuates hypertrophic and profibrotic gene expression in mice harboring heterozygous human mutations in the myosin heavy chain. These data indicate that hyperdynamic contraction is essential for HCM pathobiology and that inhibitors of sarcomere contraction may be a valuable therapeutic approach for HCM.
Addressing nonmedical needs-such as the need for housing-is critical to advancing population health, improving the quality of care, and lowering the costs of care. Accountable care organizations ...(ACOs) are well positioned to address these needs. We used qualitative interviews with ACO leaders and site visits to examine how these organizations addressed the nonmedical needs of their patients, and the extent to which they did so. We developed a typology of medical and social services integration among ACOs that disentangles service and organizational integration. We found that the nonmedical needs most commonly addressed by ACOs were the need for transportation and housing and food insecurity. ACOs identified nonmedical needs through processes that were part of the primary care visit or care transformation programs. Approaches to meeting patients' nonmedical needs were either individualized solutions (developed patient by patient) or targeted approaches (programs developed to address specific needs). As policy makers continue to provide incentives for health care organizations to meet a broader spectrum of patients' needs, these findings offer insights into how health care organizations such as ACOs integrate themselves with nonmedical organizations.
This paper introduces a human posture tracking platform to identify the human postures of sitting, standing or lying down, based on a smartwatch. This work develops such a system as a ...proof-of-concept study to investigate a smartwatch's ability to be used in future remote health monitoring systems and applications. This work validates the smartwatches' ability to track the posture of users accurately in a laboratory setting while reducing the sampling rate to potentially improve battery life, the first steps in verifying that such a system would work in future clinical settings. The algorithm developed classifies the transitions between three posture states of sitting, standing and lying down, by identifying these transition movements, as well as other movements that might be mistaken for these transitions. The system is trained and developed on a Samsung Galaxy Gear smartwatch, and the algorithm was validated through a leave-one-subject-out cross-validation of 20 subjects. The system can identify the appropriate transitions at only 10 Hz with an F-score of 0.930, indicating its ability to effectively replace smart phones, if needed.
The changing Latino demographic in the United States presents a number of challenges to health care policy makers, clinicians, organizations, and other stakeholders. Studies have demonstrated that ...Latinos tend to have worse patterns of access to, and utilization of, health care than other ethnic and racial groups. The implementation of the Affordable Care Act (ACA) of 2010 may ameliorate some of these disparities. However, even with the ACA, it is expected that Latinos will continue to have problems accessing and using high-quality health care, especially in states that are not expanding Medicaid eligibility as provided by the ACA. We identify four current policy dilemmas relevant to Latinos' health and ACA implementation: (
a
) the need to extend coverage to the undocumented; (
b
) the growth of Latino populations in states with limited insurance expansion; (
c
) demands on public and private systems of care; and (
d
) the need to increase the number of Latino physicians while increasing the direct patient-care responsibilities of nonphysician Latino health care workers.
Background
Shared decision-making (SDM) is widely recognized as a core strategy to improve patient-centered care. However, the implementation of SDM in routine care settings has been slow and its ...impact mixed.
Objective
We examine the temporal association of patient activation and patients’ experience with the SDM process to assess the dominant directionality of this relationship.
Design
Patient activation, or a patients’ knowledge, skills, and confidence in self-management, was assessed using the 13-item Patient Activation Measure (PAM). Patient-reported assessment of the SDM process was assessed using the 3-item CollaboRATE measure. Patients at 16 adult primary care practices were surveyed in 2015 and 2016 on PAM (
α
= 0.92), CollaboRATE (
α
= 0.90), and demographics. The relationship between PAM and CollaboRATE was estimated using a cross-lagged panel model with clustered robust standard errors and practice fixed effects, controlling for patient characteristics.
Participants
1222 adult patients with diabetes and/or cardiovascular disease with survey responses at baseline (51% response rate) and a 1-year follow-up (73% response rate).
Results
PAM (mean 3.27 vs 3.28 on a range of 1 to 4;
p
= 0.082) and CollaboRATE (mean 3.62 vs 3.63 on a range of 1 to 5;
p
= 0.14) did not change significantly over time. In adjusted analyses, the path from baseline PAM to follow-up CollaboRATE (
β
= 0.35;
p
< 0.0001) was stronger than the path from baseline CollaboRATE to follow-up PAM (
β
= 0.04;
p
= 0.001).
Conclusions
The relationship between patient activation and patients’ experiences of the SDM process is bidirectional, but dominated by baseline patient activation. Rather than promoting the use of SDM for all patients, healthcare organizations should prioritize interventions to promote patient activation and engage patients with relatively high activation in SDM interventions.
Despite interest in addressing social determinants of health to improve patient outcomes, little progress has been made in integrating social services with medical care. We aimed to understand how ...health care providers with strong motivation (for example, operating under new payment models) and commitment (for example, early adopters) fared at addressing patients' social needs. We collected qualitative data from twenty-two accountable care organizations (ACOs). These ACOs were early adopters and were working on initiatives to address social needs, including such common needs as transportation, housing, and food. However, even these ACOs faced significant difficulties in integrating social services with medical care. First, the ACOs were frequently "flying blind," lacking data on both their patients' social needs and the capabilities of potential community partners. Additionally, partnerships between ACOs and community-based organizations were critical but were only in the early stages of development. Innovation was constrained by ACOs' difficulties in determining how best to approach return on investment, given shorter funding cycles and longer time horizons to see returns on social determinants investments. Policies that could facilitate the integration of social determinants include providing sustainable funding, implementing local and regional networking initiatives to facilitate partnership development, and developing standardized data on community-based organizations' services and quality to aid providers that seek partners.
Background
It remains unclear whether the racial-ethnic composition or the socioeconomic profiles of eligible primary care practices better explain practice participation in the Centers for Medicare ...and Medicaid Services’ (CMS) Comprehensive Primary Care Plus (CPC+) program.
Objective
To examine whether practices serving high proportions of Black or Latino Medicare fee-for-service (FFS) beneficiaries were less likely to participate in CPC+ in 2021 compared to practices serving lower proportions of these populations.
Design
2019 IQVIA OneKey data on practice characteristics was linked with 2018 CMS claims data and 2021 CMS CPC+ participation data. Medicare FFS beneficiaries were attributed to practices using CMS’s primary care attribution method.
Participants
11,718 primary care practices and 7,264,812 attributed Medicare FFS beneficiaries across 18 eligible regions.
Methods
Multivariable logistic regression models examined whether eligible practices with relatively high shares of Black or Latino Medicare FFS beneficiaries were less likely to participate in CPC+ in 2021, controlling for the clinical and socioeconomic profiles of practices.
Main Measures
Proportion of Medicare FFS beneficiaries attributed to each practice that are (1) Latino and (2) Black.
Key Results
Of the eligible practices, 26.9% were CPC+ participants. In adjusted analyses, practices with relatively high shares of Black (adjusted odds ratio, aOR = 0.62,
p
< 0.05) and Latino (aOR = 0.32,
p
< 0.01) beneficiaries were less likely to participate in CPC+ compared to practices with lower shares of these beneficiary groups. State differences in CPC+ participation rates partially explained participation disparities for practices with relatively high shares of Black beneficiaries, but did not explain participation disparities for practices with relatively high shares of Latino beneficiaries.
Conclusions
The racial-ethnic composition of eligible primary care practices is more strongly associated with CPC+ participation than census tract–level poverty. Practice eligibility requirements for CMS-sponsored initiatives should be reconsidered so that Black and Latino beneficiaries are not left out of the benefits of practice transformation.
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