In successfully reducing healthcare expenditures, patient goals must be met and savings differentiated from cost shifting. Although the Department of Veterans Affairs (VA) Home Based Primary Care ...(HBPC) program for chronically ill individuals has resulted in cost reduction for the VA, it is unknown whether cost reduction results from restricting services or shifting costs to Medicare and whether HBPC meets patient goals. Cost projection using a hierarchical condition category (HCC) model adapted to the VA was used to determine VA plus Medicare projected costs for 9,425 newly enrolled HBPC recipients. Projected annual costs were compared with observed annualized costs before and during HBPC. To assess patient perspectives of care, 31 veterans and caregivers were interviewed from three representative programs. During HBPC, Medicare costs were 10.8% lower than projected, VA plus Medicare costs were 11.7% lower than projected, and combined hospitalizations were 25.5% lower than during the period without HBPC. Patients reported high satisfaction with HBPC team access, education, and continuity of care, which they felt contributed to fewer exacerbations, emergency visits, and hospitalizations. HBPC improves access while reducing hospitalizations and total cost. Medicare is currently testing the HBPC approach through the Independence at Home demonstration.
The forgotten 90 Becker Patterson, Margaret
Adult education quarterly,
02/2018, Letnik:
68, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Despite a highly developed U.S. adult education system, 90% of adults aged 20 years and older considered the least educated did not participate recently in formal or nonformal education. What are ...nonparticipants’ characteristics, learning backgrounds, and skill levels? What predicts their likelihood of not participating in recent formal or nonformal education? The author analyzed 2012/2014 Program for the International Assessment of Adult Competencies–USA data. Situational deterrents of increasing age, parental education, low income, and work and family responsibilities contribute to nonparticipation. Dispositional deterrents include health and disability challenges, low social trust, and difficulties relating new ideas to real life. Institutional deterrents are education costs and little work schedule flexibility. Supports reported by nonparticipants are liking to learn new things, use of computers, and getting information from television and people they trust. Results from Program for the International Assessment of Adult Competencies–USA analyses inform adult and postsecondary educators and policy makers on what happened to—and how to reach—the forgotten 90%.
The microbiome of the mosquito Aedes aegypti is largely determined by the environment and influences mosquito susceptibility for arthropod-borne viruses (arboviruses). Larval interactions with ...different bacteria can have carry-over effects on adult Ae. aegypti replication of arboviruses, but little is known about the role that mosquito host genetics play in determining how larval-bacterial interactions shape Ae aegypti susceptibility to arboviruses. To address this question, we isolated single bacterial isolates and complex microbiomes from Ae. aegypti larvae from various field sites in Senegal. Either single bacterial isolates or complex microbiomes were added to two different genetic backgrounds of Ae. aegypti in a gnotobiotic larval system. Using 16S amplicon sequencing we showed that the bacterial community structure differs between the two genotypes of Ae. aegypti when given identical microbiomes, and the abundance of single bacterial taxa differed between Ae. aegypti genotypes. Using single bacterial isolates or the entire preserved complex microbiome, we tested the ability of specific larval microbiomes to drive differences in infection rates for Zika virus in different genetic backgrounds of Ae. aegypti. We observed that the proportion of Zika virus-infected adults was dependent on the interaction between the larval microbiome and Ae. aegypti host genetics. By using the larval microbiome as a component of the environment, these results demonstrate that interactions between the Ae. aegypti genotype and its environment can influence Zika virus infection. As Ae. aegypti expands and adapts to new environments under climate change, an understanding of how different genotypes interact with the same environment will be crucial for implementing arbovirus transmission control strategies.
This chapter considers next steps of young adults with disabilities after initial education—for those who complete high school and those leaving high school early.
Culture-based studies have shown that acquisition of extended-spectrum β-lactamase-producing Enterobacterales is common during international travel; however, little is known about the role of the gut ...microbiome before and during travel, nor about acquisition of other antimicrobial-resistant organisms. We aimed to identify (1) whether the gut microbiome provided colonisation resistance against antimicrobial-resistant organism acquisition, (2) the effect of travel and travel behaviours on the gut microbiome, and (3) the scale and global heterogeneity of antimicrobial-resistant organism acquisition.
In this metagenomic analysis, participants were recruited at three US travel clinics (Boston, MA; New York, NY; and Salt Lake City, UT) before international travel. Participants had to travel internationally between Dec 8, 2017, and April 30, 2019, and have DNA extractions for stool samples both before and after travel for inclusion. Participants were excluded if they had at least one low coverage sample (<1 million read pairs). Stool samples were collected at home before and after travel, sent to a clinical microbiology laboratory to be screened for three target antimicrobial-resistant organisms (extended-spectrum β-lactamase-producing Enterobacterales, carbapenem-resistant Enterobacterales, and mcr-mediated colistin-resistant Enterobacterales), and underwent DNA extraction and shotgun metagenomic sequencing. We profiled metagenomes for taxonomic composition, antibiotic-resistant gene content, and characterised the Escherichia coli population at the strain level. We analysed pre-travel samples to identify the gut microbiome risk factors associated with acquisition of the three targeted antimicrobial resistant organisms. Pre-travel and post-travel samples were compared to identify microbiome and resistome perturbation and E coli strain acquisition associated with travel.
A total of 368 individuals travelled between the required dates, and 296 had DNA extractions available for both before and after travel. 29 travellers were excluded as they had at least one low coverage sample, leaving a final group of 267 participants. We observed a perturbation of the gut microbiota, characterised by a significant depletion of microbial diversity and enrichment of the Enterobacteriaceae family. Metagenomic strain tracking confirmed that 67% of travellers acquired new strains of E coli during travel that were phylogenetically distinct from their pre-travel strains. We observed widespread enrichment of antibiotic-resistant genes in the gut, with a median 15% (95% CI 10–20, p<1 × 10−10) increase in burden (reads per kilobase per million reads). This increase included antibiotic-resistant genes previously classified as threats to public health, which were 56% (95% CI 36–91, p=2 × 10−11) higher in abundance after travel than before. Fluoroquinolone antibiotic-resistant genes were aquired by 97 (54%) of 181 travellers with no detected pre-travel carriage. Although we found that visiting friends or relatives, travel to south Asia, and eating uncooked vegetables were risk factors for acquisition of the three targeted antimicrobial resistant organisms, we did not observe an association between the pre-travel microbiome structure and travel-related antimicrobial-resistant organism acquisition.
This work highlights a scale of E coli and antimicrobial-resistant organism acquisition by US travellers not apparent from previous culture-based studies, and suggests that strategies to control antimicrobial-resistant organisms addressing international traveller behaviour, rather than modulating the gut microbiome, could be worthwhile.
US Centers for Disease Control and Prevention and National Institute of Allergy and Infectious Diseases.
As climate change alters Earth’s biomes, it is expected the transmission dynamics of mosquito-borne viruses will change. While the effects of temperature changes on mosquito-virus interactions and ...the spread of the pathogens have been elucidated over the last decade, the impact of relative humidity changes is still relatively unknown. To overcome this knowledge gap, we exposed Aedes aegypti females to various humidity conditions. We measured different components of vectorial capacity such as survival, blood-feeding rates, and changes in infection and dissemination of Zika virus. Survival decreased as the humidity level decreased, while infection rates increased as the humidity level decreased. Alternatively, blood feeding rates and disseminated infection rates peaked at the intermediate 50% relative humidity treatment but were the same in the 30% and 80% relative humidity treatments. These results provide empirical evidence that Ae. aegypti exposure to low humidity can enhance Zika virus infection in the mosquito, which has important implications in predicting how climate change will impact mosquito-borne viruses.IMPORTANCEViruses transmitted by mosquitoes to humans are a major public health burden and are expected to increase under climate change. While we know that temperature is an important driver of variation in arbovirus replication in the mosquito, very little is known about how other relevant climate variables such as humidity will influence the interaction between mosquitoes and the viruses they transmit. Given the variability in humidity across environments, and the predicted changes in humidity under climate change, it is imperative that we also study the impact that it has on mosquito infection and transmission of arboviruses.
We establish the feasibility of evaluating US international travellers for Candida auris acquisition using a culture-based screening protocol. Candida auris was not identified in any of the ...travellers in this small cohort; further study is needed to determine the overall risk and risk factors for travel-associated acquisition.
Discourses of development are highly influential in Nepal, entwining with sets of social relations and local history to form a nationally shared vision known as bikas (development). This article ...explores how specific sets of (universalist and local) discourses of development and gender articulate in the subjectivities of young, middle-class, high-caste women in Kathmandu as they negotiate transitions to adulthood. Drawing on ethnographic research, the article highlights how education has afforded young women new possibilities and prompted new aspirations compared to earlier generations, and words such as 'choice' and 'freedom' figure prominently in their discussions of aspirations. However, generational differences in understanding how these dreams fit in women's lives are often expressed in intergenerational tension around marriage. The article highlights how different discourses fuse in ways relational to people's social locations, including along junctures of class, caste, gender and generation, arguing for attention to intersectionality in understanding the circulation of discourses of development and modernity in Nepal.
Adults with learning disabilities (LD) face educational and employment challenges and may also have other disabilities and health conditions. Little is known about these adults’ numeracy skills and ...how they use numeracy at work or home. The article’s objective was to investigate numeracy skills and skill use for U.S. adults with LD. The author conducted descriptive and regression analyses of the data from the 2012/2014/2017 U.S. Program for the International Assessment of Adult Competencies (PIAAC). Findings are presented on assessed numeracy skills and skill use, relationships of use and skills, and skill use among seven groups of adults with LD. Compared with the general population, adults with LD have lower mean numeracy scores. Skill use at home adds to the variance explained in numeracy skills, which suggests that using numeracy skills matters in gaining skills. Knowing the relationships of assessed numeracy skills with skill use helps educators implement strategies to support adult program completion. Implications of findings are discussed for adult educators and policymakers.
PDF
