Development Of Integrated Models Research Articles

Key questions and challenges in angiosperm macroevolution.

Contents Summary 1170 I. Introduction 1170 II. Six key questions 1172 III. Three key challenges 1177 IV. Conclusions 1181 Acknowledgements 1182 References 1183 SUMMARY: The origin and rapid diversification of angiosperms (flowering plants) represent one of the most intriguing topics in evolutionary biology. Despite considerable progress made in complementary fields over the last two decades (paleobotany, phylogenetics, ecology, evo-devo, genomics), many important questions remain. For instance, what has been the impact of mass extinctions on angiosperm diversification? Are the angiosperms an adaptive radiation? Has morphological evolution in angiosperms been gradual or pulsed? We propose that the recent and ongoing revolution in macroevolutionary methods provides an unprecedented opportunity to explore long-standing questions that probably hold important clues to understand present-day biodiversity. We present six key questions that explore the origin and diversification of angiosperms. We also identify three key challenges to address these questions: (1) the development of new integrative models that include diversification, multiple intrinsic and environmental traits, biogeography and the fossil record all at once, whilst accounting for sampling bias and heterogeneity of macroevolutionary processes through time and among lineages; (2) the need for large and standardized synthetic databases of morphological variation; and (3) continuous effort on sampling the fossil record, but with a revolution in current paleobotanical practice.

Service Models for Urgent and Emergency Psychiatric Care: An Overview.

There is variation in the way mental health services respond to urgent and emergency presentations, with few evidence-based models reported in the literature, and no agreed on best practice models. To inform the development of urgent and emergency psychiatric care models, a literature review was performed. The review sought to identify strengths and critiques of varying models, evidence gaps, and areas for future research. After review, significant variation was found in the design and scope of urgent and emergency care models. Most models are either community or hospital based, with few integrated models that span community and hospital care. The development of integrated models has the potential to reduce service duplication and support a shift toward provision of least restrictive care. The overall evidence base of urgent and emergency care models is limited, with few studies in the area, and there is a need for further research. [Journal of Psychosocial Nursing and Mental Health Services, 56(8), 23-30.].

A Methodological Note for the Development of Integrated Aquaculture Production Models

Aquaculture production can yield significant economic, social and environmental effects. These exceed the financial costs and benefits aquaculture producers are faced with. We propose a methodology for the development of integrated production models that allow for the inclusion of the socio-economic and environmental effects of aquaculture into the production management. The methodology develops on a Social Cost-Benefit Analysis context and it includes three parts: i) environmental, that captures the interactions of aquaculture with the environment, ii) economic, that makes provision for the incorporation of economic determinants in the production models and iii) social, that introduces the social preferences to the production and management process. Alternatives to address data availability issues are also discussed. The methodology extends the assessment of the costs and benefits of aquaculture beyond pure financial metrics and beyond the quantification of private costs and benefits. It can also support the development of integrated models of aquaculture production that take into consideration both the private and the social costs and benefits associated with externalities and effects not appropriately captured by market mechanisms. The methodology can support aquaculture management and policies targeting sustainable and efficient aquaculture production and financing from an economic, financial, social and environmental point of view.

Current Research in Land, Water, and Agroecosystems: ASABE Journals 2017 Year in Review

Abstract. This article highlights current research into land and water resources, agroecosystems, and agricultural production systems published by the Natural Resources and Environmental Systems (NRES) community of ASABE journals ( and ) in 2017. Context, scope, and key results of the published articles are reviewed and perhaps more importantly areas for increased research attention are recommended. This article describes experimental and modeling advances in hydrology, agroecosystems, climate change effects, soil erosion, agricultural irrigation, agricultural drainage, forest resource management, livestock systems, natural treatment systems, international water issues, and water quality topic areas. Three special collections were published (International Watershed Technology, Crop Modeling and Decision Support for Optimizing Use of Limited Water, and Advances in Drainage). Other focal areas included 14 articles relating to livestock waste management, 13 concerning irrigated agricultural systems, 8 addressing climate change effects on land, water, and agroecosystems, and 16 on various aspects of soil erosion measurement and modeling. Building on the articles reviewed from 2017 and toward a vision of future agroecosystems research, the NRES community of ASABE journals strives to expand its role in making new knowledge accessible to sustain agricultural and natural systems in a changing world. With this goal in mind, recommendations for future research needs are proposed with an emphasis on increased application of remote sensing data to agroecosystems research, improved assessment of agroecosystem resiliency and vulnerability to land and climate change, development of integrated models of agroecosystem services, meeting stubborn water management challenges in agricultural production systems, and focusing on publishing fully reproducible model results. Keywords: Agriculture, Climate change, Composting, Crop models, Crop water use, Crop yield, Drainage, Drought, Environment, Field experimentation, Food, Forest, Greenhouse gas emissions, Hydrologic modeling, Hydrology, Irrigation, Livestock, Manure management, Mode

Emotion-regulation ability, role stress and teachers' mental health.

Work-related stressors, including role ambiguity and role conflict, are related to psychological maladjustment and mental ill-health. However, to date, the role of personal resources such as emotion-regulation ability (ERA) in the prediction of mental health indicators has not been addressed. To examine whether ERA would contribute to explaining teachers' depression, anxiety and stress symptoms beyond role ambiguity and role conflict. We carried out a cross-sectional questionnaire survey. We used a correlation matrix and hierarchical regression models to analyse the data. Three hundred and thirty-six Spanish teachers (185 female) from several grade levels completed the surveys (40% response rate). Role ambiguity and role conflict were positively related to depression, anxiety and stress symptoms. ERA was negatively related to teachers' scores on depressive, anxious and stress symptoms, with predictive power above the main effects of role ambiguity and role conflict. An interaction between role ambiguity and ERA was also significant in predicting depression. Our study provides preliminary evidence suggesting the development of integrative models considering work-related stressors along with personal resources such as ERA aiming to prevent teachers' mental ill-health. Future studies should examine the influence of ERA on psychological symptoms using longitudinal designs.

Towards smarter and more sustainable regenerative cities: the REMOURBAN model

REMOURBAN is an European project whose main objective is the development and validation in three lighthouse cities (Valladolid-Spain, Nottingham-UK and Tepebasi/Eskisehir-Turkey) of a sustainable urban regeneration model that leverages the convergence area of the energy, mobility and ICT sectors in order to accelerate the deployment of innovative technologies, organizational and economic solutions to significantly increase resource and energy efficiency, improve the sustainability of urban transport and drastically reduce greenhouse gas emissions in urban areas. For developing this model, REMOURBAN is implementing several strategies at city level based on: the creation of a holistic catalogue of innovative technologies and solutions on energy, mobility and ICTs favouring the replicability, the identification and overcome of non-technical barriers, the development of new integrated business models oriented at the creation of a European market for innovation and the definition of a complete evaluation procedure using sustainability and smartness indicators. This urban renovation strategy is focused on the citizens, where they become the cornerstones to making a smart city a reality For this reason, citizens are being actively engaged in REMOURBAN and the population awareness about energy and environmental impact of their daily activities are increased. In order to ensure the usefulness and high replication of the REMOURBAN project at European level, the sustainable urban regeneration model is aimed at the decision makers, investors, public administrations and the industrial sector. Furthermore, in order to ensure this replicability, two follower cities, Seraing (Belgium) and Miskolc (Hungary) are involved in the project so they can apply the developed model once it is validated. The project will allow demonstrating that, by means of improving the current conditions of a city, it is possible to achieve low energy districts and more sustainable urban transport, as well as to perceive a greater quality of life. REMOURBAN, thus, will focus on improving the energy efficiency, reduction of GHG emissions, refurbishment of districts, transport sustainability, access to urban information and citizen engagement. A big impact across Europe is intended to be achieved by the REMOURBAN project results at European level, showing the model for sustainable urban regeneration can be easily applied and replicated. With the aim at maximizing the impact of the project results, REMOURBAN is deploying a powerful communication and dissemination plan that integrates a citizen engagement strategy and has started to disseminate the benefits of the project to a wide variety of audiences.

Patients' Preference for Integrating Homoeopathy Services within the Secondary Health Care Settings in India: The Part 3 (PPIH-3) Study.

Indian patients' preference for integrated homoeopathy services remains underresearched. Two earlier surveys revealed favorable attitude toward and satisfaction from integrated services. The objectives of this study were to examine knowledge, attitudes, and practice of homoeopathy and to evaluate preference toward its integration into secondary-level health care. A cross-sectional survey was conducted during May to October 2015 among 659 adult patients visiting randomly selected secondary-level conventional health care setups in Kolkata, Mumbai, Kottayam, and New Delhi (India) using a self-administered 24-item questionnaire in 4 local vernaculars (Bengali, Marathi, Malayalam, and Hindi). Knowledge and practice scores were compromised; attitude scores toward integration and legal regulation were high. Respondents were uncertain regarding side effects of homoeopathy and concurrent use and interactions with conventional medicines. A total of 82.40% (95% confidence interval = 79.23, 85.19) of the participants were in favor of integrating homoeopathy services. Preference was significantly higher in Delhi and lower in Kottayam. Probable strategic measures for further development of integrated models are discussed.

Integrating modelling of biodiversity composition and ecosystem function

There is increasing reliance on ecological models to improve our understanding of how ecological systems work, to project likely outcomes under alternative global change scenarios and to help develop robust management strategies. Two common types of spatiotemporally explicit ecological models are those focussed on biodiversity composition and those focussed on ecosystem function. These modelling disciplines are largely practiced separately, with separate literature, despite growing evidence that natural systems are shaped by the interaction of composition and function. Here we call for the development of new modelling approaches that integrate composition and function, accounting for the important interactions between these two dimensions, particularly under rapid global change. We examine existing modelling approaches that have begun to combine elements of composition and function, identifying their potential contribution to fully integrated modelling approaches. The development and application of integrated models of composition and function face a number of important challenges, including biological data limitations, system knowledge and computational constraints. We suggest a range of promising avenues that could help researchers overcome these challenges, including the use of virtual species, macroecological relationships and hybrid correlative‐mechanistic modelling. Explicitly accounting for the interactions between composition and function within integrated modelling approaches has the potential to improve our understanding of ecological systems, provide more accurate predictions of their future states and transform their management.SynthesisThere is increasing attention from researchers and policy makers around the world on both assessing and projecting the state of the planet's biodiversity, its ecosystems and the essential services they provide to society. However, existing modelling approaches largely ignore the interactions between biodiversity composition and ecosystem function. We highlight the key challenges and potential solutions to developing integrated models of composition and function. Such models will require a new effort and focus from ecologists, yet the benefits are likely to be substantial, including better informing the management of natural systems at regional, national and international scales.

Computational Social Creativity.

This article reviews the development of computational models of creativity where social interactions are central. We refer to this area as computational social creativity. Its context is described, including the broader study of creativity, the computational modeling of other social phenomena, and computational models of individual creativity. Computational modeling has been applied to a number of areas of social creativity and has the potential to contribute to our understanding of creativity. A number of requirements for computational models of social creativity are common in artificial life and computational social science simulations. Three key themes are identified: (1) computational social creativity research has a critical role to play in understanding creativity as a social phenomenon and advancing computational creativity by making clear epistemological contributions in ways that would be challenging for other approaches; (2) the methodologies developed in artificial life and computational social science carry over directly to computational social creativity; and (3) the combination of computational social creativity with individual models of creativity presents significant opportunities and poses interesting challenges for the development of integrated models of creativity that have yet to be realized.

An integrated model based on statistical process control and maintenance for two-stage dependent processes

ABSTRACTThe close relationship between quality and maintenance of manufacturing systems has contributed to the development of integrated models which use the concept of statistical process control (SPC) and maintenance. This article demonstrates the integration of the Shewhart individual-residual (ZX − Ze) joint control chart and maintenance for two-stage dependent processes by jointly optimizing their policies to minimize the expected total costs associated with quality, maintenance and inspection. To evaluate the effectiveness of the proposed model, two stand-alone models—a maintenance model and an SPC model—are proposed. Then a numerical example is given to illustrate the application of the proposed integrated model. The results show that the integrated model outperforms the two stand-alone models with regard to the expected cost per unit time. Finally, a sensitivity analysis is conducted to develop insights into time parameters and cost parameters that influence the integration efforts.

The relationship between activities of daily living and multimorbidity. A view from telecare

Introduction: The Public Telecare Service of the Basque Government (betiON) provides home care for dependent and older people through a technological device that guarantees a permanent connection with an interdisciplinary team of professionals who are trained in remote socio-health care. In 2013, the 77.57% of the telecare population were aged above 80 years, 80.69% of users were female and 65% lived alone. Most of the population of betiON lived in the most economically depressed areas. One of the main objectives of betiON is to promote the permanence of their users in their usual social environment. Moreover, this connection with health care devices allows implementing shared information systems with health and social data, which enable a characterization of the attended population and the development of integrated models for health and social provision. The users of telecare service have at least one of the following characteristics: People over 75 who live alone People over 65 who are in a situation of acknowledged dependency or in situation of vulnerability recognized by social services International Journal of Integrated Care – Volume 14, 01 November – URN:NBN:NL:UI:10-1-116558– http://www.ijic.org/ International Digital Health and Care Congress, The King’s Fund, London, September 10-12 2014. People with intellectual, physical or sensory disability and recognized dependency at any degree People who have a diagnosed mental illness and present a situation of recognized dependency or risk of social exclusion. It is well known that multimorbidity, coexistence of two or more diseases, is very common in the older population and it negatively affects the quality of life related to health. Objectives: The purpose of this study is to describe the quality of life of telecare service users collected by EQ-3D questionnaire and to establish its relationship with multimorbidity. Methods: It will be extracted information from the stratification database of the Basque Country (PREST) of more than 30,000 users of betiON. PREST has been created to classify all Basque citizens based on their future health care needs in a hundred mutually exclusive groups, Adjusted Clinical Groups (ACG), provided by the case-mix developed at Johns Hopkins University (Baltimore). This database contains demographic, socioeconomic (deprivation index of the residence area) and clinical variables, from data registered in the MBDS and annotations in electronic health records of specialist care and primary care. To detect chronic disease, it will be used information about diagnoses and prescriptions. For quality of life related to health, it is using the EQ-3D questionnaire by telephone between the users of betiON . Also it will be collect social variables (family unit, heating system, use of social services...) Multiple regression analysis on EQ-3D index will be conducted to determine the simultaneous effect with chronic diseases, social and demographic variables on quality of life related to health in our study population. Results and Conclusions: The results will be presented at the Congress, as well as, future findings. Applications: This study will have applications in the development of specific interventions in subgroups with similar characteristics to improve the quality of life and for management of multimorbidity.

Taking charge of high-risk and high-cost patients in the public healthcare system.

Many healthcare systems are struggling with the issue of providing high-quality care to high-needs patients at lower costs. Our comments in this paper draw on insights that we have gained from the development and implementation of integrated models of care in Québec. This experience highlights the importance of developing a clear clinical approach to the delivery and coordination of care and to support providers in new roles. Our second insight is that system-level policy guidelines may help to focus the attention of organizations and providers on key priorities, but they need to take into account differing needs in various contexts. Third, a crucial factor for success over the longer term is the ability of local networks to reshape the allocation and use of resources to bring about change in day-to-day operations. We conclude by highlighting key characteristics of high-performing health systems and with the final observation that politicians and policymakers need to allow enough time to harness the full benefit of change initiatives.

Tracking neuroinflammation in Alzheimer's disease: the role of positron emission tomography imaging.

Alzheimer’s disease (AD) has been reconceptualized as a dynamic pathophysiological process, where the accumulation of amyloid-beta (Aβ) is thought to trigger a cascade of neurodegenerative events resulting in cognitive impairment and, eventually, dementia. In addition to Aβ pathology, various lines of research have implicated neuroinflammation as an important participant in AD pathophysiology. Currently, neuroinflammation can be measured in vivo using positron emission tomography (PET) with ligands targeting diverse biological processes such as microglial activation, reactive astrocytes and phospholipase A2 activity. In terms of therapeutic strategies, despite a strong rationale and epidemiological studies suggesting that the use of non-steroidal anti-inflammatory drugs (NSAIDs) may reduce the prevalence of AD, clinical trials conducted to date have proven inconclusive. In this respect, it has been hypothesized that NSAIDs may only prove protective if administered early on in the disease course, prior to the accumulation of significant AD pathology. In order to test various hypotheses pertaining to the exact role of neuroinflammation in AD, studies in asymptomatic carriers of mutations deterministic for early-onset familial AD may prove of use. In this respect, PET ligands for neuroinflammation may act as surrogate markers of disease progression, allowing for the development of more integrative models of AD, as well as for the measuring of target engagement in the context of clinical trials using NSAIDs. In this review, we address the biological basis of neuroinflammatory changes in AD, underscore therapeutic strategies using anti-inflammatory compounds, and shed light on the possibility of tracking neuroinflammation in vivo using PET imaging ligands.

Systems biology approaches to understanding the cause and treatment of heart, lung, blood, and sleep disorders.

Development of powerful new high-throughput technologies for probing the transcriptome, proteome, and metabolome is driving the rapid acquisition of information on the function of molecular systems. One of the greatest challenges that we now confront is to understand how behavior at the level of genome, proteome, and metabolome shapes physiological function at the level of cell, tissue and organ in both health and disease. Because of the inherent complexity of biological systems, the development, analysis, and validation of integrative computational models based directly on experimental data is necessary to achieve thisunderstanding. This approach,knownassystemsbiology,integratescomputationaland experimental approaches through iterative development of mathematical models and experimental validation and testing. The combination of these approaches allows for a mechanistic understanding of the function of complex biological systems in health, and their dysfunction in disease. In 2006, the National Heart, Lung, and Blood Institute (NHLBI) announced the Exploratory Program in Systems Biology, followed in 2010 by the NHLBI Systems Biology Collaborations. The goal of these programs is to support collaborative teams of investigators in using experimental and computational strategies to integrate the component parts of biological networks and pathways into computational models that are based firmly on and validated using experimental data. These validated models are then applied to gain insights into the mechanisms of altered system function in disease, to generate novel hypotheses regarding these mechanisms that can be tested experimentally, and to then use the results of experiments to refine the models. This Research Topic is comprised of articles by researchers funded by this NHLBI program. One set of publications focus on lung function in health and disease. Lauzon et al. (2012) present a multi-scale model of lung function spanning molecular (force production by actin-myosin proteins), cellular (regulation of force production by calcium signaling), tissue (smooth muscle contraction coupled with the biomechanics of airway narrowing), and organ scales (mechanical lung impedance). The model provides a new tool for investigating airway hyper responsiveness in the setting of asthma and other lung diseases. O’Connor et al. (2012) present a closed-loop model of neural control of breathing that includes a neural network model of the respiratory pattern generator that drives a systems-level model of lung contraction with feedback to the respiratory pattern generator driven by mechano- and baro-receptor reflexes. The model provides a framework for studying cough disorders. Segers et al. (2012) present results from an experimental study aimed at identifying the role of different neuronal populations in regulating fricative cough. Finally, Fallahi-Sichani et al. (2012) present a multi-scale model of the lung immune response to Mycobacterium tuberculosis and use the model to examine the ways in which the NF-kB signaling pathway regulates inflammatory responses. Another set of publications focus on blood disease. Dick et al. (2012) develop a multi-scale model of acute inflammatory disease, such as sepsis, that describes baro-, chemo-, and cytokine-reflex control of cardio-pulmonary function mediated by the nucleus tractus solitarius (nTS). They present the model-motivated hypothesis that the dis-regulation of cardio-respiratory patterns in the setting of sepsis results from expression of cytokines in the nTS. Goldman et al. (2012) develop models of the erythrocyte signaling pathways that control ATP release as a function of hemoglobin oxygen saturation. These models provide a new framework for studying regulation of microvascular perfusion distribution. Diamond et al. (2013) resent a modeling approach that combines fluiddynamicssimulationofbloodflowinthepresenceofadeveloping

Modeling structured population dynamics using data from unmarked individuals

The study of population dynamics requires unbiased, precise estimates of abundance and vital rates that account for the demographic structure inherent in all wildlife and plant populations. Traditionally, these estimates have only been available through approaches that rely on intensive mark-recapture data. We extended recently developed N-mixture models to demonstrate how demographic parameters and abundance can be estimated for structured populations using only stage-structured count data. Our modeling framework can be used to make reliable inferences on abundance as well as recruitment, immigration, stage-specific survival, and detection rates during sampling. We present a range of simulations to illustrate the data requirements, including the number of years and locations necessary for accurate and precise parameter estimates. We apply our modeling framework to a population of northern dusky salamanders (Desmognathus fuscus) in the mid-Atlantic region (USA) and find that the population is unexpectedly declining. Our approach represents a valuable advance in the estimation of population dynamics using multistate data from unmarked individuals and should additionally be useful in the development of integrated models that combine data from intensive (e.g., mark-recapture) and extensive (e.g., counts) data sources.

Insight into the pathophysiology of insomnia

Insomnia is a major public health hazard. Complexity of insomnia patho-physiology is intriguing and is an exciting subject of inquiry. The current article summarizes the recent developments in our understanding of insomnia. Although the early models of insomnia were unidirectional, they provided foundation for development of more integrative models. Sleep- wake regulation and more specifically conceptual understanding of sleep homeostasis, circadian influence, and hyperarousal further added new dimensions to our understanding of insomnia. However, there is more appreciation than ever of the fact that a lot more work must be done before even thinking about finding a conclusive evidence of what causes insomnia and what maintains it. Some of the legendary work is cited in the reference section to develop an understanding of intricate interplay of multiple systems within the body that cause sleep and lack of it.

Prevalencia de cronicidad y multimorbilidad en la población cubierta por el servicio público de teleasistencia de Euskadi: impacto en costes y calidad de la atención

The public telecare service in the Basque Autonomous Community (betiON) is a service offered by the Department of Employment and Social Policy of the Basque Government and offers telephone support to elderly and disabled populations, providing communication with an assistance centre. This connection with health care devices makes it possible to implement shared information systems with health and social data, which enable a characterization of the population attended to and the development of integrated models for health and social provision. To describe the distribution of chronic diseases and multimorbidity among users of betiON, to estimate the cost of their health care and to compare these indicators with those of the general population. We extracted information from betiON and public healthcare databases. We characterized the telecare population above 65 years (N = 23.742) and compared it with the total population in the Basque Autonomous Community (N = 2.262.707) with respect to variables in demography socio-economic burden, costs and ambulatory care conditions. In the telecare population, the average age is 83 years, 80% are women, 55.1% live alone and reside in poorer neighbourhoods. Forty-two point five per cent of males and 36.5% of women are affected by five or more chronic conditions, averaging 4.06 pathologies per person. They also show higher healthcare costs than the general population. Telecare users have a higher disease burden, greater need for healthcare and unfavourable social conditions. Telecare provides an opportunity for innovation and intervention, through the coordination of social and healthcare services.

A biophysically based mathematical model for the catalytic mechanism of glutathione reductase

Glutathione reductase (GR) catalyzes the reduction of oxidized glutathione (GSSG) to reduced glutathione (GSH) using NADPH as the reducing cofactor, and thereby maintains a constant GSH level in the system. GSH scavenges superoxide (O2−) and hydroxyl radicals (OH) nonenzymatically or by serving as an electron donor to several enzymes involved in reactive oxygen species (ROS) detoxification. In either case, GSH oxidizes to GSSG and is subsequently regenerated by the catalytic action of GR. Although the GR kinetic mechanism has been extensively studied under various experimental conditions with variable substrates and products, the catalytic mechanism has not been studied in terms of a mechanistic model that accounts for the effects of the substrates and products on the reaction kinetics. The aim of this study is therefore to develop a comprehensive mathematical model for the catalytic mechanism of GR. We use available experimental data on GR kinetics from various species/sources to develop the mathematical model and estimate the associated model parameters. The model simulations are consistent with the experimental observation that GR operates via both ping–pong and sequential branching mechanisms based on relevant concentrations of its reaction substrate GSSG. Furthermore, we show the observed pH-dependent substrate inhibition of GR activity by GSSG and bimodal behavior of GR activity with pH. The model presents a unique opportunity to understand the effects of products on the kinetics of GR. The model simulations show that under physiological conditions, where both substrates and products are present, the flux distribution depends on the concentrations of both GSSG and NADP+, with ping–pong flux operating at low levels and sequential flux dominating at higher levels. The kinetic model of GR may serve as a key module for the development of integrated models for ROS-scavenging systems to understand protection of cells under normal and oxidative stress conditions.

Reported Experiences with Medicaid Managed Care Models Among Parents of Children

The proportion of children enrolled in Medicaid managed care arrangements has grown significantly over the past decade. Yet, few studies have attempted to assess differences in parental reports and ratings of care for children enrolled in different types of Medicaid managed care. We examine parental reports and ratings of care to explore whether and how patient and parent experiences vary by child health status and managed care plan type, including provider-sponsored specialized plans serving only children. Parents of children in a Florida Medicaid demonstration project in two counties over 3 years were surveyed using Consumer Assessment of Health Providers and Systems surveys (n = 2,741-11,067). Ordered logistic regression models with interaction terms were used to assess relationships between plan type, presence of chronic condition, and measures of patient experience. Parents of children enrolled in provider-sponsored plans that focus on pediatrics were more likely to provide a positive rating for their doctor, health plan, and specialty care compared to parents of children in an health maintenance organization (HMO). Parents of children with a chronic condition were less likely than parents of children without a chronic condition to provide a favorable rating of overall health care, their doctor, or health plan. The interaction term that assessed whether patient experience by plan type was impacted by the child's health status was not statistically significant. Parents of Medicaid children may prefer provider-sponsored arrangements over HMOs. Findings can inform the future development of other integrated models of care involving provider-sponsored arrangements, such as pediatric Accountable Care Organizations and Patient-Centered Medical Homes.

Health outcomes and cost of care among older adults with schizophrenia: a 10-year study using medical records across the continuum of care.

The population of older patients with schizophrenia is increasing. This study describes health outcomes, utilization, and costs over 10 years in a sample of older patients with schizophrenia compared with older patients without schizophrenia. An observational cohort study of 31,588 older adults (mean age: 70.44 years) receiving care from an urban public health system, including a community mental health center, during 1999-2008. Of these, 1,635 (5.2%) were diagnosed with schizophrenia and 757 (2.4%) had this diagnosis confirmed in the community mental health center. Patients' electronic medical records were merged with Medicare claims, Medicaid claims, the Minimum Dataset, and the Outcome and Assessment Information Set. Information on medication use was not available. Rates of comorbid conditions, healthcare utilization, costs, and mortality. Patients with schizophrenia had significantly higher rates of congestive heart failure (45.05% versus 38.84%), chronic obstructive pulmonary disease (52.71% versus 41.41%), and hypothyroidism (36.72% versus 26.73%) than the patients without schizophrenia (p <0.001). They had significantly lower rates of cancer (30.78% versus 43.18%) and significantly higher rates of dementia (64.46% versus 32.13%). The patients with schizophrenia had significantly higher mortality risk (hazard ratio: 1.25, 95% confidence interval: 1.07-1.47) than the patients without schizophrenia. They also had significantly higher rates of healthcare utilization. The mean costs for Medicare and Medicaid were significantly higher for the patients with schizophrenia than for the patients without schizophrenia. The management of older adult patients with schizophrenia is creating a serious burden for our healthcare system, requiring the development of integrated models of healthcare.