Health Cooperative Research Articles

A Digital Language Divide? The Relationship between Internet Medication Refills and Medication Adherence among Limited English Proficient (LEP) Patients.

Use of an Internet portal to refill medicines positively affects medication adherence among English-speakers. No prior studies, however, have specifically examined the relationship between Internet refills and medicationadherence among patients who are limited English proficient (LEP). (1) Examine the relationship between Internet medication refill system use and medication adherence among linguistically diverse patients with chronic conditions and (2) compare this relationship between LEP and English-proficient (EP) patients. We analyzed 2013-2014 cross-sectional data from 509 surveyed adults in the Group Health Cooperative. Surveys were merged with plan enrollment, claims data, and electronic medical records. Medication adherence was calculated by the "Continuous Measure of Medication Gaps" (CMG) method. For Internet refill system use, patients were asked, "Have you used the health systems Internet site to refill any medications in the last 12 months?" LEP status was captured in the electronic medical record by a non-English primary language and a claims record of interpreter use in at least one clinical encounter between 2005 and 2012. We used multivariate linear regression models to examine Internet refill system use and medication adherence and compared the association between LEP and EP patients. Three hundred eighty-four patients (75%) had a calculable CMG: 134 EP and 250 LEP in the adherence analyses. In unadjusted analyses, LEP patients had lower use of the Internet refill system (p < .001) and lower adherence versus the EP group (p < .001). In multivariate analyses, LEP status (β = - 0.022, p = .047) was negatively associated with adherence, while use of the Internet refill system (β = 0.030, p = .002) was positively associated. In stratified models, use of Internet refills was positively associated with adherence, even when examining LEP (β = 0.029, p = .003) and EP patients (β = 0.027, p = .049) separately. These findings suggest that LEP patients may be under-utilizing a beneficial Internet tool. Should our healthcare systems fail to ensure that LEP patients have full and meaningful access to Internet patient portals, we risk worsening healthcare disparities.

The Availability and Efficiency of Health Insurance to Expatriates: Empirical Findings from Saudi Arabia

Health Insurance represents the largest sectors among all types of insurance in Saudi Arabia with a Gross Written Premiums of 51% of the whole insurance market in Saudi Arabia. The high growth of health insurance sector in Saudi Arabia was driven by the obligation mandated by the Ministry of Health "MOH" and Council of Cooperative Health Insurance "CCHI" for expatriates and their families living in Saudi Arabia to have their health insurance, affected mid of 2014. However, the regulations didn’t specify the types and quality of health insurance used. The regulations also didn’t take into consideration the salaries of the expatriates which might affect their financial positions in case of policy cancelation. No studies have been conducted on the Saudi Arabian health insurance market to explore the efficiency and quality of expatriates’ health insurance policy. This paper attempts to fill the gap. The main aim of this study was to explore the availability and efficiency of health care system to expatriates. The quality of health insurance policy relies on the selections made by the employers. The research used qualitative methodology for collection of primary data. A total of 324 responds were received and considered usable for the research. The results were astonishing that most of the participants have their own health insurance policy, however not all service are available to them. Most of the participants clarified that their health insurance policy, did not cover of most of the risk they encountered, it did not cover the medical treatment expenses, as well as the surgery and operation expenses. Such results will put financial burden on expatriates in case their health insurance claims been canceled.

Time Series Changes in Cataract Surgery in Korea.

PurposeWe analyzed time series changes in cataract surgeries in Korea, and provide basic data to enhance the efficiency of medical services for cataract surgery.MethodsAmong cataract surgery statistics registered in the Korean National Health Insurance Cooperation from 2006 to 2012, we used data regarding the number of patients and operations and the number of patients and operations per 100,000 people. We analyzed various time series changes, including differences by sex and age.ResultsThe total numbers of patients from 2006 to 2012 by year were 207,370; 228,170; 250,289; 268,548; 289,867; 308,111; and 302,182, respectively. The total numbers of operations from 2006 to 2012 by year were 272,920; 305,807; 338,332; 365,874; 398,338; 428,158; and 420,905, respectively. The number of patients and operations per 100,000 people were highest in men 80 to 84 years old and women 75 to 79 years old. Comparing the number of operations in 2006 and after, the patient age group with the highest increase rate changed from over 85 years old to 75–79 years old since 2010 in men and from over 85 years old to 50–54 years old since 2009 in women. For each year investigated, the number of operations performed was higher than the number of patients who received operations.ConclusionsOver the study period, the number of cataract surgeries increased, while the age of cataract patients decreased. Additionally, the number of cataract-related surgeries increased in relation to the number of patients.

Impact of Opioid Dose Reduction and Risk Mitigation Initiatives on Chronic Opioid Therapy Patients at Higher Risk for Opioid-Related Adverse Outcomes

We aimed to determine if opioid risk reduction initiatives including dose reduction and risk mitigation strategies for chronic noncancer pain patients receiving chronic opioid therapy (COT) had a differential impact on average daily opioid doses of COT patients at higher risk for opioid-related adverse outcomes compared with lower-risk patients. Interrupted time series. Group Health Cooperative (GH), a health care delivery system and insurance within Washington State, between 2006 and 2014. GH enrollees on COT defined as receiving a supply of 70 or more days of opioids within 90 days using electronic pharmacy data for filled prescriptions. We compared the average daily morphine equivalent doses (MED) of COT patients with and without each of the following higher-risk characteristics: mental disorders, substance use disorders, sedative use, and male gender. In all four pairwise comparisons, the higher-risk subgroup had a higher average daily MED than the lower-risk subgroup across the study period. Adjusted for covariates, modest differences in the annual rate of reduction in average daily MED were noted between higher- and lower-risk subgroups in three pairwise comparisons: those with mental disorders vs without (-8.2 mg/y vs -5.2 mg/y, P = 0.005), with sedative use vs without (-9.2 mg/y vs -5.8 mg/y, P = 0.004); mg), in men vs women (-8.8 mg/y vs -5.9 mg/y, P = 0.01). Using clinical policy initiatives in a health care system, dose reductions were achieved among COT patients at higher risk for opioid-related adverse outcomes that were at least as large as those among lower-risk patients.

Evaluasi sistem pengelolaan limbah medis Puskesmas di wilayah Kabupaten Bantul

Evaluation of community health center's medical waste management system in Bantul RegencyPurposeThis study aimed to evaluate the Primary health centers medical waste management systems.MethodsThis research was a qualitative study using a case study design in five Puskesmas of Bantul Dis­trict.ResultsThe manage­ment of medical waste in Bantul Regency is a new model using private party as a user (health cooperative) to hire services to the private transporter (CV. Jogya Prima Per­kasa) to carry out the transportation and destruction of medical waste generated by health facilities of Puskesmas, Pustu, Polindes and private health facilities. Con­sideration of Health Cooperation is a private institution belonging to Dinas Kesehatan and has a legal entity con­sidered more flexible to bail out the initially issued funds to pay the financing of transport and extermination services to the transporter.ConclusionPrimary health care medical waste man­agement has followed the regulations. Health center has conducted medical waste management starting from the sorting, collection, pack­aging, storage, and transport. There should be improvements in some aspects, especially the creation of TPS for Puskesmas that do not have them yet, while Puskesmas who already have TPS need to make im­provements ac­cording to the conditions specified.

Administrative billing codes accurately identified occurrence of electrical cardioversion and ablation/maze procedures in a prospective cohort study of atrial fibrillation patients.

Administrative billing codes for electrical cardioversion and ablation/maze procedures may be useful for atrial fibrillation (AF) research if the codes are accurate relative to medical record documentation. Administrative billing codes accurately identify occurrence of electrical cardioversion and ablation/maze procedures in AF patients. We studied adults ages 30 to 84 who experienced new-onset AF between October 2001 and December 2004 in Group Health Cooperative (acquired by Kaiser Permanente in 2017), an integrated healthcare system in Washington state and northern Idaho. Using medical record review as the gold standard, we calculated sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for 3 administrative billing codes for electrical cardioversion and 3 codes for AF ablation/maze procedures. Of 1953 study participants, during a mean (SD) of 1.5 (0.7) years of follow-up after AF onset, 470 (24%) experienced electrical cardioversion and 44 (2%) experienced ablation/maze procedures, according to medical record review. For electrical cardioversion, individual codes had 7.7% to 76.4% sensitivity, >99% specificity, 83.7% to 96.5% PPV, and 77.3% to 93.0% NPV. Considering any of 3 codes (code 1 or code 2 or code 3) improved sensitivity to 84.9%. For ablation/maze, individual codes had 18.2% to 47.7% sensitivity, >99% specificity, 66.7% to 95.5% PPV, and >98% NPV. Considering any of 3 codes improved sensitivity to 84.1%. Administrative billing data accurately identified electrical cardioversion and ablation/maze procedures and can be used instead of medical record review. Our findings apply to healthcare settings with available administrative billing databases.

JAPAN: Supreme Court (First Petty Bench) Ms X v. Hiroshima Central Health Care Cooperative

JAPAN: Supreme Court (First Petty Bench) Ms X v. Hiroshima Central Health Care Cooperative

A RETROSPECTIVE SUMMARY OF RAPTOR MORTALITY IN ONTARIO, CANADA (1991-2014), INCLUDING THE EFFECTS OF WEST NILE VIRUS.

The causes of mortality of free-ranging raptors range from anthropogenic (e.g., trauma) to dynamic environmental conditions that may affect habitat suitability and prey availability. The province of Ontario, Canada, is vulnerable to anthropogenic and environmental changes because of its northern latitudes and expanding human populations, both of which may impact wildlife. We retrospectively evaluated diagnostic data from raptors submitted to the Ontario/Nunavut node of the Canadian Wildlife Health Cooperative (CWHC) from 1991 to 2014 ( n=1,448). Submissions encompassed 29 species, most commonly the Red-tailed Hawk ( Buteo jamaicensis; n=308) and Great Horned Owl ( Bubo virginianus; n=237). Trauma ( n=716) accounted for the majority of deaths among all species, followed by emaciation ( n=241). Traumatic deaths were most commonly attributed to collisions with stationary objects, and the odds of a diagnosis of trauma were significantly higher in adult versus immature raptors. The odds of being diagnosed with emaciation were significantly higher in males than in females but not in any age class or season. Mortality was less commonly attributed to infectious diseases ( n=214), for which West Nile virus (WNV) was the most common etiology, making up 53.1% of infectious diagnoses after its 2001 arrival in Ontario. The odds of a raptor being diagnosed with an infectious disease were significantly greater in summer and fall versus spring. Immature Red-tailed Hawks had significantly greater odds of being diagnosed with WNV compared to adults. These results reveal that human- and potentially environmentally-associated deaths (e.g., trauma and emaciation, respectively) are commonly diagnosed among Ontario raptors submitted to the CWHC. Infectious diseases are less commonly diagnosed, but WNV may have underlying, ongoing impacts on the health of some raptor species.

A Comparative Study on Outcome of Government and Co-Operative Community-Based Health Insurance in Nepal.

There are different models for community-based health insurance (CBHI), and in Nepal, among them, the government and the local communities (co-ops) are responsible for operating the CBHI models that are in practice. The aim of this study is to compare the outcomes in relation to benefit packages, population coverage, inclusiveness, healthcare utilization, and promptness of treatment for the two types of CBHI models in Nepal. This study was an observational and interactive descriptive study using the concurrent mixed approach of data collection, framing, and compilation. Quantitative data were collected from records, and qualitative data were collected from key informants in all 12 CBHI groups. Unstructured questionnaires, observation checklists, and memo notepads were used for data collection. Descriptive statistics and the Mann-Whitney U test were used when appropriate. Ethically, written informed consent was obtained from the respondents who participated in the study, and they were told that they could withdraw from the study anytime. The study revealed the following: new enrolment did not increase in either group; however, the healthcare utilization rate did (Government 107% and co-ops 137%), while the benefit packages remained almost same for both groups. Overall, inclusiveness was higher for the government group. For the CBHI co-ops, enrollment among the religious minority and the discount negotiated with the hospitals for treatment were significantly higher, and the promptness in reaching a hospital was significantly faster (p < 0.05) than that in the government-operated CBHI. Findings indicate that CBHI through co-ops would be a better model because of its lower costs and ability to enhance self-responsiveness and the overall health system. Health insurance coverage is the most important component to achieve universal health coverage.

Development and Validation of a Tool to Identify Patients With Type 2 Diabetes at High Risk of Hypoglycemia-Related Emergency Department or Hospital Use

Hypoglycemia-related emergency department (ED) or hospital use among patients with type 2 diabetes (T2D) is clinically significant and possibly preventable. To develop and validate a tool to categorize risk of hypoglycemic-related utilization in patients with T2D. Using recursive partitioning with a split-sample design, we created a classification tree based on potential predictors of hypoglycemia-related ED or hospital use. The resulting model was transcribed into a tool for practical application and tested in 1 internal and 2 fully independent, external samples. Development and internal testing was conducted in a split sample of 206 435 patients with T2D from Kaiser Permanente Northern California (KPNC), an integrated health care system. The tool was externally tested in 1 335 966 Veterans Health Administration and 14 972 Group Health Cooperative patients with T2D. Based on a literature review, we identified 156 candidate predictor variables (prebaseline exposures) using data collected from electronic medical records. Hypoglycemia-related ED or hospital use during 12 months of follow-up. The derivation sample (n = 165 148) had a mean (SD) age of 63.9 (13.0) years and included 78 576 (47.6%) women. The crude annual rate of at least 1 hypoglycemia-related ED or hospital encounter in the KPNC derivation sample was 0.49%. The resulting hypoglycemia risk stratification tool required 6 patient-specific inputs: number of prior episodes of hypoglycemia-related utilization, insulin use, sulfonylurea use, prior year ED use, chronic kidney disease stage, and age. We categorized the predicted 12-month risk of any hypoglycemia-related utilization as high (>5%), intermediate (1%-5%), or low (<1%). In the internal validation sample, 2.0%, 10.7%, and 87.3% were categorized as high, intermediate, and low risk, respectively, with observed 12-month hypoglycemia-related utilization rates of 6.7%, 1.4%, and 0.2%, respectively. There was good discrimination in the internal validation KPNC sample (C statistic = 0.83) and both external validation samples (Veterans Health Administration: C statistic = 0.81; Group Health Cooperative: C statistic = 0.79). This hypoglycemia risk stratification tool categorizes the 12-month risk of hypoglycemia-related utilization in patients with T2D using only 6 inputs. This tool could facilitate targeted population management interventions, potentially reducing hypoglycemia risk and improving patient safety and quality of life.

Japanese citizens' attitude toward end-of-life care and advance directives: A qualitative study for members of medical cooperatives.

BackgroundJapanese citizens are interested in choosing their own end‐of‐life care, but few have created their own advance directive. This study examined changes among Japanese citizens' attitudes toward end‐of‐life care and advance directives and explored factors that affected these attitudes.MethodsWe conducted five focus groups with 48 participants in 2009 and 2010. All participants were members of health cooperatives in Tokyo.ResultsWe identified many barriers and reasons for creating and writing down advance directives. Experience caring for dying people and having a serious disease affected attitudes toward advance directives. Some participants changed their attitude toward end‐of‐life care by writing their own advance directive.ConclusionsWhen someone is writing advance directives, asking about his/her past experience of caring may be helpful. And learning about or filling out advance directives may help to break down resistance to using these documents.

Sexual function in infertile women with polycystic ovary syndrome and unexplained infertility

While female sexual dysfunction is a frequent occurrence, characteristics in infertile women are not well delineated. Furthermore, the impact of infertility etiology on the characteristics in women with differing androgen levels observed in women with polycystic ovary syndrome and unexplained infertility has not been assessed. The objective of the study was to determine the characteristics of sexual dysfunction in women with polycystic ovary syndrome and unexplained infertility. A secondary data analysis was performed on 2 of Eunice Kennedy Shriver National Institute of Child Health and Human Development Cooperative Reproductive Medicine Networks clinical trials: Pregnancy in Polycystic Ovary Syndrome Study II and Assessment of Multiple Intrauterine Gestations From Ovarian Stimulation. Both protocols assessed female sexual function using the Female Sexual Function Inventory and the Female Sexual Distress Scale. Women with polycystic ovary syndrome had higher weight and body mass index than women with unexplained infertility (each P<.001), greater phenotypic (Ferriman-Gallwey hirsutism score, sebum score, and acne score; each P < .001), and hormonal (testosterone, free testosterone, and dehydroepiandrosterone; each P < .001) evidence of androgen excess. Sexual function scores, as assessed by the Female Sexual Function Inventory, were nearly identical. The Female Sexual Distress Scale total score was higher in women with polycystic ovary syndrome. The mean Female Sexual Function Inventory total score increased slightly as the free androgen index increased, mainly as a result of the desire subscore. This association was more pronounced in the women with unexplained infertility. Reproductive-age women with infertility associated with polycystic ovary syndrome and unexplained infertility, despite phenotypic and biochemical differences in androgenic manifestations, do not manifest clinically significant differences in sexual function.

A Survey of Women's Awareness of and Reasons for Lack of Postfracture Osteoporotic Care.

To identify women's beliefs and other factors associated with lack of osteoporosis (OP) pharmacotherapy (OP-RX) during the 6 months after a fragility fracture, including the woman's perspective on fracture risk, OP, and treatment. Cross-sectional. Group Health Cooperative, a mixed-model delivery system. Female Group Health Cooperative enrollees aged 55 and older with an OP-related fracture according to diagnostic and procedure codes from January 1, 2013, to March 30, 2014 (N = 985). OP-RX and participant characteristics were ascertained from electronic health records including medications dispensed. A mailed survey was used to obtain data on health behaviors; OP-related history; concern about, knowledge of, and perceived risk of future fracture; beliefs about OP-RX; sources of information on OP; postfracture discussions with providers; and provider recommendations. The response rate was 73%. Of 634 eligible respondents, 84% did not undergo OP-RX during the 6 months after fracture. Fewer than 20% of women thought that OP caused their fracture, 52% did not think they were at risk of future fracture, and 75% did not think or know whether OP-RX reduces risk of fracture. Knowledge about OP and the benefits of treatment was higher in the 16% of women who underwent OP-RX after their fracture. Women reported low levels of engagement with their healthcare providers regarding OP and fracture risk management. These findings suggest low awareness about OP and its contribution to fracture risk, lack of understanding about the benefits of pharmacotherapy, and limited discussion about OP with primary care physicians. Information about individual's beliefs and knowledge gaps can help design targeted patient and provider education to improve treatment rates.

The Health Cooperative Perception Scale: Development and Validation

The cooperative movement has a long history and is quite a widespread business style these days. As the cooperative movement develops, many different cooperatives have been established such as consumer cooperatives, agricultural cooperatives, and housing cooperatives. Health cooperatives have also been established to provide equity in and improve access to health services. In spite of having a deep-rooted history, health cooperatives are uncommon in Turkey. Only one health cooperative is found in Turkey, and the health cooperative movement should be supported here. Therefore, this study aims to develop a valid and reliable scale for measuring perceptions about health cooperatives. Accordingly, the researchers have constructed a 21-item scale. After conducting factor analysis, the scale was reduced to 15 statements. Validity and reliability analyses have also been performed. According to these analyses, the developed scale has high consistency and is a valid and reliable measuring tool.

Food Security Status is Associated with Diet Quality in Indiana Supplemental Nutrition Assistance Program‐Education (SNAP‐Ed) Eligible Adults

BackgroundFood security and socioeconomic status have been associated with diet quality. Supplemental Nutrition Assistance Program‐Education (SNAP‐Ed) aims to improve the diet quality of low resource populations; however, little is known about the association of food security status with diet quality in the SNAP‐Ed eligible population.ObjectiveThe objective of this study was to determine whether food security status is associated with diet quality in a sample of Indiana SNAP‐Ed eligible adult participants.MethodsSNAP‐Ed eligible adults age ≥18 y (n = 261) from 31 Indiana counties were recruited to participate from August 2015 to May 2016. Baseline food security score was assigned for household adults using the 10‐item United States Household Food Security Survey Module and used to classify participants as food secure (0–2) or food insecure (3–10). Baseline Healthy Eating Index‐2010 (HEI‐2010) score was assigned using dietary data collected from the National Cancer Institute Automated Self‐Administered 24‐Hour Recall Tool (2014 version with 1–2 days of recalls per participant). A generalized linear regression model was used to estimate the association between food security status and HEI‐2010 score for this cross‐sectional study.ResultsFood security status is significantly associated with total HEI‐2010 score (β = 4.7; p = 0.01) at baseline. The mean total HEI‐2010 score was 45.1 ± 14.0 (Mean ± SD) for food secure participants (n = 68) and 40.4 ± 12.1 (Mean ± SD) for food insecure participants (n = 139).ConclusionDiet quality is lower in food insecure SNAP‐Ed eligible Indiana adults compared with their food secure counterparts. There is a strong need for nutrition interventions to improve diet quality, particularly targeting food insecure audiences within in low‐resource populations.Support or Funding InformationThis activity was funded, by Purdue, as part of AgSEED Crossroads funding to support Indiana's Agriculture and Rural Development and the Purdue Health and Human Sciences Cooperative Extension Nutrition Education Program.

Research on Sustainable Development of New Rural Cooperative Medical System: Based on the Perspective of Rural Preventive Health Care Investment

With China’s New Rural Cooperative Medical System (CNRCMS) reforming and innovating, the health industry has been concerned by rural commercial investors. However, the new rural cooperative health insurance system based on medical services improve the health of farmers simultaneously, there are also problems of resources-wasted and low-efficiency in security. Preventive health care has gradually replaced the medical industry has become a new direction for the farmers’ health investment. This article uses the World Health Organization (WHO) and the latest authoritative statistics in China and combined with the research group survey and according to the theory of industrial development study the new rural cooperative security benefits. The conclusion is that, the rural prevention and health care investment will effectively promote sustainable development of CNRCMS, has a broad market prospect.

Evidence for Detection Bias by Medication Use in a Cohort Study of Breast Cancer Survivors.

In previous studies, we found modestly decreased and increased risks of second breast cancer events with the use of statins and antibiotics, respectively, after adjustment for surveillance mammography. We evaluated detection bias by comparing receipt of surveillance mammography among users of these 2 disparate classes of medication. Adult women diagnosed with early-stage breast cancer during 1990-2008 (n=3,965) while enrolled in an integrated health-care plan (Group Health Cooperative; Washington State) were followed for up to 10 years in the Commonly Used Medications and Breast Cancer Outcomes (COMBO) Study. Categories of antibiotic use included infrequent (1-3 dispensings/12 months) and frequent (≥4 dispensings/12 months) use, and categories of statin use included less adherent (1 dispensing/6 months) and adherent (≥2 dispensings/6 months). We examined associations between medication use and surveillance mammography using multivariable generalized estimating equations and evaluated the impact of adjusting for surveillance within Cox proportional hazard models. Frequent antibiotic users were less likely to receive surveillance mammography (odds ratio (OR)=0.90, 95% confidence interval (CI): 0.82, 0.99) than were nonusers; no association was found among infrequent users (OR=0.96, 95% CI: 0.90, 1.03). Adherent statin use was associated with more surveillance compared with nonuse (OR=1.11, 95% CI: 1.01, 1.25), but less adherent statin use was not (OR=1.03, 95% CI: 0.81, 1.31). No difference in associations between medications of interest and second breast cancer events was observed when surveillance was removed from otherwise adjusted models. The influence of detection bias by medication use warrants further exploration.

Physician Service Attribution Methods for Examining Provision of Low-Value Care.

Objectives:There has been significant research on provider attribution for quality and cost. Low-value care is an area of heightened focus, with little of the focus being on measurement; a key methodological decision is how to attribute delivered services and procedures. We illustrate the difference in relative and absolute physician- and panel-attributed services and procedures using overuse in cervical cancer screening.Study Design:A retrospective, cross-sectional study in an integrated health care system.Methods:We used 2013 physician-level data from Group Health Cooperative to calculate two utilization attributions: (1) panel attribution with the procedure assigned to the physician’s predetermined panel, regardless of who performed the procedure; and (2) physician attribution with the procedure assigned to the performing physician. We calculated the percentage of low-value cervical cancer screening tests and ranked physicians within the clinic using the two utilization attribution methods.Results:The percentage of low-value cervical cancer screening varied substantially between physician and panel attributions. Across the whole delivery system, median panel- and physician-attributed percentages were 15 percent and 10 percent, respectively. Among sampled clinics, panel-attributed percentages ranged between 10 percent and 17 percent, and physician-attributed percentages ranged between 9 percent and 13 percent. Within a clinic, median panel-attributed screening percentage was 17 percent (range 0 percent–27 percent) and physician-attributed percentage was 11 percent (range 0 percent–24 percent); physician rank varied by attribution method.Conclusions:The attribution method is an important methodological decision when developing low-value care measures since measures may ultimately have an impact on national benchmarking and quality scores. Cross-organizational dialogue and transparency in low-value care measurement will become increasingly important for all stakeholders.

Building a family network from genetic testing.

BackgroundGenetic testing has multigenerational and familial repercussions. However, the “trickle‐down effect” of providing genetic counseling and testing to family members at risk after an initial identification of a pathogenic variant in a medically actionable gene has been poorly understood.MethodsThree probands were identified during the pharmacogenetics research phase of eMERGEII (electronic MEdical Record and Genomics, phase II) to have variants in genes associated with autosomal dominant adult‐onset disorders determined to be actionable by the American College of Medical Genetics (ACMG). Two of the three probands had variants that were classified as pathogenic and the third proband had a variant ultimately classified of uncertain significance, but of concern due to the proband's own phenotype. All probands had additional family members at risk for inheriting the variant. Two of the three probands had family members who received their medical care from the same health care system, Group Health Cooperative (GHC). It was recommended that the proband contact their family members at risk to be referred to genetic counseling for consideration of genetic testing.ResultsThe two probands with pathogenic variants contacted some of their family members at risk. Individuals contacted included children and adult grandchildren, particularly if they received their medical care at GHC. To the best of our knowledge, siblings and more distant relatives at risk were not informed by the proband of their genetic risk.ConclusionsEstablishing a family network is essential to disseminate knowledge of genetic risk. These three initial cases describe our experience of contacting eMERGE participants with identified variants, providing the probands with appropriate genetic counseling and care coordination, and recommendations for contacting family members at risk. Greater challenges were observed for coordinating genetics care for family members and extending the family network to include other relatives at risk.

PENGARUH EFISIENSI BIAYA TERHADAP TINGKAT KESEHATAN KOPERASI SIMPAN PINJAM (KSP) DAN UNIT SIMPAN PINJAM (USP) (STUDI PADA KOPERASI DI SURAKARTA TAHUN 2015)

This paper aims to determine the influence of cost efficiency by six proxies on each KSP and USP Cooperative which has been assessed by Dinas Koperasi and UMKM Surakarta in 2015 on the level of health of the cooperative based on the results of the cooperative health assessment. In total, KSP and USP Cooperative samples in this paper were 25 cooperative that have been assessed an implement RAT in 2016. This research method using a model of quantitative research. The data analysis technical use analysis of the ratio consisting of 6 ratios (BOAPB, BUSK, EP, RA, RMS, and KOP) is calculated with guidelines health assessment to generate score ratings healthy assessment cooperative on each ratios and multiple linear regression analysis with independent variable cost efficiency and the dependent variable levels of health cooperative. Based on the research it was found that the level of efficiency by 6 proxies KSP and USP Cooperative on average have sufficient predicates efficient. However, the results also found 2 of 6 proxies affect cost efficiency and 4 proxies do not affect the level of health cooperatives. Then, the results of the paper concluded that the cost efficiency 4 proxies has no the influence because the paper sample indicated divergence conducted by KSP and USP Cooperative, these statements are based on the data obtained and the analysis of the health assessment score of each ratio. Therefore, 4 proxies is not significant influence partially.