Quality Measures Research Articles

Association of Palliative Care Timing With End-of-Life Quality in Children With Heart Disease.

Children with heart disease are at risk for early mortality and parents often perceive suffering at end-of-life (EOL). Involvement of pediatric palliative care (PPC) is a proposed quality measure at the EOL in children with cancer, and early PPC involvement is associated with other quality measures. The impact of early PPC involvement on EOL quality is unknown in children with heart disease. Evaluate the association of early PPC on potential EOL quality indicators for children with heart disease. Children (0-21 years) treated in a cardiac ICU and who died between January 2014 to December 2022 were identified. Details about EOL, including location and mode of death, and EOL quality indicators were extracted manually from the electronic medical record. We compared demographics, EOL characteristics, and EOL quality indicators by receipt and timing of PPC (i.e. ≥30 days from (early) or <30 days of death (late). Of 140 children, 75 (54%) received early PPC and 65 (46%) received late PPC. EOL quality indicators did not vary significantly between groups, with the exception of children with early PPC were less likely to have been intubated in the last 14 days of life compared to those with late PPC (40% vs 63%, P = 0.006). Our findings may indicate that quality indicators extrapolated from pediatric oncology do not apply to children with heart disease, as they have notably different disease trajectories and intervention options. We recommend defining high-quality EOL care indicators for children with heart disease as a priority.

Research participation effects and where to find them: a systematic review of studies on alcohol.

The term 'research participation effects' (RPEs) is intended to capture features and artefacts of study design that may affect measured outcomes in ways that introduce bias into research findings, impacting inference and outcome validity. This systematic review aims to identify which RPEs have been studied in the context of alcohol research and provide an overview of estimates of RPEs on self-reported alcohol consumption. This systematic review summarises the available evidence on research participation effects in alcohol research. Twenty-seven reports were included in the review. The reports included randomized controlled trials, studies-within-a-trial, between-subjects experiments, and qualitative investigations. A range of RPEs were addressed: assessment reactivity (N=15), being randomized to a waiting list control group (N=3), the impact of obtaining informed consent (N=2), experimentally induced social desirability (N=3), and the Hawthorne effect either specifically by name (N=2, one quantitative, one qualitative) or described as general RPE presence (N=2). The literature provided proportionally stronger evidence in favour of assessment reactivity and waiting list designs affecting alcohol outcomes contra obtaining informed consent or inducing social desirability. Variation in study quality, terminology, and outcome measures hinder comprehensive understanding and discussion of RPEs at present. Improved knowledge of RPEs and their potential long-term consequences in alcohol research, including a unified lexicon, would enhance trial design and improve on the certainty of evidence in alcohol research.

Children's executive functioning and health behaviors across pediatric life stages and ecological contexts.

Executive functioning (EF) has been linked to chronic disease risk in children. Health behaviors are thought to partially explain this association. The current cross-sectional study evaluated specific domains of EF and varied health behaviors in three pediatric life stages. Pediatric participants (early childhood n = 2074, Mage = 6.4 ± 0.9y; middle childhood n = 3230, Mage = 9.6 ± 1.2y; adolescence n = 1416, Mage = 15.2 ± 1.7y) were part of the Environmental influences on Child Health Outcomes (ECHO) Program. They completed neurocognitive tasks measuring cognitive flexibility, behavioral inhibition, and working memory. Parent- and/or child-report measures of dietary intake, physical activity, sleep duration and quality, income, and positive parenting were also collected. Neighborhood crime and greenspace were calculated from publicly available census-tract level indices. After adjusting for study site, child body mass index, and demographics, working memory was related in the hypothesized direction to several dietary behaviors within all pediatric life stages. Working memory and cognitive flexibility were positively related to physical activity in middle childhood and adolescence. In adolescence, behavioral inhibition was positively related to physical activity and inversely related to sugar-sweetened beverage and total caloric intake. Associations with sleep were all non-significant. All significant associations reflected small effect sizes. Income, positive parenting, greenspace, and crime did not significantly influence any of the EF-health behavior associations. Findings highlight the need to consider EF domains, specific health behaviors, and developmental stage in creating intervention strategies that target EF to improve health behaviors. The small effect sizes reinforce the need for multi-tiered interventions to maximize health.

ASO Visual Abstract: Commission on Cancer Center Performance with the New Breast Cancer Quality Measures: A Review of Historical Data.

ASO Visual Abstract: Commission on Cancer Center Performance with the New Breast Cancer Quality Measures: A Review of Historical Data.

Use of Telehealth for Follow-up Care After Children's Mental Health Hospitalizations.

This study measured the extent to which the COVID-19 pandemic disrupted follow-up care for children and adolescents with acute mental health hospitalizations and the use of telehealth to offset barriers to in-person follow-up care. The study used statewide claims data from Alabama's Children's Health Insurance Program, ALL Kids, from 2017 to 2022. Logit regressions measured associations between receipt of follow-up care within 30 days of acute mental health hospitalization and patient characteristics, timing of the COVID-19 pandemic, and receipt of care via telehealth. Interaction terms and likelihood ratio tests measured whether patient characteristics were associated with follow-up over time. Of 1698 mental health hospitalizations, 1323 (77.9%) received follow-up care from a mental health provider within 30 days, with no statistically meaningful difference before (78.3%) vs after (77.4%) the COVID-19 pandemic. Lower rates of timely follow-up were observed for children in age groups 10years and older, those with diagnoses for behavioral disorders and suicidal ideation/intentional self-harm relative to mood disorders, and racial/ethnic groups other than non-Hispanic white. Approximately 23% of follow-up was via telehealth. We observed no statistically meaningful changes in associations between patient characteristics and follow-up during the COVID-19 pandemic. Follow-up after a mental health hospitalization, an important quality measure for mental health care, was unchanged during the COVID-19 pandemic. Telehealth was not used prior to the COVID-19 pandemic but may have helped maintain follow-up care rates. Disparities in receipt of follow-up care were observed prior to the COVID-19 pandemic and persisted despite telehealth options.

Does Management of Postoperative Nausea and Vomiting Differ by Patient Demographics? An Evaluation of Perioperative Anesthetic Management - An Observational Study.

Disparities in postoperative nausea and vomiting (PONV) and its prophylaxis may exist based on race, ethnicity, and socioeconomic status (SES). Our objective was to evaluate whether patients from racial and ethnic minority groups and patients from lower SES backgrounds received less appropriate PONV prophylaxis and experienced higher rates of PONV and post-discharge nausea and vomiting (PDNV). This retrospective cohort study included 23,333 adults who underwent major surgeries (total knee arthroplasty, cholecystectomy, hysterectomy, and prostatectomy) from 2017-2022 in a single, multi-state hospital system. Outcomes included prophylactic antiemetic administration according to consensus guidelines as well as occurrence of PONV and PDNV, with predictors being patient race and ethnicity, payor type, and community-level SES. About 45% (n=10,407) of patients received guideline-recommended PONV prophylaxis. Regression models showed statistically significant differences in appropriate PONV prophylaxis by race and ethnicity as well as community-level SES, with Black (OR=0.76; 95% CI: 0.63, 0.92) and Hispanic (OR=0.82; 95% CI: 0.70, 0.96) patients having lower odds of receiving appropriate antiemetic prophylaxis compared to non-Hispanic White patients. Approximately 11% of patients (n=2522) experienced PONV in the Post-Anesthesia Care Unit (PACU), and about 19.5% of patients (n=4540) experienced PDNV. No significant differences in PONV were observed in the PACU among different groups, however, Black, Hispanic, Other races and ethnicities, and patients with Medicaid had higher odds of PDNV. The study identified differences in appropriate PONV prophylaxis by race and ethnicity as well as community-level SES. There were no differences in PONV by our predictors, but higher odds of PDNV by race and ethnicity and payor. This study underscores the importance of data stratification in quality measures to identify disparities in perioperative care; it can lead to changes in perioperative anesthetic management. Further research should explore these associations in a broader cohort and address potential confounding sources.

North American Pilot of TBIconneCT: A Social Communication Intervention via Telehealth for Individuals With Traumatic Brain Injury and Their Conversation Partners.

The purpose of this pilot investigation was to identify formative feedback to guide the development of a North American version of the TBIconneCT program. A secondary purpose was to examine the feasibility of delivering the intervention by graduate students. Two cohorts of individuals with chronic brain injuries and their communication partners were recruited for a 10-week, modified TBIconneCT program delivered by graduate student clinicians via telehealth. Eight dyads were recruited for the first cohort, but only four dyads completed the investigation. Ten dyads participated in the second cohort, but only seven dyads completed the investigation. Along with pre and post self-reported measures of communication and participation, participants completed an interview about their experiences. Interviews were transcribed and qualitatively coded using reflexive thematic analysis. Participants from both cohorts improved in all pre- and postmeasures of communication and participation; however, gains were modest across the cohorts. Qualitative analyses were conducted separately by cohort, as results from the first cohort informed modifications that were implemented in the second cohort, primarily to address Australian English dialects. Across both contexts, overarching constructs included "participant perspectives regarding outcomes," "assessments of the effectiveness of specific portions of the program," and "suggestions for improvement." The modified TBIconneCT program (North American pilot version) produced modest gains in measures of social communication, participation, and quality of life. Qualitative analyses provided insights into the strengths and weaknesses of the modified program, along with suggestions for refinement of the pilot version.

Patient-centred outcome measures for oncological surgery: a narrative review.

Peri-operative medicine is becoming increasingly relevant in the context of managing frail patients with cancer. This paper outlines how demographic shifts in populations are affecting cancer incidence and frailty rates, the relevance this holds to the management of cancer care, and the outcome measures that should be used to gauge best clinical practice to ensure patient-centred care. A targeted literature review was conducted using the search terms 'surgical oncology', 'outcomes', 'frailty', 'quality of life' and 'end of life' from 10 to 17 June 2024. Articles were reviewed by all authors and core themes from the literature review were identified. Core themes were then discussed by the authors to construct a narrative review. The review identified several core themes in relation to patient-centred outcome measures for oncological surgery. The UK population is ageing and consequently, the number of older people being diagnosed with cancer is increasing. There is much evidence to show that older patients have poorer outcomes in terms of mortality and postoperative complications across all types and severities of cancer. Traditional outcome measures such as 30-day mortality, duration of stay and recurrence rates fail to capture the outcomes that are most pertinent to this patient cohort. These include patient quality of life and treatment burden. We discuss the measurement of quality of life through the use of patient-reported outcome measures and their limitations. We also highlight the need for patient-centred, holistic care with the use of tools such as comprehensive geriatric assessment, which have been shown to improve patient outcomes. There is need for a greater emphasis on quality-of-life measures alongside mortality and patient-reported outcome measures. We argue that holistic care approaches should play a greater role in enabling the measurement of outcome states beyond simply dead or alive.

Evaluating major element hydrogeochemistry and fluoride occurrence in groundwater of crystalline bedrock aquifers and associated controlling factors of Eumseong basin area, South Korea.

Long-term intake of high-fluoride water can cause fluorosis in bones and teeth or damage to organs. Fluoride in groundwater is primarily derived from reactions with rocks containing fluorine-related minerals, and fluoride concentrations are elevated in groundwater that has been reacting with these rocks for a long time. The purpose of this study is to investigate the origin and distribution of fluoride in groundwater and to assess the influence of various factors, including geology, on fluoride concentrations in groundwater. The Eumseong basin and surrounding areas were selected as the study area due to the diversity of geologic factors. 139 groundwater samples and 14 rock samples were collected, with groundwater samples subjected to field water quality measurements, chemical analysis, and statistical analysis, and rock samples subjected to microscopic observation and chemical analysis. Fluoride concentration in groundwater increased with well depth, and was highest in groundwater associated with granitic rocks rich in biotite. The fluoride concentration in groundwater showed a negative correlation with the distance to the fault, suggesting that deep groundwater may preferentially flow along fault zones in certain areas. In addition, high-fluoride groundwater had depleted water-stable isotope values, which is likely to be resulted from higher degree of water-rock interaction in groundwater recharged at higher elevations. Calcite precipitation in most groundwater appears to weaken fluorite solubility control on fluoride concentration. Multivariate statistical analysis revealed that water-rock interactions generally governed fluoride and major element concentrations, with high-fluoride groundwater clearly distinguished. These findings can aid in assessing fluoride occurrence in groundwater and managing water quality in areas with similar geological characteristics.

National Telehealth Contingency Staffing Program and Primary Care Quality in the VHA

The Veterans Health Administration (VHA) launched the Clinical Resource Hub (CRH), a national telehealth contingency staffing program, to address primary care staffing shortages and improve veteran access to primary care. How this large-scale telehealth intervention affects quality of care is unknown. To assess the quality of care for chronic disease management among US veterans receiving high vs low levels of CRH-delivered primary care services and whether racial and ethnic minority veterans experience outcomes similar to those of White veterans when receiving CRH-delivered care. This retrospective quality improvement study was conducted using VHA administrative data. Veterans receiving primary care services from CRH clinicians between October 1, 2022, to September 30, 2023, were included. Low, medium, and high tertiles of CRH intensity, defined as the proportion of a veteran's CRH primary care visits to their total primary care visits within the study period. The main outcomes were chronic disease quality measures for 2 common conditions in ambulatory care: diabetes and hypertension. Logistic regression models were used to estimate the association between individual-level receipt of care from a CRH clinician and the study outcomes. This study included 71 508 veterans (mean [SD] age, 66 [15] years; 91.4% were male). Veterans who received a higher proportion of care from CRH clinicians were more likely to have improved blood pressure control compared with those who received a lower proportion of care. Higher vs lower CRH intensity was associated with improved blood pressure control among veterans with diabetes (79.5% [95% CI, 78.5%-80.4%] vs 76.6% [95% CI, 75.7%-77.5%]) and veterans with hypertension (76.8% [95% CI, 76.0%-77.5%] vs 73.9% [95% CI, 73.2%-74.7%]). Among racial and ethnic minority veterans, no association between CRH intensity and clinical quality was observed. In this large retrospective cohort study among veterans receiving primary care services through a national telehealth contingency staffing program, veterans with a higher proportion of care from CRH clinicians had improvement in blood pressure outcomes. These findings suggest that the CRH program may be helpful in addressing veteran primary care needs without introducing or worsening disparities in ambulatory quality measures among racial and ethnic minority veterans. As health systems face staffing shortages in primary care, these findings can inform strategies for equitable implementation of large-scale telehealth initiatives to fill these gaps and maintain timely access to primary care.

PSAURON: a tool for assessing protein annotation across a broad range of species.

Evaluating the accuracy of protein-coding sequences in genome annotations is a challenging problemfor which there is no broadly applicable solution. In this manuscript,we introduce PSAURON (Protein Sequence Assessment Using a Reference ORF Network), a novel software tool developed to help assess the quality of protein-coding gene annotations. Utilizing a machine learning model trained on a diverse dataset from over 1000 plant and animal genomes, PSAURON assigns a score to coding DNA or protein sequence that reflects the likelihood that the sequence is a genuine protein-coding region. PSAURON scores can be used for genome-wide protein annotation assessment as well as the rapid identification of potentially spurious annotated proteins. Validation against established benchmarks demonstrates PSAURON's effectiveness and correlation with recognized measures of protein quality, highlighting its potential use as a widelyapplicable method to evaluate precision in gene annotation. PSAURON is open source and freely available at https://github.com/salzberg-lab/PSAURON.

Contrast sensitivity before and after refractive error correction among refractive error patients in Hawassa, Sidama, Ethiopia 2023

BackgroundContrast sensitivity is an important measure of vision quality. Risk of falling injury is strongly associated with poor contrast sensitivity compared with poor near- and distance visual acuity. Since good visual acuity is not necessarily associated with good visual performance in the “real world” it is important to consider contrast sensitivity when prescribing corrective lenses. There is limited evidence on how refractive error and its correction affect contrast sensitivity in the study area. Therefore, this study is important to understand how refractive correction affects contrast sensitivity, which is important baseline information for prescribing refractive error correction.Objective of this studyThis study aimed to measure the mean difference in contrast sensitivity with and without corrective lenses in patients with refractive error.MethodsObjective and subjective refractions were done for each patient, then Pelli- Robson contrast sensitivity was measured for them using computer based Pelli-Robson chart at 1 m. Pelli- Robson contrast sensitivity value (Log CS) with and without corrective lenses were recorded for each study participant. The collected data were checked for completeness and analyzed using SPSS 26. Descriptive analyses, independent sample t-tests, and one-way ANOVA were performed to compare CS means; the findings are presented using tables and pie charts. A P-value of ≤ 0.05 was used to indicate statistical significance.ResultsOne hundred sixty-two patients attending refraction clinics participated in this study with response rate 98.19% of which 51.9% were male. The mean age of the participants was 34.28 ± 12.79 (SD). The mean contrast sensitivity increased from 1.29 ± 0.35 (SD) to1.51 ± 0.28 (SD) LogCS units with refractive correction (p = 0.000). There is no significant difference in contrast sensitivity between the types of refractive errors.Conclusion and recommendationUncorrected refractive can affect contrast sensitivity; therefore, proper refractive correction is essential to improve visual acuity and contrast sensitivity.

Ayahuasca-assisted meaning reconstruction therapy for grief: a non-randomized clinical trial protocol.

Psychotherapy for Prolonged Grief Disorder (PGD), a condition characterized by an intense and persistent grief response, has received increased attention over the past decades. Evidence-based approaches to prevent PGD are currently scarce, and not always effective. This paper introduces a protocol for a clinical trial exploring the effectiveness of a Meaning Reconstruction psychotherapy approach (MR) assisted with ayahuasca, a traditional indigenous medicine. The outlined protocol is a three-arm, non-randomized controlled trial focused on reducing normal and pathological grief symptoms, comparing the effectiveness of Ayahuasca-assisted MR therapy (A-MR), MR therapy alone (MR) and No Treatment (NT). At least 69 people who lost a first-degree relative during the prior year, and with a Texas Revised Inventory of Grief score up 39 (TRIG ≥ 40), will participate in the trial. Participants will be allocated to an A-MR (n ≥ 23), MR (n ≥ 23) or NT (n ≥ 23) group. Those from the A-MR and MR therapy groups will undergo a therapeutic process involving 9 sessions of online psychotherapy. In addition, the A-MR condition involves 2 group sessions of ayahuasca. The primary outcomes will be normal and pathological grief severity as measured by the TRIG and Traumatic Grief Inventory Self-Report (TGI-SR), administered at baseline, post-treatment, and 3-month follow up. Measures of quality of life, post-traumatic growth, meaning-made, psychological flexibility, and self-belief consistency will be also included. In addition, subjective effects of ayahuasca and acceptance-avoidance promoting effects will be assessed following ayahuasca administration. Finally, we will analyze the potential mediating effect of meaning-made, psychological flexibility and self-belief consistency in grief symptoms (as measured by the TRIG and TGI). This trial is the first to empirically examinate the potential of psychedelic-assisted psychotherapy for grief, as well as the potential processes of change that may account for it. https://clinicaltrials.gov, identifier NCT06150859.

Piloting a minimum data set for older people living in care homes in England: a developmental study.

We developed a prototype minimum data set (MDS) for English care homes, assessing feasibility of extracting data directly from digital care records (DCRs) with linkage to health and social care data. Through stakeholder development workshops, literature reviews, surveys and public consultation, we developed an aspirational MDS. We identified ways to extract this from existing sources, including DCRs and routine health and social care datasets. To address gaps, we added validated measures of delirium, cognitive impairment, functional independence and quality of life to DCR software. Following routine health and social care data linkage to DCRs, we compared variables recorded across multiple data sources, using a hierarchical approach to reduce missingness where appropriate. We reported proportions of missingness, mean and standard deviation (SD) or frequencies (%) for all variables. We recruited 996 residents from 45 care homes in three English Integrated Care Systems. 727 residents had data included in the MDS. Additional data were well completed (<35% missingness at wave 1). Competition for staff time, staff attrition and software-related implementation issues contributed to missing DCR data. Following data linkage and combining variables where appropriate, missingness was reduced (≤4% where applicable). Integration of health and social care is predicated on access to data and interoperability. Despite governance challenges we safely linked care home DCRs to statutory health and social care datasets to create a viable prototype MDS for English care homes. We identified issues around data quality, governance, data plurality and data completion essential to MDS implementation going forward.

Inpatient Hypoglycemic Rate Reduction Through the Implementation of Prescriber Targeted Decision Support Tools.

Hypoglycemia has been shown to increase mortality and length of hospital stay and is now reportable to the Centers for Medicare and Medicaid Services as a quality measure. The purpose of this article is to review clinical decision support (CDS) tools designed to reduce inpatient hypoglycemic events. CDS tools such as order set development, medication alerts, and data visibility have all been shown to be valuable tools in improving glycemic performance. This is especially true for hyperglycemic events with mixed results in hypoglycemia prevention. CDS solutions may be targeted directly to healthcare professionals or to specialty diabetes management teams to reduce hypoglycemia. Not all organizations have the financial resources to develop a diabetes management team so non-interruptive alerts may serve as an important tool to alert health care professionals of individuals with additional risk factors for the development of hypoglycemia. CDS can provide a mechanism to reduce the risk of hypoglycemia in hospitalized individuals. Although new research is promising, more studies are needed to determine future directions including the impact and feasibility of continuous glucose monitoring and predictive models to improve overall glycemic performance.

Exploring the Potential Effects of Soybean By-Product (Hulls) and Enzyme (Beta-Mannanase) on Laying Hens During Peak Production.

This study determined the interaction between soybean hulls (SHs) and enzymes (β-mannanase) to improve the sustainability and efficacy of feeding programs for laying hens during peak production while ensuring the best health and efficiency. In a completely randomized design (CRD), 200 golden-brown hens were fed for four weeks (33 to 36 weeks) and randomly distributed into four groups, each containing four replicates of ten birds, with one group receiving a control diet (P0) and the others receiving diets that contained four combinations of SHs and enzymes (ENZs). e.g., 3% SHs and 0.02 g/kg ENZs (P1), 3% SHs and 0.03 g/kg ENZs (P2), 9% SHs and 0.02 g/kg ENZs (P3), and 9% SHs and 0.03 g/kg ENZs (P4). Although most egg quality measures remained similar, the P2 group showed enhanced (p = 0.630) egg weight, albumen weight, and height. Moreover, the P2 group improved gut (p < 0.05) shape by increasing villus width, height, crypt depth, and surface area throughout intestinal sections, while the P4 group markedly improved total cholesterol and LDL (p = 0.022) levels. The P1, P2, and P4 groups exhibited a significant enhancement in dry matter (p = 0.022) and crude fiber (p = 0.046) digestibility, while the P2 group demonstrated superior crude protein digestibility (p = 0.032), and the P1 and P2 groups showed increased crude fat digestibility compared to the other groups. In conclusion, adding 3% of SHs and 30 mg/kg of ENZs (β-mannanase) to the feed may help laying hens, enhance gut health and some egg quality indices, and decrease blood cholesterol and LDL levels without compromising nutrient digestibility.

Adding New Components to a Composite Quality Metric

Objectives: This study illustrates how the statistical reliability of an individual measure relates to the overall reliability of a composite metric, as understanding this relationship provides additional information when evaluating measures for endorsement. Background: National quality measure endorsement processes typically evaluate individual metrics on criteria such as importance and scientific acceptability (eg, reliability). In practice, quality measures may be used in composite rating systems, which aid in the interpretation of overall quality differences. Methods: We define an individual measure’s reliability by its intraclass correlation and analytically establish the relationship between a composite’s reliability and the reliability of its components. We use real data to confirm this relationship under various scenarios. We are motivated by 8 quality measures, which comprise the Quality of Patient Care Star Ratings on Dialysis Facility Care Compare. These measure 4 primary outcomes (mortality, hospitalizations, readmissions, and blood transfusions), vascular access (2 measures), and facility processes (2 measures). Results: Depending on the reliability of the individual measures, their respective weights in the composite, and their pairwise correlations, there are circumstances when adding a new measure, even if it is less reliable, increases the composite’s reliability. For the dialysis facility Star Ratings, we find that the combined reliability of measures grouped within certain domains of care exceeded the reliability of the individual measures within those domains. Conclusions: New quality measures may add utility to a composite rating system under certain circumstances—a consideration that should, in part, factor into quality measure endorsement processes.

Improving Sleep Quality and Well-Being in Institutionalized Older Adults: The Potential of NESA Non-Invasive Neuromodulation Treatment.

Background/Objectives: Ageing is associated with several cognitive, physical, and emotional changes, including a decrease in sleep quality and mental health issues. This study studies NESA (Spanish acronym for Neuromodulación Superficial Aplicada) non-invasive neuromodulation using microcurrents as something that may provide a potential improvement in the quality of sleep and general health of older adults and residents in a healthcare institution. Methods: This observational study recruited 24 people who were residents at a long-term care facility. Participants were divided into two groups: one intervention group, who underwent NESA therapy twice a week for a total of 20 sessions, and a control group, who did not receive this treatment. The outcomes measured include sleep quality (Pittsburgh Sleep Quality Index), diary of sleep, symptoms of depressed mood (Yesavage Geriatric Depression Scale), and quality of life with the World Health Organization Quality of Life-Old (WHOQOL-OLD). Scores were collected at baseline, after 10 and 20 sessions, and 3 months after finishing the treatment. Results: The intervention group exhibited a notable improvement in sleep quality (p = 0.05). Additionally, there were fewer nocturnal awakenings. The quality of life also showed better scores, especially in relation to social relations and physical and mental health, which matches the slight decrease in scores and clinical improvement regarding depressive symptoms. In contrast, the control group demonstrated no improvement in symptoms, and in some cases, there was a worsening of symptoms. Conclusions: Our findings indicate that NESA non-invasive neuromodulation therapy is likely to enhance sleep quality and health-related measures in institutionalized older adults. Despite the limitations of the current study, the results support the potential of NESA microcurrents to enhance the well-being of this population.

Medicare Risk Arrangement and Use and Outcomes Among Physician Groups.

Many physician groups are in 2-sided risk payment arrangements with Medicare Advantage plans (at-risk MA). Analysis of quality and health resource use under such arrangements may inform ongoing Medicare policy concerning payment and service delivery. To compare quality and efficiency measures under 2 payment models: at-risk MA and fee-for-service (FFS) MA. This cross-sectional study used Medicare encounter and enrollment data from 2016 to 2019 covering 17 physician groups, 15 488 physicians, and 35 health insurers to compare quality and health resource use for Medicare beneficiaries within the same physician groups. The data were analyzed between August 4 and October 30, 2024. Care delivered under at-risk MA and FFS MA payment arrangements by the same physicians and medical groups. Twenty quality and efficiency measures across 4 domains of patient care (hospital care, avoidance of the emergency department [ED], avoidance of disease-specific admissions, and outpatient care) were examined using logistic regression analysis. The overall sample comprised 5 278 717 person-years (37.7% at-risk MA and 62.3% FFS MA). The mean (SD) age of beneficiaries was 73.6 (9.2) years in the at-risk MA group (56.8% women) and 71.8 (10.4) years in the FFS MA group (57.4% women). For at-risk MA compared with FFS MA, inpatient admissions and 30-day readmissions per 1000 were 10.03 (95% CI, -10.61 to -9.44) and 1.95 (95% CI, -2.18 to -1.73) lower. ED use measures per 1000 ranged from 2.95 (95% CI, -3.28 to -2.63) lower for avoidable ED visits to 26.02 (95% CI, -26.92 to -25.12) lower for overall ED visits. Avoidance of disease-specific admissions per 1000 ranged from 0.24 (95% CI, -0.35 to -0.13) lower for composite diabetes-related admissions to 2.18 (95% CI, -2.43 to -1.94) lower for the composite of chronic disease-related admissions. High-risk drug use per 1000 was 14.26 (95% CI, -14.85 to -13.67) lower. Overall, compared with FFS MA, at-risk MA was associated with higher quality and efficiency in 18 of 20 measures after adjusting for differences in demographics, Hierarchical Condition Categories Risk Adjustment Factor scores, and other health characteristics. In this cross-sectional study, at-risk MA payment arrangements managed by physician groups were associated with higher quality and efficiency compared with FFS MA managed by the same groups. The population and methods used provide robust evidence that at-risk payment arrangements in MA may improve health care delivery for the MA population.

Teachers' Attitudes toward the National Assessment of Knowledge in Third-Grade Mathematics in Slovenia

National assessment of knowledge (NAK) was introduced into the Slovenian elementary schooling programme with the initiation of the nine-year elementary school in 2001. Based on feedback on student performance, teachers can evaluate the effectiveness of their own teaching and, based on these findings, adapt their teaching methods to the needs of students. NAK is obligatory for all students from the sixth and ninth grade and voluntary for third-grade students, where the school decides about participating. Data from the National Examination Centre show that only a third of Slovenian elementary schools register for NAK in the third grade, hence we wanted to identify the reasons for the low participation. The survey included 114 randomly selected classroom teachers (i.e. teachers from 1st to 5th grade of primary school), who participated by completing an online questionnaire specifically designed for the purpose of this study.. The questionnaire aimed to investigate teachers' attitudes towards the NAK in the 3rd grade, to elucidate the reasons behind the low participation rate of schools in the NAK and the reasons for their non-participation in these assessments. Qualitative and quantitative data analysis revealed that teachers recognize the importance of the feedback provided by the NAK; however, they oppose the mandatory inclusion of NAK in the 3rd grade and the influence of NAK results on students' final grades in the subject (mathematics). The responses also indicate that many teachers had not participated in NAK due to a lack of opportunity rather than opposition to the assessment itself. Among the teachers whose schools opted out of NAK, reasons included perceptions of NAK as useless and unimportant, and concerns about student stress. Additionally, some teachers considered NAK not to be a measure of quality or believed it was implemented too early in the academic year.