Percentage Points Research Articles

Federally Qualified Health Centers and Performance of Medicare Accountable Care Organizations

ImportanceFederally qualified health centers (FQHCs) have increasingly participated in the Medicare Shared Savings Program (MSSP) accountable care organizations (ACOs), one of the most widespread value-based programs. Although FQHCs may strengthen ACOs’ ability to provide affordable care to diverse Medicare beneficiaries, evidence on ACOs’ performance by FQHC participation is limited.ObjectivesTo compare beneficiary characteristics, utilization, expenditure, and quality between ACOs with and without FQHC participation and assess changes in ACO performance after including first FQHCs.Design, Setting, and ParticipantsUsing MSSP public use files, this cross-sectional study compared performance of ACOs that always had FQHC participation with ACOs that never had FQHC participation from January 1, 2016, to December 31, 2022, supplemented with staggered difference-in-differences analyses of ACOs’ first-time inclusion of FQHCs on performance measures. Data analysis was performed from December 1, 2023, to February 29, 2024.ExposureParticipation of FQHCs in the MSSP.Main Outcomes and MeasuresMeasures of ACO-assigned beneficiaries, utilization, expenditure, and quality per ACO-year.ResultsAmong 752 ACOs in the descriptive analysis, 140 ACOs always had at least 1 FQHC participant, whereas 612 ACOs never had FQHC participants. Compared with ACOs that never had FQHC participation, those that always had FQHC participation provided care to more socioeconomically disadvantaged beneficiaries (mean [SD] with dual eligibility, 2035.8 [2110.6] vs 1040.9 [1084.2] person-years; with disability, 3341.1 [3474.9] vs 1705.1 [1664.9] person-years; in racial and ethnic minoritized groups, 3690.6 [4118.4] vs 2515.1 [2762.9] person-years), with fewer primary care visits (mean [SD], 9956.6 [1926.3] vs 10 858.8 [2383.4] per 1000 person-years), more emergency department visits (mean [SD], 771.6 [190.9] vs 657.2 [160.0] per 1000 person-years), and lower levels of several quality measures. In the difference-in-differences analysis, 43 ACOs included FQHCs for the first time. Including first FQHCs was associated with increases of 872.9 dual-eligible (95% CI, 345.9-1399.8), 1137.6 disability (95% CI, 390.1-1885.1), and 1350.8 racial and ethnic minority (95% CI, 447.4-2254.1) person-years, with increases in rates of influenza immunization (5.9 percentage points [pp]; 95% CI, 1.4-10.4 pp), tobacco screening and cessation intervention (11.8 pp; 95% CI, 3.7-20.0 pp), and depression screening and follow-up (8.9 pp; 95% CI, 0.5-17.4 pp). No associations were observed between FQHC inclusion and utilization or expenditure.Conclusions and RelevanceIn this repeated cross-sectional study, MSSP ACOs with FQHC participation served more socioeconomically disadvantaged Medicare beneficiaries than those without FQHC participation. The inclusion of first FQHCs was associated with increased rates of several preventive services without increasing costs. Participation of safety net practices appeared to improve access to ACOs among beneficiaries from underserved communities.

Systemic Postnatal Corticosteroids, Bronchopulmonary Dysplasia, and Survival Free of Cerebral Palsy

ImportanceSystemic postnatal corticosteroids have been shown to reduce rates of bronchopulmonary dysplasia (BPD) in infants born preterm, but both corticosteroids and BPD are associated with cerebral palsy.ObjectiveTo describe how the association between systemic postnatal corticosteroids and survival free of cerebral palsy varies with the risk of BPD in infants born preterm, and if the association differs between dexamethasone and hydrocortisone, or with age at starting treatment.Design, Setting, and ParticipantsThis comparative effectiveness research used weighted meta-regression analysis of eligible randomized clinical trials (RCTs) of systemic postnatal corticosteroids reported from June 1989 through March 2022 that included rates of all of BPD, mortality, and cerebral palsy in neonatal intensive care units in 10 countries. Infants born preterm at risk of BPD were included. Data were analyzed from April and July 2024.InterventionsSystemic dexamethasone or hydrocortisone.Main Outcomes and MeasuresType and timing of corticosteroid, control group rate of BPD, and risk difference in survival free of cerebral palsy between corticosteroid and control arms.ResultsTwenty-six RCTs with data on 3700 randomized infants were eligible; 18 (69%) investigated dexamethasone and 8 (31%) hydrocortisone; 12 (46%) started treatment in the first week after birth. There was evidence for a differential association of the type of corticosteroid with the effect of systemic dexamethasone on survival free of cerebral palsy and the risk of BPD in control groups (interaction coefficient, 0.54; 95% CI, 0.25-0.82; P = .001). For dexamethasone, for every 10–percentage point increase in the risk of BPD, the risk difference for survival free of cerebral palsy increased by 3.74% (95% CI, 1.54 to 5.93; P = .002). Dexamethasone was associated with improved survival free of cerebral palsy at a risk of BPD greater than 70%. Conversely, dexamethasone was associated with harm at a risk of BPD less than 30%. There was some evidence for a negative association with hydrocortisone, with possible benefit with risk of BPD less than 30%. There was no strong evidence for a differential effect of timing among those treated with dexamethasone (interaction coefficient, 0.13; 95% CI, −0.04 to 0.30; P = .14).Conclusions and RelevanceThe findings suggest that dexamethasone (compared with control) was associated with improved rates of survival free of cerebral palsy in infants at high risk of BPD but should be avoided in those at low risk. A role for hydrocortisone is uncertain.

Electronic Nudges and Influenza Vaccination Among Patients With a History of Myocardial Infarction: Insights From 3 Nationwide Randomized Clinical Trials.

Influenza vaccination in patients with acute myocardial infarction (AMI) reduces major adverse cardiac events and is strongly recommended in clinical practice guidelines. Effective strategies to improve vaccination are needed in these high-risk patients. To evaluate whether electronically delivered behavioral nudges improve influenza vaccine uptake in patients with AMI across 3 nationwide implementation randomized clinical trials (RCTs). Nationwide Utilization of Danish Government Electronic Letter System for Increasing Influenza Vaccine Uptake (NUDGE-FLU), Nationwide Utilization of Danish Government Electronic Letter System for Confirming the Effectiveness of Behavioral Nudges in Increasing Influenza Vaccine Uptake Among Older Adults (NUDGE-FLU-2), and Nationwide Utilization of Danish Government Electronic Letter System for Increasing Influenza Vaccine Uptake Among Adults With Chronic Disease (NUDGE-FLU-CHRONIC) were RCTs conducted during the 2022 to 2023 and 2023 to 2024 influenza seasons in Denmark. Participants were randomized to either usual care or various behaviorally informed, electronically delivered, letter-based nudges. In a prespecified participant-level pooled meta-analysis, interaction of AMI status on the effects of letter-based nudges vs usual care was examined. Pooled treatment effects were estimated using binomial regression models with identity link, adjustment for trial, and 2-way clustered SEs at the household and participant levels. Effect modification by recency of AMI as a continuous variable was assessed using restricted cubic spline modeling in NUDGE-FLU-CHRONIC. Behaviorally informed, electronically delivered, letter-based nudges or usual care. The primary end point was influenza vaccination receipt. Of 2 146 124 individual randomizations (mean [SD] age, 71.1 [11.6] years; 1 114 725 female [51.9%]) across all 3 trials, 59 458 (2.8%) had a history of AMI. Improvement in vaccine uptake was similar in patients with vs without a history of AMI who received any nudge letter compared with usual care (+1.81 vs +1.32 percentage points; P for interaction by AMI status = .09). A letter highlighting the cardiovascular benefits of vaccination (ie, cardiovascular-gain frame) resulted in larger improvements in vaccine uptake among patients with (vs without) a history of AMI (+3.91 vs +2.03 percentage points; P for interaction by AMI status = .002). Among patients with AMI, the benefits of the cardiovascular-gain frame letter were more pronounced in those not vaccinated in the prior season (+13.7 vs +1.48 percentage points; P for interaction <.001). Among younger participants with chronic disease, the cardiovascular-gain frame letter was particularly effective in patients with more recent AMI (P for interaction by continuous recency of AMI <.001). Across 3 nationwide RCTs of Danish citizens, messaging emphasizing the cardiovascular benefits of vaccination improved influenza vaccination uptake, with greater benefits observed in patients with a history of AMI. This low-cost, scalable implementation strategy should be considered to encourage influenza vaccination in high-risk patients. ClinicalTrials.gov Identifiers: NCT05542004, NCT06030726, NCT06030739.

Emotional bargaining after litigation: An experimental study of the Coase theorem

AbstractEntitlement assignment is unimportant if transaction cost is sufficiently low, as post‐litigation bargaining can redress allocative inefficiency, or so goes the Coase theorem. Ward Farnsworth, based on interviews with lawyers, argues that animosity created during litigation, a key mechanism to (re)allocate entitlement, will hinder the conclusion of any deal following litigation. Using a laboratory experiment, we test whether animosity generated before negotiations reduce the rate at which deals are successfully concluded and find evidence for a lower deal rate under one of the treatment conditions (the raw difference being three percentage points). The small practical effect may be attributed to rationality carrying the day and/or the limited degree of animosity we can generated in the lab with human subjects. The Coase theorem holds, while Farsworth's observation should not be ignored.

Treatment Preferences of Physicians Treating Adult Patients with Attention-Deficit/Hyperactivity Disorderin the United States and Canada: A Discrete Choice Experiment.

Factors influencing attention-deficit/hyperactivity disorder (ADHD) treatment preferences have been studied among patients but not physicians in the United States (US) and Canada. This study assessed treatment preferences of physicians treating adult patients with ADHD in both countries. An online discrete choice experiment (DCE) was conducted (October 4-20, 2023) among physicians from Dynata's US and Canadian panel who treated adult patients with ADHD. Preference weights for efficacy (improvement in ADHD symptoms) and safety [risks of adverse events (AEs)] attributes were estimated using a conditional logistic regression model, and were used to calculate the willingness to trade-off and relative importance of the attributes. Among 510 US and 347 Canadian physicians (64.1% and 69.2% male, respectively), improvement in ADHD symptoms had a significant positive impact, and the risks of AEs (except the risk of feeling jittery in Canada) had a significant negative impact on physician preferences for ADHD treatments. US physicians were willing to tradeoff 0.44, 0.35, 0.20, 0.17, and 0.17 percentage points of improvement in ADHD symptoms to avoid a one-percentage-point risk of insomnia, nausea, feeling jittery, anxiety, and dry mouth, respectively; among Canadian physicians, these were 0.31, 0.21, 0.12, 0.20, and 0.07, respectively. The relative importance of the efficacy versus safety attributes (i.e., the risks of AEs included in the DCE taken together) was 45.5% versus 54.5% in the US and 56.3% versus 43.7% in Canada. Efficacy was the most important single attribute for physicians treating adult patients with ADHD in both the US and Canada; however, the risks of AEs taken together had greater relative importance than efficacy alone among US but not Canadian physicians. These findings highlight potential discrepancies in physician and patient preferences based on existing evidence and underscore the importance of shared decision-making, which may in turn increase patients' treatment satisfaction.

You Only Look Once Version 5 and Deep Simple Online and Real-Time Tracking Algorithms for Real-Time Customer Behavior Tracking and Retail Optimization

The speedy progress of computer vision and machine learning engineering has inaugurated novel means for improving the purchasing experiment in brick-and-mortar stores. This paper examines the utilization of YOLOv (You Only Look Once) and DeepSORT (Deep Simple Online and Real-Time Tracking) algorithms for the real-time detection and analysis of the purchasing penchant in brick-and-mortar market surroundings. By leveraging these algorithms, stores can track customer behavior, identify popular products, and monitor high-traffic areas, enabling businesses to adapt quickly to customer preferences and optimize store layout and inventory management. The methodology involves the integration of YOLOv5 for accurate and rapid object detection combined with DeepSORT for the effective tracking of customer movements and interactions with products. Information collected in in-store cameras and sensors is handled to detect tendencies in customer behavior, like repeatedly inspected products, periods expended in specific intervals, and product handling. The results indicate a modest improvement in customer engagement, with conversion rates increasing by approximately 3 percentage points, and a decline in inventory waste levels, from 88% to 75%, after system implementation. This study provides essential insights into the further integration of algorithm technology in physical retail locations and demonstrates the revolutionary potential of real-time behavior tracking in the retail industry. This research determines the foundation for future developments in functional strategies and customer experience optimization by offering a solid framework for creating intelligent retail systems.

Effects of teachers' aides on students with special needs

AbstractThis study investigates the effect of increasing educational support in regular classes on students with special education needs (SEN). We exploit previous randomized controlled trials that added teachers' aides to Danish grade 6 classes combined with rich register data informative about SEN and school assignment. There were three types of teachers' aides: a co‐teacher with a teaching degree, a teaching assistant without a teaching degree, and a coach. We find that the treatments increased inclusion of SEN students in regular classes, by 7–8 percentage points, and that SEN students gained academically. Long‐term follow‐up data indicate that while the academic gains evaporated over time, the treated students were able to stay in regular classes throughout compulsory education and largely followed the same progression as their counterparts in the control group when they moved to upper secondary education. Finally, we show that the costs of the teachers' aides are outweighed by the saved costs of special education.

Evaluating rice lipid content, yield, and quality in response to nitrogen application rate and planting density

To investigate the effects of nitrogen (N) application rate and planting density (D) on the contents of lipid and free fatty acid, fatty acid composition, yield and quality of rice grain, a field experiment was conducted using Koshihikari (japonica) as experimental material from 2021 to 2022 with three N levels (90, 150 and 210 kg ha-1, denoted as N1, N2 and N3, respectively) and three transplanting densities (19.0 × 104, 26.7 × 104 and 40.0 × 104 plants ha-1, denoted as D1, D2 and D3, respectively). The results showed that N application rate and planting density had highly significant impacts only on the contents of free fatty acid and saturated fatty acid, respectively. Increased N and planting density enhanced the contents of lipid (29.41 mg g-1) and free fatty acid (21.47%). The highest values were obtained under N3D3 increasing by 7.02% and 3.23 percentage points, respectively, compared to other treatments. No significant differences in lipid content were found among treatments, whereas free fatty acid exhibited significant differences. The unsaturated fatty acid content increased with increasing N but first decreased and then increased with increasing planting density, while saturated fatty acid content showed the opposite trend. Appropriate N level and planting density improved the relative chlorophyll content and net photosynthetic rate of rice flag leaves, as well as increased grain yield, effective panicle number and spikelete number per panicle, but decreased the seed setting rate. Under N2D2, the relative chlorophyll content and net photosynthetic rate remained relatively high throughout the grain filling stage, resulting in the highest grain yield, with increases of 43.87-47.03% compared to other treatments. A moderate N level improved the milling quality of rice, while increased planting density reduced it. However, both increased N and planting density reduced the appearance quality and cooking and eating quality of rice. Overall, the effects of increasing N application rate and planting density on enhancing rice lipid and free fatty acid contents were limited. A combination of 150 kg ha-1 N application rate and 26.7 × 104 plants ha-1 was recommended for achieving relatively higher yield, lipid content and better grain quality.

Trends and inequalities in adequate antenatal care coverage among women in Sierra Leone, 2008-2019.

Prenatal care is a critical component of maternal and child health, providing essential preventive, diagnostic, and therapeutic services to pregnant women. Adequate antenatal care has been linked to reduced maternal and infant mortality and improved birth outcomes. Despite its importance, disparities in antenatal care coverage persist globally, including Sierra Leone,with significant implications for maternal and child health. This study examined the trends and inequalities in antenatal care utilisation in Sierra Leone. We used data from the 2008, 2013, and 2019 Sierra Leone Demographic and Health Surveys. Simple inequality measures (Difference and Ratio) and complex measures (Population Attributable Risk and Population Attributable Fraction) were computed using the World Health Organization's Health Equity Assessment Toolkit software. Inequality in antenatal care was calculated on six stratefiers:age groups for women, birth order, educational levels, economic status, residential areas, and sub-national province. There was a significant increase in adequate antenatal care coverage from 2008 (15.2%) to 2013 (36.5%) but a decrease in 2019 (22.1%). The inequality in age increased over time from a Difference of2.7 percentage points in 2008 to a Difference of 5.3 percentage points in 2019, indicating age-related inequalities. The Population Attributable Fraction decreased from 2.7% in 2008 to zero in 2013, indicating no further improvement in the national average of adequate antenatal care coverage can be achieved in the absence of age-related inequalities. However, it increased to 7.7% in 2019, indicating that the national average of adequate antenatal care coverage would have increased by 7.7% in the absence of age-related inequalities. The birth order inequality increased from a Difference of - 5.2 percentage points in 2008 to 2.6 percentage points in 2019. The Population Attributable Fraction was zero in 2008 and3.4% in 2019, showing that the national average of adequate antenatal care coverage would have increased by 3.4% if there was no parity-based inequality. Inequality in economic status decreased from 32.1 percentage points in 2008(Difference = 32.1) to 2.8 percentage points in 2019(Difference = 2.8). The Population Attributable Fraction revealed that the national average could have been 164.4% higher in 2008 and 20.8% higher in 2013; however, it was zero in 2019, indicating that no further improvement can be achieved in the national average if there was no inequality related to economic status. Inequality for education decreased from 49.9 percentage points in 2008(Difference = 49.9) to 11.0 percentage points in 2019(Difference = 11.0). Inequality decreased from a Difference of20.8 percentage points in 2008 to a Difference of1.7 percentage points in 2019 for place of residence inequality, showing a reduction in inequality. Provincial inequality decreased from a Difference of 33.9 percentage points in 2008 to 8.5 percentage points in 2019. While there have been notable improvements in antenatal care coverage in Sierra Leone, adequate antenatal care coverage is still below the WHO target of 78% in 2016, and significant inequalities persist. Addressing these inequalities requires a multifaceted approach considering demographic, economic, educational, and geographic indicators considered in this study. Sustained efforts and targeted interventions are critical by the Sierra Leone government to ensure that all women, regardless of their background, have access to essential antenatal care services up to at least eight visits.

Treatments and Patient Outcomes Following Stroke Center Expansion.

It is unclear how certified stroke center expansion contributes to improved access to stroke treatment and patient outcomes, and whether these outcomes differ by baseline stroke center access. To examine changes in rates of admission to stroke centers, receipt of thrombolysis and mechanical thrombectomy, and mortality when a community gains a newly certified stroke center within a 30-minute drive. This cohort study compared changes in patient outcomes when a community (defined by area zip code) experienced a stroke center expansion relative to the same community type that did not experience a change in access. Medicare fee-for-service beneficiaries with a primary diagnosis of acute ischemic stroke who were admitted to hospitals between January 1, 2009, and December 31, 2019, were included. The data analysis was performed between October 1, 2023, and September 9, 2024. New certification of a stroke center within a 30-minute driving time of a community. The main outcomes were rates of admission to a certified stroke center, receipt of thrombolytics (delivered using drip-and-ship and drip-and-stay methods), mechanical thrombectomy, and 30-day and 1-year mortality estimated using a linear probability model with community fixed effects. Among the 2 853 508 patients studied (mean [SD] age, 79.5 [8.5] years; 56% female), 66% lived in communities that had a stroke center nearby at baseline in 2009, and 34% lived in communities with no baseline access. For patients without baseline access, after stroke center expansion, the likelihood of admission to a stroke center increased by 38.98 percentage points (95% CI, 37.74-40.21 percentage points), and receipt of thrombolytics increased by 0.48 percentage points (95% CI, 0.24-0.73 percentage points). Thirty-day and 1-year mortality decreased by 0.28 percentage points (95% CI, -0.56 to -0.01) and 0.50 percentage points (95% CI, -0.84 to -0.15 percentage points), respectively, after expansion. For patients in communities with baseline stroke center access, expansion was associated with an increase of 9.37 percentage points (95% CI, 8.63-10.10 percentage points) in admission to a stroke center but no significant changes in other outcomes. In this cohort study, patients living in communities without baseline stroke center access experienced significant increases in stroke center admission and thrombolysis and a significant decrease in mortality after a stroke center expansion. Improvements were smaller in communities with preexisting stroke center access. These findings suggest that newly certified stroke centers may provide greater benefits to underserved areas and are an important consideration when deciding when and where to expand health care services.

Health Insurance Coverage Changes Under the Affordable Care Act Among High Housing Cost Households, 2010-18.

This study examines the impact of the Affordable Care Act (ACA) on health insurance coverage among rent-burdened households-those spending more than 30% of their income on rent-and non-rent-burdened households. Using data from American Community Survey, we find that Medicaid take-up rate increased 8.88 percentage points (pp) among rent-burdened households and 7.54 pp among non-rent-burdened households in expansion states. Conditional on household income and demographic characteristics, rent-burdened households exhibit a 1.5 pp higher likelihood of Medicaid enrollment, with an additional decline of 0.7 pp in employer-sponsored insurance and 1.0 pp in directly purchased insurance enrollment. These effects were more pronounced among individuals aged over 26 and those in states without state-run exchanges. The findings show the importance of tailored Medicaid policies to assist households facing housing burdens, especially for those ineligible for housing vouchers.

Performance of cash transfer program on farmers’ livelihood: evidence from PM-KISAN scheme of India

IntroductionResearch into various aspects of vulnerability and poverty has played a key role in shaping cash transfer systems. Cash-based direct benefit transfers (DBT) are frequently discussed, as they help reduce corruption and limit intermediary involvement, which often impedes policy implementation in countries like India. Small and marginal farmers (SMFs), constituting 86% of India’s farming population, are essential for sustainable agricultural growth and ensuring food and nutrition security. The Pradhan Mantri Kisan Samman Nidhi (PM-KISAN) scheme provides Rs.6000 annually to the farmer families via DBT mechanism. Despite reports and information from various government sources, significant concerns remain regarding the performance of PM-KISAN scheme in improving living conditions of SMFs.MethodsFor having the highest number of SMFs, a research study was conducted in Bihar and Uttar Pradesh. Two cluster of villages from each of these two states were chosen by simple random sampling (SRS) method. An ex post facto research design was used; data was gathered from 240 SMFs, with 120 beneficiaries and 120 non-beneficiaries, using a stratified disproportionate simple random sampling technique. The study used 18 indicators related to livelihood assets—human capital, social capital, natural capital, physical capital, and financial capital—to generate a Livelihood Index (LI) through Principal Component Analysis (PCA).ResultsThe beneficiaries of the scheme had an average LI score of 0.396, while non-beneficiaries had a score of 0.366. Propensity Score Matching (PSM) was employed to compare the beneficiaries and non-beneficiaries in order to determine the impact of the scheme. In the Livelihood Index of beneficiaries, in comparison to non-beneficiaries, there was a significant improvement of 3.34 to 4.13 percentage points, according to the analysis, which utilized a variety of matching algorithms.DiscussionImplications from the study suggests that PM-KISAN should be integrated into a broader rural development strategy to maximize multiplier effects. By combining cash transfers with complementary initiatives like modern technology adoption and high-yield seeds, farmers can make productive investments that could enhance their livelihood status.

The effectiveness and costs of intensive stroke rehabilitation and improvements in patient pathway in Finland: a retrospective benchmarking controlled trial.

To assess the effectiveness and costs of intensive stroke rehabilitation and improvements in patient pathway in the city of Lahti and in Päijät-Häme region compared with other parts in Finland. Retrospective benchmarking controlled trial. Three cohorts of Finnish community-dwelling patients (n = 94,749, n = 4,184, and n = 105,458) with ischaemic stroke between 2001 and 2019. This study is based on the PERFECT 2001-2019 database of ischaemic stroke patients. PERFECT indicators describe how the stroke patients recover. The difference-in-difference method was used in the main analysis. Improved stroke rehabilitation in Lahti increased the share of patients discharged home (p = 0.005) and decreased the length of first institutional episode (-4 days, p = 0.006), the share of patients institutionalized (-5.1%, p = 0.001), and the costs of first institutional episode (€-2,085, p < 0.001) compared with the rest of Finland. Discharges to home increased 6.6 percentage points (p = 0.021) in Lahti compared with rest of Päijät-Häme. After 2013, the costs of first institutional episode per patient in Päijät-Häme decreased significantly compared with the rest of Finland (p < 0.001). Investments in intensive stroke rehabilitation and patient pathway seem to provide both faster and better return to home for patients and reduced costs for the healthcare system.

Model-Based Assessment of Energy Efficiency in Industrial Pump Systems: A Case Study Approach

Outdated, oversized variable speed pump drives (VSDPs) in industry lead to sub-optimal energy efficiency and considerable energy losses. This paper proposes methods to develop 2D efficiency maps for motors, converters, and pumps using polynomial surface fitting, which enables efficiency evaluation in a wide operating range. The method was applied to an oversized VSDP in an industrial chilled water supply system, comparing the original system with five alternative VSDP combinations with high-efficiency motors and pumps. The five VSDP variants demonstrated average energy savings of around 30%, with the synchronous reluctance motor (SRM) configurations outperforming the induction motor (IM) configurations by up to 7 percentage points, particularly at low loads. The high-efficiency SRM-based 252-IE5 variant delivered the best overall energy performance, highlighting the benefits of optimised system sizing and motor selection for energy savings. The proposed method can be used in both industrial and residential applications and offers great advantages in process systems that require variable flow and pressure of water or other fluids during operation, such as HVAC, water supply and wastewater treatment, district heating, etc. The development of a VSDP drive with efficient energy optimisation is an interdisciplinary problem of mechanical and electrical engineering, and without the interaction of engineers from both fields the result will not be optimal. We try to present our method so that it can be a reliable tool for mechanical, electrical, and other engineers or researchers to assist them in finding possible energy savings, performing energy audits, and selecting the most suitable components when modernising existing or developing new systems.

Peace Versus Profit: Rebel Fragmentation and Conflict Resurgence in Colombia

Abstract Why do rebel splinter groups emerge during peace processes, and who chooses to defect? Since Colombia's landmark peace agreement with the FARC in 2016, roughly half of the territory once controlled by the group has seen a resurgence of rebel activity by FARC splinter groups. I argue that the FARC's return to arms is a case of “middle-out fragmentation,” whereby opportunities for profit induce mid- or low-ranking rebel commanders to establish splinter groups. In Colombia, I argue that profits from the cocaine trade incentivized local-level FARC officers to defect from the peace agreement and allowed them to rapidly mobilize viable splinter groups. I offer several lines of evidence for this argument. I first construct a chronology of splinter group formation, which demonstrates that mid- and low-level commanders, rather than high-level commanders, were the key drivers of fragmentation. Second, I show that splinter groups emerged in areas where opportunities for profit were greatest. Among areas previously controlled by the FARC, those with coca cultivation prior to the peace agreement were up to thirty-seven percentage points more likely to see splinter groups emerge by 2020 than areas without significant production. Using soil and weather conditions to instrument for coca cultivation produces similar results. Further, I use a novel measure of how critical each municipality is to drug trafficking to show that areas that are theoretically most important for drug trafficking are also more likely to see FARC resurgence. I also address competing explanations related to state capacity, terrain, and popular support for the rebels. These findings highlight an important challenge to peacebuilding: satisfying the political demands of rebel leadership is a necessary but insufficient component of peace agreements in cases where opportunities for profit motivate fragmentation from the middle out.

Meeting the Demand for Different Nitrogen Forms in Potato Plants Without the Use of Nitrification Inhibitors

The preference of potato plants for specific nitrogen (N) form changes with growth stage. Potato plants prefer nitrate N before tuber formation, while they favor ammonium N after tuber formation. However, few studies have focused on N species management in potato production. In this study, 2-year field experiments were conducted from 2020 to 2021 in Inner Mongolia, China, under drip irrigation with four N treatments: (1) CK (no N was used), (2) conventional farming practices (F) (urea was the only N source applied for potato growth), (3) nitrate N supplied before tuber formation and ammonium N with nitrification inhibitor supplied after tuber formation (N-NI), and (4) nitrate N supplied before tuber formation and frequent, low-dose ammonium N applied after tuber formation (Opt). The results demonstrated that, compared with the F, the Opt treatment facilitated potato N uptake, with a 33–40% increase in plant N accumulation, and significantly increased potato growth, which ultimately resulted in a yield increase of 12–20% and an increase of 11–22 percentage units in NUE. In addition, the Opt treatment reduced the soil N residual by ~14% after harvest. Compared with the N-NI, the Opt treatment did not result in a decrease in tuber yield or NUE. Therefore, supplying nitrate N before tuber formation and frequent, low-dose ammonium N after tuber formation can result in a better match between the supply and demand of potato plants for N forms without the use of nitrification inhibitors, improving both potato yield and NUE, which is of substantial agronomic and environmental value.

Association of Lameness Prevalence and Severity in Early-Lactation Cows with Milk Traits, Metabolic Profile, and Dry Period

This study investigated the prevalence and severity of lameness in dairy cow herds, focusing on its relationship with milk traits, metabolic profile, and dry period management. Lameness was evaluated in 4221 multiparous Holstein dairy cows during early lactation (up to 60 days postpartum) using a 1-to-5 scale. The average lameness score was 1.67, with a prevalence of 10.66% (scores 3 to 5) and 4.55% classified as severe (scores 4 to 5). Severe lameness was associated with energy-corrected milk losses of −11.00 kg/day (p &lt; 0.001) and a decrease in milk lactose concentration by −0.16 percentage points (p &lt; 0.001), alongside a rise in somatic cell scores by +0.11. The incidence of cows with a milk fat-to-protein ratio below 1.2 increased by 21.7 percentage points, while those with a ratio above 1.4 rose by 19.1 percentage points as lameness worsened. Additionally, non-esterified fatty acid concentrations increased by 1.46 times as lameness severity intensified (p &lt; 0.001). Cows without lameness had blood cortisol levels 1.86 times lower than affected cows, with cortisol tripling in those with the highest scores. A dry period of 30 to 60 days was correlated with more healthy cows, whereas periods over 90 days resulted in 1.586 times higher odds of lameness (p &lt; 0.05). This research underscores the need for improved management strategies to enhance dairy cow welfare and productivity.

Abstract 4138609: Patient Care Experience Worsens After Private Equity Acquisition of US Hospitals: Implications for Cardiovascular Outcomes

Background: Patient care experience is strongly associated with outcomes among individuals with cardiovascular disease. There is growing concern that the recent and precipitous rise in private equity acquisitions of US hospitals may worsen patient-centered care, and ultimately, cardiovascular outcomes. However, little is known about how private equity acquisitions of hospitals impact patient care experience. Research Question: To evaluate whether the acquisition of US hospitals by private equity firms was associated with changes in measures of patient-reported experience compared with matched control hospitals (not acquired by private equity) between 2007-2019. Methods: This cohort study identified 74 US acute care hospitals newly acquired by private equity firms and 298 matched control (non-acquired) hospitals from 2007 to 2019. CMS Hospital Compare files were used to obtain patient experience measure scores for each hospital from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS) survey results. A quasi-experimental difference-in-differences design was used to evaluate changes in patient experience measures at private-equity acquired hospitals compared with matched control hospitals 3 years before vs 3 years after acquisition. Results: The percentage of patients rating hospitals as a 9 or 10 out of 10 at private equity acquired hospitals and control hospitals is shown in the Figure. There was a differential decrease in patient ratings (of 9 or 10 out of 10) at hospitals acquired by private equity firms compared with control hospitals (-2.4 percentage points [95% CI -3.9, -0.9]). A similar trend was seen in the percentage of patients that would definitely recommend the hospital, with a differential decrease at private equity-acquired hospitals relative to control hospitals (-2.2 percentage points [95% CI -3.6, -0.7]). For both measures, the relative decrease in patient care experience at private equity hospitals compared with control hospitals steadily grew with each subsequent year after acquisition. Conclusion: In this national study, patient-reported care experience worsened after private equity acquisition of US hospitals, which has important implications for cardiovascular care and outcomes.

Institutional Betrayal in Inpatient Psychiatry: Effects on Trust and Engagement With Care.

Patients' experiences of inpatient psychiatry have received limited empirical scrutiny. The authors examined patients' likelihood of experiencing institutional betrayal (harmful actions or inactions toward patients) at facilities with for-profit, nonprofit, or government ownership; patient-level characteristics associated with experiencing institutional betrayal; associations between betrayal and patients' trust in mental health providers; and associations between betrayal and patients' willingness to engage in care postdischarge. Former psychiatric inpatients (N=814 adults) responded to an online survey. Data were collected on patients' demographic characteristics; experiences of institutional betrayal; and the impact of psychiatric hospitalization on patients' trust in providers, willingness to engage in care, and attendance at 30-day follow-up visits. Participants' responses were linked to secondary data on facility ownership type. Experiencing institutional betrayal was associated with less trust in mental health providers (25-percentage-point increase in reporting less trust, 95% CI=17-32), reduced willingness (by 45 percentage points, 95% CI=39-52) voluntarily undergo hospitalization, reduced willingness (by 30 percentage points, 95% CI=23-37) to report distressing thoughts to mental health providers, and lower probability of reporting attendance at a 30-day follow-up visit (11-percentage-point decrease, 95% CI=5-18). Participants treated at a for-profit facility were significantly more likely (by 14 percentage points) to report experiencing institutional betrayal than were those treated at a nonprofit facility (p=0.01). Institutional betrayal is one mechanism through which inpatient psychiatric facilities may cause iatrogenic harm, and the potential for betrayal was larger at for-profit facilities. Further research is needed to identify the determinants of institutional betrayal and strategies to support improvement in care quality.

Abstract 4128187: Does Health-related Quality of Life Differ by Race over time in Older Patients with Heart Failure from Before to After Heart Transplantation or Long-term Mechanical Circulatory Support?

Background: Minority patients are disproportionately affected by heart failure. Therefore, we aimed to determine the impact of race on health-related quality of life in three groups of older patients (60-80 years) with heart failure who underwent advanced surgical therapies (within race and by surgery group): (1) heart transplantation (HT, with pre-transplant mechanical circulatory support [HT MCS]), (2) HT without pre-transplant MCS (HT Non-MCS), or (3) long-term MCS, if ineligible for HT. Methods: Secondary analyses were conducted using data from the Sustaining Quality of Life of the Aged: Heart Transplant or Mechanical Support study. From 10/1/15 to 12/31/18, 396 patients with heart failure were recruited at 13 U.S. medical centers, of which 305 patients underwent HT (n=161 [68 HT MCS and 93 HT Non-MCS]) or long-term MCS (n=144) and had data through 1 year follow-up. Analysis included non-inferiority testing (Long-term MCS vs HT MCS; Long-term MCS vs HT Non-MCS). To demonstrate non-inferiority, the surgical strategies by race needed to show a difference of at least 5 percentage points, with a 95% lower confidence boundary and a two-tailed p-value&lt;0.05 in health-related quality of life, using the Kansas City Cardiomyopathy-12 Questionnaire Overall Summary Score at baseline and 3-, 6-, and 12 months. Results: The entire cohort was on average 66.2±4.7 years, 78% male, and 84% White. All three surgical groups experienced improved health-related quality of life from before to 1 year follow-up; with the largest gain through 3-months. Using non-inferiority testing, the long-term MCS minority group did not demonstrate non-inferiority when compared to both the HT MCS minority group and HT Non-MCS minority group confidence limits above the non-inferiority margin of -5 (Figure). Also, the White long-term MCS group did not demonstrate non-inferiority when compared to the White HT MCS and White HT Non-MCS groups. Conclusion: Differences in health-related quality of life among groups based on race were not statistically significant. Per non-inferiority testing, HT is superior to long-term MCS for health-related quality of life, regardless of race.