Value-based Models Research Articles

Modeling Students’ Perceptions of Chatbots in Learning: Integrating Technology Acceptance with the Value-Based Adoption Model

As technology continues to advance, chatbots are likely to become an increasingly vital tool in education. This study digs further into how students perceive and accept chatbots for use in learning activities. The study examines the integrated relationships between the constructs of the technology acceptance model (TAM) and the constructs of the value-based model (VAM), including perceived enjoyment, perceived risk, and perceived value, to predict students’ attitudes and, consequently, their acceptance of chatbots for learning in higher education. A total of 432 respondents participated in an online survey, and the proposed hypotheses were evaluated through structural equation modeling (SEM-PLS). The study offers useful insights on chatbot adoption in Saudi higher education, as the results highlight important drivers of chatbot acceptance among students, including perceived usefulness, perceived ease of use, attitude, perceived enjoyment, and perceived value. Perceived risk was not a significant predictor of students’ attitudes or their acceptance of chatbot use in learning. The results are expected to foster the adoption of chatbot technology in supporting distance learning in Saudi Arabia’s higher education.

Primary Care Redesign for Value-Based Care

Summary To address the inefficiencies and high costs associated with the U.S. health care system’s dominant fee-for-service (FFS) model, leaders at Spectrum Health in Michigan — now Corewell Health West — decided in 2019 to undertake a transformation to value-based care, starting with primary care. The aim is to maximize value for patients by achieving the best outcomes at the lowest cost. A set of guiding principles was established to address this primary care initiative: to incorporate population segmentation (clinics tailored to distinct patient cohorts, including healthy, rising risk, high risk, and others); to integrate interdisciplinary care teams (emphasizing top-of-license care); to align physicians’ efforts to their clinical expertise (to create and manage care plans for complex patients); to deliver care through multiple modalities (including virtual care, asynchronous care, home visits, or other ways to meet patient needs); to utilize integrated data and information (facilitated by a robust electronic medical record and analytics capacity to track key performance indicators supporting operational, technical, and clinical workflows); to align provider compensation and incentives with value-based outcomes while shifting away from FFS volume); and to integrate specialty care in primary care (where primary and specialty providers function as members of a joint care team). Recognizing that value-based care delivery typically requires upfront investment and delayed financial ROI, the team effort adopted a two-pronged approach by implementing the value-based care model and simultaneously optimizing primary care FFS. Despite some challenges in meeting all the targeted metrics — including resistance to change management — surveys show improvement in experience scores among patients (rating provider communication and likelihood to recommend the clinic) and well-being scores among physicians and advanced practice providers (lower rates of high distress).

Effects of Primary Care-Led, Integrated Palliative Care for Medicare Patients in a Value-Based Model

ContextFaced with a projected shortage of specialized palliative care physicians, scalable palliative solutions are required to better meet the aging population's needs. ObjectivesTo determine whether a multi-site, primary care-led, integrated palliative care model improves clinical, utilization, and economic outcomes. MethodsPropensity score-matched comparison group formed from participants who were Medicare beneficiaries, died January 1, 2021–January 31, 2023, were patients of eight primary care practices that partner with agilon health, and enrolled in palliative care for at least seven days. Each practice operates in a value-based model, where primary care providers (PCPs) take on full-risk for the cost and quality of patient outcomes. Each program includes symptom management, defining goals of care/advance directives, PCP care coordination, and assistance with care transitions if patients enroll in hospice. ResultsFinal sample included 1778 decedents, with 889 in both enrolled and matched cohorts, average age 83. Palliative care is associated with improved patient outcomes from palliative care enrollment until death, including 5.4 more days at home (p < 0.001), 0.4 fewer hospitalizations (p < 0.001), 17% fewer deaths in a hospital (p < 0.001), and $10,393 lower overall healthcare costs (p < 0.001). ConclusionA primary care-led, integrated approach of delivering palliative care within a full-risk model can be an effective care delivery mechanism to meet the healthcare needs of an aging population by impacting patient outcomes and reducing avoidable utilization and cost at the end of life. These findings demonstrate that PCPs in a scaled, full-risk model can simultaneously improve care for patients while reducing costs to the healthcare system.

An integrated model predicting the drivers of mobile payment outcomes: evidence from emerging markets

PurposeBecause the success of m-payment services depends on the enablers and barriers that affect user satisfaction, the present research explores the effects of perceived value and sacrifices on users' satisfaction with m-payment services. The predicted relationships among perceived value, perceived sacrifices, users' satisfaction, continuance intention, word-of-mouth (WOM), shopping effectiveness, quality of life (QOL) and stickiness were established based on the mobile technology acceptance model (MTAM) and the value-based adoption model (VAM).Design/methodology/approachA representative data sample of 430 Egyptian banking clients was analyzed to test the hypotheses using partial least squares-structural equation modeling (PLS-SEM).FindingsThe findings revealed that all perceived value constructs significantly positively affect users' satisfaction. Moreover, all perceived sacrifice constructs significantly negatively affect users' satisfaction. Users' satisfaction, in turn, has a significant positive effect on continuance intention, WOM, shopping effectiveness, QOL and stickiness with m-payment services.Originality/valueThis is the first study to examine several levels of m-payment outcomes, including m-payment, consumer and bank outcomes, based on the integration of MTAM and VAM models.

Exploring the perception of value in cancer care: A comparison of patients, providers, and payers.

60 Background: As the healthcare system moves towards value-based models, defining "value" is crucial. In the context of cancer care, there are multiple metrics essential to the aggregate of “value”, however their relative importance to the various stakeholders in value-based care are unknown. This study assesses the priorities of key stakeholders in value-based cancer care. Methods: A survey was administered to international cancer patients through online support groups and to healthcare providers and payers within a large regional health system. Respondents ranked the relative importance of treatment costs, longevity, treatment experience, functional and emotional well-being, and longevity (survival). Agreement among groups was analyzed using Kendall's coefficient of concordance (W). The priorities of each group were compared among stakeholders. Results: A total of 1,103 respondents including 782 patients, 216 healthcare providers, and 105 payers/policymakers participated. The majority of respondents were female (70%), white (89%), and had completed a four-year degree (63%). The patient cohort represented six continents and 20 cancer types. The most common cancer site was the pancreas (35%), followed by the esophagus (11%), bile duct (10%), and peritoneal surface malignancy (9%). Among providers, 29% were physicians, 21% nurses, 11% advanced practice providers, and 39% other providers. Among payers, 24% were administrators and 24% held were business analysts. Patients prioritized longevity and functional independence (W=39%, p&lt;0.001), while providers prioritized patient emotional well-being over functional independence and experience (W=35%, p&lt;0.001). Payers prioritized emotional well-being and patient longevity (W=26%, p&lt;0.001). The overall ratings for each value metric among the three groups differed significantly (all p &lt; 0.05). All groups ranked treatment costs as least important. Rankings were consistent across gender, education level, and time spent with patients within the cohorts. Conclusions: With general consistencies amongst the views of stakeholders, there are remains significant discordances in the perception of value. While the highest priority across stakeholder groups differed, costs of treatment consistently ranked as the least important value domain. These findings have important implications for the development of value-based cancer care models that account for the diverse perspectives of key stakeholders. Further research is needed to develop a generalizable measure of healthcare value.

The role of laboratory medicine in a value-based healthcare system: the example of heart failure patient management in the Italian context.

As of today, healthcare systems worldwide face severe challenges that undermine their sustainability. The value-based healthcare (VBHC) approach has been proposed as a strategic and methodological framework to ensure the delivery of the best patient outcomes with economic efficiency. Through the illustrative example of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) for heart failure (HF) patient management in the context of the Italian National Healthcare system, this article explores the role that in vitro diagnostics (IVDs) can play in enabling value-based care models. 14 healthcare professionals representing the relevant professional figures involved in HF patient management met to revise the current HF patient journey and design a new care pathway that, leveraging on BNP/NT-proBNP, reflects the VBHC principles. The literature recognizes the dosage of BNP/NT-proBNP as the gold stan-dard for diagnosing HF. However, as of today, these IVDs are not employed at their full potential regarding HF patient management. A new patient journey is proposed so that patients are diagnosed early and properly monitored in the aftermath of hospitalization, improving outcomes at contained costs. As testified by the example of HF patient management in Italy, laboratory medicine can represent a lever for adopting value-based care models. Still, large-scale adoption of VBHC will call for structural reforms that revise how healthcare delivery is organized, measured, and reimbursed.

The impact of dosing approaches for lenalidomide on total cost of care in episodic value-based care models at a community oncology network.

16 Background: The Oncology Care Model (OCM) was a 6-year long Medicare value-based care (VBC) program that rewarded practices for maintaining high-quality cancer care, while decreasing the total cost of care (TCOC) compared to a benchmark price. Lenalidomide, an oral medication used to treat multiple myeloma and other hematologic cancers, had the highest total Part D spending in the OCM. Lenalidomide is available as capsules of multiple strengths (2.5mg, 5mg, 10mg, 15mg, 20mg and 25mg), having the same cost per pill (mean cost of $735 per pill (over the 6 years)) for each of the strengths. Standard lenalidomide dosing includes one of the dose strengths taken once daily for 21 days on a 28-day cycle, 14 days on a 21-day cycle, or 28 days on a 28-day cycle. Doses and schedules may be adjusted to account for patient toxicities, different indications, or individual preferences. We studied the impact of different dosing approaches for Lenalidomide on TCOC. Methods: We used Medicare prescription dispense data for Lenalidomide for 15 practices in The US Oncology Network (The Network), participating in the OCM. We grouped dispenses based on pills per day (calculated using count of pills dispensed &amp; days' supply), and evaluated the prevalence of different dosing approaches, cost of Lenalidomide, and the impact on TCOC throughout the OCM time periods (July 2016 to June 2022). Results: 85.5% of 52,793 total dispenses were for one pill daily doses, 10% (5,281) for fewer than one pill daily doses, and 4.5% (2,377) for alternative dosing approaches using more than one pill per day, such as multiple pills taken once daily, one pill taken more frequently than once daily, or the total strength being dispensed as a combination of multiple smaller strengths. Alternative dosing approaches led to a mean total cost of $28,300 per dispense, versus $15,600 per dispense for one pill daily doses. 95% of the episodes with alternative dosing approaches had TCOC more than the benchmark, whereas only 52% of the episodes with one pill daily dosing had TCOC more than the benchmark. Total strengths of Lenalidomide dispensed as a combination of multiple smaller strengths had the highest mean total cost of all alternative dosing approaches. Conclusions: Dosing approaches utilizing more than one pill per day for oral medications like Lenalidomide can lead to significantly higher total cost and unfavorable VBC outcomes. Similar impacts may be found with other oral medications where per pill costs are high. Appropriate dosing strategies for optimizing pill counts of oral medications can lead to cost savings for patients, and the health system at large.

The impact of hospice on end-of-life expenditures and total cost of care in episodic value-based care models at a community oncology network.

228 Background: The Institute of Medicine highlighted that multiple care transitions and fragmented care delivery at the end-of-life (EOL) is a burden to patients and caregivers. Hospice care has been shown to deliver high-quality, coordinated, and comprehensive EOL care while reducing unneeded healthcare interventions and improving EOL patient experience (preference of place of death, type of EOL care). The impact of timely hospice care on Total Cost of Care (TCOC) in episodic value-based care (VBC) models and patient experience at the EOL is largely unknown. The Oncology Care Model (OCM) was a 6-year long Medicare VBC program that encouraged care transformation at Oncology practices to drive better quality of care and patient experience, while decreasing TCOC. We studied the impact of timely hospice enrollment on TCOC, EOL expenditures, and patient experience. Methods: We obtained episode level data for patients who died in an episode (decedents) during the 6-years of the OCM (July 2016 to June 2022), for 15 practices in The US Oncology Network (The Network) participating in the OCM, along with several expenditure, clinical and episodic characteristics. We evaluated utilization and experience outcomes for episodes with and without hospice. Results: Of the 26,074 decedents during the 6-year period of the OCM, 55% were enrolled in hospice for 3 or more days (Hsp), and 45% were not enrolled or enrolled in hospice for less than 3 days (NoHsp). Mean TCOC for Hsp episodes ($41,297, n = 14,240) was significantly lower (Mann Whitney U test, p-value &lt; 0.0001, significance level = 0.01) than NoHsp ($47,601, n = 11,834) episodes. TCOC comparison by expense cohort results are provided in Table 1. Median duration of hospice for Hsp episodes was 9 days. Mean ICU and inpatient spend in last 30 days of life in NoHsp group was more than 2 times the spend in Hsp group. 44% of patients in NoHsp group died in a hospital or an ICU setting, whereas 97% of patients in Hsp group died at home or in a hospice setting. Conclusions: Patients enrolled in hospice for 3 or more days had lower EOL care expenditures, fewer acute care interventions, and died at home or in hospice. Timely and proactive enrollment in hospice and coordinated EOL care can improve patient experience, but also reduce EOL costs for the healthcare system and patients. CMMI Disclaimer: The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.[Table: see text]

The economic value of insulin glargine 300 U/mL (Gla-300) in people ≥18 years of age with type 2 diabetes mellitus: a value-based economic model from a U.S. payer perspective

AimsThis study aimed to evaluate the value and affordability of insulin glargine 300 U/mL (Gla-300) in a budget impact model from a United States (U.S.) payer perspective by leveraging recent real-world evidence (RWE) studies and incorporating the recent insulin price caps where applicable.Materials and methodsAn economic model for a hypothetical one million U.S. health-plan population was developed to assess the budgetary impact of therapeutic interchanges in either direction between the two long- and longer-acting basal insulins (BIs) for patients with type 2 diabetes over a three-year model horizon. The utilization of long-acting BIs, longer-acting BIs, biosimilar BIs, and insulin degludec (IDeg-100) were informed by IQVIA data and internal forecasting at Sanofi. The DELIVER-2 and DELIVER-naïve studies provided healthcare resource utilization (HCRU) parameters. In the model base case, 24% of patients switched from long-acting BIs to insulin glargine biosimilars, IDeg-100, and other longer-acting BIs (Gla-300) by projected year 3.ResultsThe base case total costs were $10,145 per patient per year (PPPY) in year 3 for the cumulative population. When all patients switched to Gla-300, the total costs in year 3 were $8,799, reflecting a net savings of -$660 PPPY compared to the budget increase of $686 PPPY in the base case. However, the longer-acting to long-acting BIs reversal scenario demonstrated a budgetary decrease of $676 PPPY over the model horizon. The reduction in incremental PPPY cost of $93 was observed using net drug costs rather than wholesale acquisition costs (WAC).LimitationsThe market shares for years 1–3 were based on expectations supported by the clinicians’ expert opinions and were not obtained from real-world data.ConclusionsThe economic value of increased utilization of Gla-300 was driven by the reduction in HCRU, costs and market shares assumptions. Budgetary reductions were achieved by switching patients from long-acting BIs to Gla-300.

Value-based care models for chronic hepatitis B and C among vulnerable populations: a scoping review

Abstract Background Chronic viral hepatitis B and C are a significant public health burden worldwide. The prevalence of these infections is much higher among migrants than in the general population, due to factors such as inadequate access to healthcare. The EU VH-COMSAVAC project aims to implement community-based HBV/HCV models of care among migrant populations with documented high HBV/HCV incidence and prevalence, using person-centred referral processes. Our study aims to provide an overview of the scientific evidence on value-based models of care for prevention, treatment and linkage-to-care in high-risk groups. Methods This scoping review was performed in the context of the EU VH-COMSAVAC project, following the PRISMA-ScR Checklist, by searching on 5 databases: Medline, EMBASE, GlobalHealth, Scopus and Web of Science. Articles published up to December 2020 investigating models of care targeting migrant populations and related to HBV/HCV prevention, treatment and linkage-to-care, were included. Results Out of a total of 2,767 articles screened, 83 were included and preliminarly categorized according to stages of care (prevention, treatment and linkage-to-care) and Bodenheimer’ pillars. Further investigation will be conducted concerning the dimensions of patient experience; utilized resources; population health; care-team well-being. Conclusions Implementing patient-centered care models for critical public health issues among specific populations is becoming incresingly relevant. This study will provide the conceptual basis for building a value-based assessment tool capable of evaluating new models of care for prevention, treatment and linkage-to-care for hepatitis B/ C in high-risk groups. Key messages • In order to reach viral hepatitis elimination targets, initiatives must pay particular attention to high-risk groups. • The value (population health, patient experience, care-team wellbeing and costs) of such care strategies should be assessed to contribute to their continuity.

A review of cost-effectiveness analysis: From theory to clinical practice.

Cost-effectiveness analysis has long been practiced; registries date back to the United States of America War Department in 1886. In addition, everyone does intuitive cost-effectiveness analyses in their daily lives. In routine medical care, health economic assessment becomes increasingly important due to progressively limited resources, rising demands, population increases, and continuous therapeutic innovations. The health economic assessment must analyze the outcomes and costs of actions and technologies as objectively as possible to guarantee efficient assessment of novel interventions for Public Health Policy. In other words, it is necessary to determine how much society or patients are willing to or able to pay for novel interventions compared with existing alternatives, given the available resources. In addition, increased cost may displace other health care services already provided in case of fixed budget health care systems. To conduct such analyses, researchers must use standard methodologies and interpretations in light of regional characteristics according to social and economic determinants as well as clinical practice. Such an approach may be essential for transforming the current healthcare system to a value-based model. In this narrative review, concepts of the importance of and some approaches to health economic evaluation in clinical practice will be discussed.

Accelerating Care Delivery Transformation — The CMS Innovation Center’s Role in the Next Decade

Summary Over the past decade, the U.S. Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (CMS Innovation Center) has tested more than 50 payment models with a range of participants and value-based payment features. Value-based payment models can provide the necessary flexibility to support care delivery that better addresses people’s health and health-related social needs. This transformation of the delivery system, supported by value-based payment models, can drive better care, improve outcomes, and lower costs. The impact of CMS Innovation Center models has largely focused on financial impacts, with varied results in terms of total health care cost reduction. There has been less focus on the extent to which payment models have enabled care delivery transformation. To inform the development of a new framework to better assess the impacts of payment models and to drive care delivery transformation, the CMS Innovation Center undertook a retrospective review and synthesis of select models to assess if — and which — care delivery changes have been observed. The review indicated demonstrable evidence of enhanced care delivery in several areas, such as care coordination, team-based care, and leveraging data to risk-stratify patients, among other strategies. Three broad themes are shared among the more successful efforts. (1) Participants across models used common care coordination and other strategies to deliver person-centered care, (2) practice changes enabled by value-based care models showed evidence of tailoring care to local needs, and (3) care delivery trends and changes extend beyond the CMS Innovation Center models. This article summarizes those findings, which are informing the development of a new framework to accelerate care transformation.

A Prospective Evaluation of Cost and Space Utilization Following Implementation of an Intelligent Delivery Platform for Forefoot Single-use Implants and Instrumentation in the ASC Setting

Category: Midfoot/Forefoot; Other Introduction/Purpose: The transition of the US healthcare system from a fee-for-service model to a value-based care model calls for a deeper evaluation of patient care in order to uphold quality and efficiency. Sterile-packed single-use instruments have been introduced as a tool to help facilities streamline operating room logistics and reduce sterilization needs and requirements thus reducing cost, time, and valuable shelf space. With the added intelligent delivery platform, procedure mapping (physician specific stocking of implants) and automatic restocking is now possible1-3. The purpose of this study was to examine the efficiencies of cost savings and reduction of shelf space required for storage of an intelligent delivery platform (Pulse Intelligent Delivery Platform, Stryker, Memphis, TN) with single-use surgery-ready forefoot implants. Methods: A total of 19 cases were performed during a 3-month period (August to November 2022) at a single ambulatory surgery center. Instrument tray reduction was tabulated and compared to the number of trays typically utilized using reusable instruments. Tray management time was evaluated clinically by direct observation. A cost analysis of reprocessed instrumentation trays was then performed looking at sterilization, surgical delay, and instrumentation costs per tray and then compared to pricing for the sterile instrument kits. The instrument, sterilization, and case delay costs/tray at the facility were calculated2. A comparison of space utilization was also performed between the two groups (reprocessed trays versus sterile kits). Results: There was a substantial decrease in the need for reusable instrument trays by 80%. 70% of cases did not require even one tray of reusable instruments to be opened. The delivery platform was shown to lower instrument tray cost per case by 74.25%. Space was also evaluated, and the sterile kits were found to have an 85.9% reduction in space when compared to the reprocessed trays2,3. Conclusion: A forefoot single-use surgery ready intelligent delivery platform has been shown to effectively lower overall instrument tray cost per case by 74.25% in a highly efficient ASC. In addition, an 85.9% reduction in shelf space per tray was also seen comparing reprocessed instrumentation to sterile instrument kits. Pricing is variable per facility, and sterilization and usage processes vary1-6. However, we believe that sterile kits can be more cost effective than reprocessed sets. In addition, space can be saved with the use of sterile instrument kits adding to the established benefits of the delivery platform of procedure mapping and automatic restocking1-3.

Value-based Blended Learning Model for Strengthening Students’ Character

Value-based Blended Learning Model for Strengthening Students’ Character

Understanding consumer repurchase intentions towards luxury retail brands: Evidence from an emerging market

Prior studies have mostly concentrated on consumers' intentions to purchase luxury brands, and research on luxury consumers' repurchase intentions is limited. In this study, we identify the drivers of luxury repurchase intention using the Value-based Adoption Model and Expectation-Confirmation theory. Further, we examine the moderating role of gender and public vs private consumption patterns on the luxury brands' value dimensions. The study employed a mixed-methods approach comprising qualitative essays and focus group discussions (N = 62) followed by primary surveys of luxury consumers (N = 501). The data for the empirical study was collected through a questionnaire designed using established scales. Using structural equation modeling, the conceptual model was evaluated. The hypotheses developed concerning interplay of VAM and ECT were accepted. Three main predictors of the repurchase intention of luxury brands were perceived value, relationship quality and satisfaction. Also, most of the hypothesized perceived value dimensions (except sensory value and perceived cognitive effort) significantly influenced the overall perceived value. However, the moderating role of (gender and consumption value) was not observed in the relationship between the consumption value dimension and perceived value.

Commodity layout in supermarkets: using the integration of the comprehensive related value method and genetic algorithm

The existing shelf layout methods do not explicitly consider the attention and relevancy of the commodity systematically and thus have failed to capture the invalid associations, resulting in poor sales impact and customer satisfaction. For such shortcomings, in this paper, we propose a mathematical programming approach for shelf layout problems based on comprehensive related value. First, we introduce the concepts of related value considering both attention and relevancy; second, we give the concept of adjacent utility value and the freedom of placement, and further analyze the impact of the same commodity on surrounding commodities due to different placement positions; third, we establish a new comprehensive related value-based commodity layout optimization model (CRV-CL) and provide the solution steps integrating with a genetic algorithm. Finally, we analyze the characteristics of CRV-CL through a specific case. The simulation results indicate the overall relevancy after applying the CRV-CL model.

Standardized Protocol for Chest Tube Management for Trauma Patients Significantly Decreases Complications.

As health care shifts to a value-based model with a focus on patient outcomes per dollar spent, it is important to develop and evaluate standardized protocols that ultimately lead to improved patient outcomes and decreased hospital complications. Prior to our chest tube protocol, chest tube management at our Trauma Center was nonuniform and surgeon-specific. The aim of this study was to (1) develop an institutional standardized protocol for chest tube management at our Level II Trauma Center and (2) compare patient outcomes before and after the implementation of our protocol. An institutional, standardized protocol was initiated at our Level II-Certified Trauma Center teaching hospital in 2014. An IRB-approved, single-institution retrospective chart review was performed between January 2011 and May 2017, in order to capture the 3 years prior and 3 years after protocol implementation. All patients with a diagnosis of hemothorax or pneumothorax (H/PTX) from blunt or penetrating trauma that resulted in a >24 French chest tube placement were included in the study. Patients were excluded if interventional radiology (IR) placed the chest tube, the mechanism was nontraumatic, or the patient expired at index hospitalization. Univariate analyses were performed to evaluate significant differences in patient outcomes before and after the implementation of the protocol. A total of 143 patients were analyzed for this study, with 43 preprotocol patients and 100 postprotocol patients. Hospital length of stay (LOS), persistent H/PTX, and the need for further surgical intervention all improved after the implementation of the standardized protocol (p < 0.04). Our standardized protocol for chest tube management at our Level II Trauma Center significantly improved patient outcomes and can serve as a model for similar institutions.

Implications of immersive technologies in healthcare sector and its built environment.

This research focuses on how built environment experts can contribute to the MXR-enabled digital innovation as part of the multidisciplinary team effort to ensure post-pandemic resilience in healthcare built environment. The goal of this research is to help healthcare providers, built environment experts, and policy makers respectively: (1) Advocate the benefits of MXR for innovating health and social care; (2) Spark debate across networks of expertise to create health-promoting environment; and (3) Understand the overriding priorities in making effective pathways to the implementation of MXR. To highlight the novelty of this research, the study relies on two qualitative methodologies: exploratory literature review and semi-structured interviews. Based on the evaluation of prior works and cross-national case studies, hypotheses are formulated from three arenas: (1) Cross-sectional Initiatives for Post-pandemic Resilience; (2) Interoperability and Usability of Next-gen Medicines; and (3) Metaverse and New Forms of Value in Future Healthcare Ecosystems. To verify those hypotheses, empirical findings are derived from in-depth interviews with nine key informants. The main findings are summarized under the following three themes: (1) Synergism between Architecture and Technology; (2) Patient Empowerment and Staff Support; and (3) Scalable Health and Wellbeing in Non-hospital and Therapeutic Settings. Firstly, both built environment and healthcare sectors can benefit from the various capabilities of MXR through cross-sectional initiatives, evidence-based practices, and participatory approaches. Secondly, a confluence of knowledge and methods of HCI and HBI can increase the interoperability and usability of MXR for the patient-centered and value-based healthcare models. Thirdly, the MXR-enabled technological regime will largely affect the new forms of value in healthcare premises by fostering more decentralized, preventive, and therapeutic characteristics in the future healthcare ecosystems. Whether it's virtual or physical, our healthcare systems have placed great emphasis on the rigor of evidence-based approach linking health outcome to a clinical environment. Henceforth, built environment experts should seek closer ties with the MXR ecosystems for the co-production of scalable health and wellbeing in non-hospital and therapeutic settings. Ultimately, this is to improve resource efficiency in the healthcare sector while considering the transition of health resources towards in silico status by increasing the implementation of MXR.

Development and Internal Validation of an Emergency Department Admission Intensity Measure Using Data From a National Group.

We develop and assess variation in an emergency department (ED) admission intensity measure intended for value-based payment models. The measure includes ED diagnoses amenable to evidence-based protocols and where admission decisions vary based on physician discretion. Measure International Classification of Diseases (ICD)-10 codes were selected by face validity by 3 emergency physicians using expertise and administrative data. Feedback was sought from a separate technical panel. Using data from a national group (2018 to 2019), we assessed measure stability at the physician and facility level by quarter using descriptive plots, multilevel linear probability models, and intraclass correlation coefficients (ICC). A total of 535 ICD-10 measure codes were selected from 23,590 codes. Across 127 EDs, facility-quarter admission rates averaged 26.1% (95% confidence interval [CI] 24.5 to 27.7). Between- and within-facility standard deviations were 9.2 (95% CI 8.2 to 10.5) and 2.9 (95% CI 2.7 to 3.0), respectively, with an ICC of 0.91. Most ED-quarters (749/961) fell within 2.5% of their facility's average. Among 2,398 physicians, quarterly rates averaged 29.1% (95% CI 28.6 to 29.6). The between- and within-physician standard deviation was 6.3 (95% CI 6.1 to 6.5) and 5.3 (95% CI 5.3 to 5.4), respectively, with an ICC of 0.58; 220 physicians (9.2%) had an admission rate consistently higher than average and 193 (8.0%) consistently lower. This set of ICD-10 diagnoses demonstrates face validity and stability for quarterly admission rates at the facility and physician levels. The measure may be useful to monitor facility admission rates in value-based models and reliably identify high and low admitters within facilities to manage admission variation.

Tata Kelola Laut dan Pesisir Berbasis Kearifan Lokal Desa Lewomuda Kabupaten Flores Timur

Increased exploration of coastal and marine areas can damage the environment and threaten ecosystem sustainability. Renewal of governance based on local values is needed. The article seeks to introduce local values in the Letu Ai and Lara Lowa rituals while offering a local value-based governance model. This research is a descriptive qualitative research. Ritual analysis unravels local values: ecosystem harmonization; religiosity, social integration and the existence of customary institutions. Governance reform is directed at improving conservation points and systems; increasing ethical awareness in the form of environmental respect attitudes and behaviors; local government intervention to protect the existence of customary institutions, involving the active role of young people in maintaining ancestral heritage.