Impact of Provider Incentives on Quality and Value of Health Care

The use of financial incentives to improve quality in health care has become widespread. Yet evidence on the effectiveness of incentives suggests that they have generally had limited impact on the value of care and have not led to better patient outcomes. Lessons from social psychology and behavioral economics indicate that incentive programs in health care have not been effectively designed to achieve their intended impact. In the United States, Medicare's Hospital Readmission Reduction Program and Hospital Value- Based Purchasing Program, created under the Affordable Care Act (ACA), provide evidence on how variations in the design of incentive programs correspond with differences in effect. As financial incentives continue to be used as a tool to increase the value and quality of health care, improving the design of programs will be crucial to ensure their success. Expected final online publication date for the Annual Review of Public Health Volume 38 is March 20, 2017. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates

Expansion of Nature Conservation Areas: Problems with Natura 2000 Implementation in Poland?

In spite of widespread support from most member countries’ societies for European Union policy, including support for the sustainable development idea, in many EU countries the levels of acceptance of new environmental protection programmes have been and, in particular in new member states, still are considerably low. The experience of the countries which were the first to implement union directives show that they cannot be effectively applied without widespread public participation. The goal of this study was, using the example of Poland, to assess public acceptance of the expansion of nature conservation in the context of sustainable development principles and to discover whether existing nature governance should be modified when establishing new protected areas. The increase in protected areas in Poland has become a hotbed of numerous conflicts. In spite of the generally favourable attitudes to nature which Polish people generally have, Natura 2000 is perceived as an unnecessary additional conservation tool. Both local authorities and communities residing in the Natura areas think that the programme is a hindrance, rather than a help in the economic development of municipalities or regions, as was initially supposed. This lack of acceptance results from many factors, mainly social, historic and economic. The implications of these findings for current approach to the nature governance in Poland are discussed

Nitric oxide enhances salt secretion and Na+ sequestration in a mangrove plant, Avicennia marina, through increasing the expression of H+-ATPase and Na+/H+ antiporter under high salinity

Modulation of nitric oxide (NO) on ion homeostasis, by enhancing salt secretion in the salt glands and Na+ sequestration into the vacuoles, was investigated in a salt-secreting mangrove tree, Avicennia marina (Forsk.) Vierh. The major results are as follows: (i) under 400 mM NaCl treatment, the application of 100 mu M sodium nitroprusside (SNP), an NO donor, significantly increased the density of salt crystals and salt secretion rate of the leaves, along with maintaining a low Na+ to K+ ratio in the leaves. (ii) The measurement of element contents by X-ray microanalysis in the epidermis and transversal sections of A. marina leaves revealed that SNP (100 mu M) significantly increased the accumulation of Na+ in the epidermis and hypodermal cells, particularly the Na+ to K+ ratio in the salt glands, but no such effects were observed in the mesophyll cells. (iii) Using non-invasive micro-test technology (NMT), both long-term SNP (100 mu M) and transient SNP (30 mu M) treatments significantly increased net Na+ efflux in the salt glands. On the contrary, NO synthesis inhibitors and scavenger reversed the effects of NO on Na+ flux. These results indicate that NO enhanced salt secretion by increasing net Na+ efflux in the salt glands. (iv) Western blot analysis demonstrated that 100 mu M SNP stimulated protein expressions of plasma membrane (PM) H+-ATPase and vacuolar membrane Na+/H+ antiporter. (v) To further clarify the molecular mechanism of the effects of NO on enhancing salt secretion and Na+ sequestration, partial cDNA fragments of PM H+-ATPase (HA1), PM Na+/H+ antiporter (SOS1) and vacuolar Na+/H+ antiporter (NHX1) were isolated and transcriptional expression of HA1, SOS1, NHX1 and vacuolar H+-ATPase subunit c (VHA-c1) genes were analyzed using real-time quantitative polymerase chain reaction. The relative transcript abundance of the four genes were markedly increased in 100 mu M SNP-treated A. marina. Moreover, the increase was reversed by NO synthesis inhibitors and scavenger. Taken together, our results strongly suggest that NO functions as a signal in salt resistance of A. marina by enhancing salt secretion and Na+ sequestration, which depend on the increased expression of the H+-ATPase and Na+/H+ antiporter.Natural Science Foundation of China (NSFC) [30930076, 30770192, 30670317, 30271065, 39970438]; Foundation of the Chinese Ministry of Education [209084]; Xiamen University [NCETXMU X071l5]; Changjiang Scholarship [X09111

Epidemiology of surgery associated acute kidney injury (EPIS-AKI): a prospective international observational multi-center clinical study

Purpose: The incidence, patient features, risk factors and outcomes of surgery-associated postoperative acute kidney injury (PO-AKI) across different countries and health care systems is unclear. Methods: We conducted an international prospective, observational, multi-center study in 30 countries in patients undergoing major surgery (> 2-h duration and postoperative intensive care unit (ICU) or high dependency unit admission). The primary endpoint was the occurrence of PO-AKI within 72 h of surgery defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary endpoints included PO-AKI severity and duration, use of renal replacement therapy (RRT), mortality, and ICU and hospital length of stay. Results: We studied 10,568 patients and 1945 (18.4%) developed PO-AKI (1236 (63.5%) KDIGO stage 1500 (25.7%) KDIGO stage 2209 (10.7%) KDIGO stage 3). In 33.8% PO-AKI was persistent, and 170/1945 (8.7%) of patients with PO-AKI received RRT in the ICU. Patients with PO-AKI had greater ICU (6.3% vs. 0.7%) and hospital (8.6% vs. 1.4%) mortality, and longer ICU (median 2 (Q1-Q3, 1-3) days vs. 3 (Q1-Q3, 1-6) days) and hospital length of stay (median 14 (Q1-Q3, 9-24) days vs. 10 (Q1-Q3, 7-17) days). Risk factors for PO-AKI included older age, comorbidities (hypertension, diabetes, chronic kidney disease), type, duration and urgency of surgery as well as intraoperative vasopressors, and aminoglycosides administration. Conclusion: In a comprehensive multinational study, approximately one in five patients develop PO-AKI after major surgery. Increasing severity of PO-AKI is associated with a progressive increase in adverse outcomes. Our findings indicate that PO-AKI represents a significant burden for health care worldwide