Longitudinal evaluation of physician payment reform and team-based care for chronic disease management and prevention

Background:

We evaluated a large-scale transition of primary care physicians to blended capitation models and team-based care in Ontario, Canada, to understand the effect of each type of reform on the management and prevention of chronic disease.

Methods:

We used population-based administrative data to assess monitoring of diabetes mellitus and screening for cervical, breast and colorectal cancer among patients belonging to team-based capitation, non–team-based capitation or enhanced fee-for-service medical homes as of Mar. 31, 2011 (n = 10 675 480). We used Poisson regression models to examine these associations for 2011. We then used a fitted nonlinear model to compare changes in outcomes between 2001 and 2011 by type of medical home.

Results:

In 2011, patients in a team-based capitation setting were more likely than those in an enhanced fee-for-service setting to receive diabetes monitoring (39.7% v. 31.6%, adjusted relative risk [RR] 1.22, 95% confidence interval [CI] 1.18 to 1.25), mammography (76.6% v. 71.5%, adjusted RR 1.06, 95% CI 1.06 to 1.07) and colorectal cancer screening (63.0% v. 60.9%, adjusted RR 1.03, 95% CI 1.02 to 1.04). Over time, patients in medical homes with team-based capitation experienced the greatest improvement in diabetes monitoring (absolute difference in improvement 10.6% [95% CI 7.9% to 13.2%] compared with enhanced fee for service; 6.4% [95% CI 3.8% to 9.1%] compared with non–team-based capitation) and cervical cancer screening (absolute difference in improvement 7.0% [95% CI 5.5% to 8.5%] compared with enhanced fee for service; 5.3% [95% CI 3.8% to 6.8%] compared with non–team-based capitation). For breast and colorectal cancer screening, there were no significant differences in change over time between different types of medical homes.

Interpretation:

The shift to capitation payment and the addition of team-based care in Ontario were associated with moderate improvements in processes related to diabetes care, but the effects on cancer screening were less clear.Health care systems with a strong primary care orientation have better health outcomes, lower costs and fewer disparities across population subgroups.¹ Countries around the world have been experimenting with reforms to improve the delivery of primary care, changing the way physicians are organized and paid. In the United States, several national organizations^2,3 and policy experts^4,5 have advocated a shift away from fee for service toward capitation or blended payments, and in 2015, the Centers for Medicare and Medicaid Services brought in blended payment in primary care, introducing a non–visit-based payment for chronic care management.⁶Patient-centred medical homes have provided an opportunity to transition physicians to new payment models, but they also necessitate changes in care delivery, including incorporation of team-based care, enhancement of access for patients, coordination of care and a focus on quality and safety.^7–9 Evidence suggests that team-based care is a particularly important element in improving the management and prevention of chronic disease and reducing related costs.¹⁰ Early evaluations of patient-centred medical home pilots were promising,^11,12 but a recent study of large-scale implementation showed limited improvements in the quality of chronic disease care and no reduction in health care utilization or total costs over 3 years.¹³Before 2002, primary care physicians in Ontario, Canada, were almost universally paid through a fee-for-service system. Over the past decade, more than three-quarters have transitioned to patient-centred medical homes.^14,15 About half of Ontario physicians working in patient-centred medical homes have shifted to blended capitation payments, with a portion of these physicians working in groups that also receive government funding for nonphysician health professionals to enable team-based care. However, about 40% of physicians in patient-centred medical homes still receive most of their income through fee-for-service payments. This natural health policy experiment offers a unique opportunity to compare the effectiveness of different payment models and team-based care. Early studies have shown small differences in the quality of cardiovascular¹⁶ and diabetes mellitus¹⁷ care between physicians receiving capitation payments and those receiving fee-for-service payments, but no studies have assessed changes in quality of care over time.We evaluated a large-scale transition of primary care physicians to blended capitation models and team-based care to understand the effect of each type of reform on chronic disease management and prevention over time.     

Regional function-structure relationships in lungs of an elastase murine model of emphysema

Changes in lung function and structure were studied using hyperpolarized (3)He MRI in an elastase-induced murine model of emphysema. The combined analysis of the apparent diffusion coefficient (ADC) and fractional ventilation (R) were used to distinguish emphysematous changes and also to develop a model for classifying sections of the lung into diseased and normal. Twelve healthy male BALB/c mice (26 ± 2 g) were randomized into healthy and elastase-induced mice and studied ～8-11 wk after model induction. ADC and R were measured at a submillimeter planar resolution. Chord length (L(x)) data were analyzed from histology samples from the corresponding imaged slices. Logistic regression was applied to estimate the probability that an imaged pixel came from a diseased animal, and bootstrap methods (1,000 samples) were used to compare the regression results for the morphological and imaging results. Multivariate ANOVA (MANOVA) was used to analyze transformed ADC (ADC(BC)), and R (R(BC)) data and also to control for the experiment-wide error rate. MANOVA and ANOVA showed that elastase induced a statistically measureable change in the average transformed L(x) and ADC(BC) but not in the average R(BC). Marginal mean analysis demonstrated that ADC(BC) was on average 0.19 [95% confidence interval (CI): 0.16, 0.22] higher in the emphysema group, whereas R(BC) was on average 0.05 (95% CI: 0.04, 0.06) lower. Logistic regression supported the hypothesis that ADC(BC) and R(BC), together, were better at differentiating normal from diseased tissue than either measurement alone. The odds ratios for ADC(BC) and R(BC) were 7.73 (95% CI: 5.23, 11.42) and 9.14 × 10(-5) (95% CI: 3.33 × 10(-5), 25.06 × 10(-5)), respectively. Using a 50% probability cutoff, this model classified 70.6% of pixels correctly. The sensitivity and specificity of this model at the 50% cutoff were 74.9% and 65.2%, respectively. The area under the receiver operating characteristic curve was 0.76 (95% CI: 0.74, 0.78). The regression model presented can be used to map MRI data to disease probability maps. These probability maps present a future possibility of using both measurements in a more clinically feasible method of diagnosing this disease.     

Current therapies for the soluble lysosomal forms of neuronal ceroid lipofuscinosis

The NCLs (neuronal ceroid lipofuscinoses) are the most common inherited paediatric neurodegenerative disorder. Although genetically distinct, NCLs can be broadly divided into two categories: one in which the mutation results in a defect in a transmembrane protein, and the other where the defect lies in a soluble lysosomal enzyme. A number of therapeutic approaches are applicable to the soluble lysosomal forms of NCL based on the phenomenon of cross-correction, whereby the ubiquitously expressed mannose 6-phosphate/IGF (insulin-like growth factor) II receptor provides an avenue for endocytosis, trafficking and lysosomal processing of extracellularly delivered enzyme. The present review discusses therapeutic utilization of cross-correction by enzyme-replacement therapy, gene therapy and stem cell therapy for the NCLs, along with an overview of the recent progress in translating these treatments into the clinic.     

Control of energy production in the heart: a new function for fatty acid binding protein

The quantitative subcellular distribution of the fatty acid binding protein (FABP) in heart muscle is reported for the first time. A gradient-like distribution according to the following pattern was observed: 6.96 mg X mL-1 on the myofibrils, 2.77 mg X mL-1 in the spaces surrounding the mitochondria, and 2.21 mg X mL-1 in the mitochondria. This heterogeneous distribution suggests that the local in vivo concentration of FABP might fluctuate as a function of time. The consequences of these possible fluctuations, particularly in the mitochondrial vicinity, were analyzed in an in vitro system containing a fixed concentration of cardiac mitochondria and stearic acid but variable concentrations of FABP. Competition for the fatty acid was observed between the mitochondrial membranes and the binding sites on the protein. Maximal binding of fatty acid to FABP was detected in the range of FABP concentration between 1 and 3 mg X mL-1. Remarkably, in this concentration range, two emerging peaks of beta-oxidative activity were also detected. As a major conclusion, it appears that the fatty acid pool, bound to FABP, is the source of fatty acid providing the beta-oxidative system with substrate. The mechanism of fatty acid transfer from this pool toward the beta-oxidative system remains an open question. However, it is suggested that a gradient-like distribution of FABP in the mitochondrial vicinity leads to the coexistence of multispecies of the protein by self-aggregation. Only two of these species seem to be involved in this fatty acid transfer. As a consequence, a strong modulation of fatty acid beta-oxidation rate is observed in isolated mitochondria when the concentrations of these two species are allowed to fluctuate. In conclusion, this unique cardiac fatty acid carrier, via its self-aggregation capacity and its in vivo gradient-like distribution, may act as a powerful effector in the regulation of heart energy.     

Gα and Gβ Proteins Regulate the Cyclic AMP Pathway That Is Required for Development and Pathogenicity of the Phytopathogen Mycosphaerella graminicola

We identified and functionally characterized genes encoding three Gα proteins and one Gβ protein in the dimorphic fungal wheat pathogen Mycosphaerella graminicola, which we designated MgGpa1, MgGpa2, MgGpa3, and MgGpb1, respectively. Sequence comparisons and phylogenetic analyses showed that MgGPA1 and MgGPA3 are most related to the mammalian Gα_i and Gα_s families, respectively, whereas MgGPA2 is not related to either of these families. On potato dextrose agar (PDA) and in yeast glucose broth (YGB), MgGpa1 mutants produced significantly longer spores than those of the wild type (WT), and these developed into unique fluffy mycelia in the latter medium, indicating that this gene negatively controls filamentation. MgGpa3 mutants showed more pronounced yeast-like growth accompanied with hampered filamentation and secreted a dark-brown pigment into YGB. Germ tubes emerging from spores of MgGpb1 mutants were wavy on water agar and showed a nested type of growth on PDA that was due to hampered filamentation, numerous cell fusions, and increased anastomosis. Intracellular cyclic AMP (cAMP) levels of MgGpb1 and MgGpa3 mutants were decreased, indicating that both genes positively regulate the cAMP pathway, which was confirmed because the WT phenotype was restored by adding cAMP to these mutant cultures. The cAMP levels in MgGpa1 mutants and the WT were not significantly different, suggesting that this gene might be dispensable for cAMP regulation. In planta assays showed that mutants of MgGpa1, MgGpa3, and MgGpb1 are strongly reduced in pathogenicity. We concluded that the heterotrimeric G proteins encoded by MgGpa3 and MgGpb1 regulate the cAMP pathway that is required for development and pathogenicity in M. graminicola.Signal transduction pathways are important for sensing and responding to different environmental stimuli in both lower and higher eukaryotes. The highly conserved heterotrimeric guanine nucleotide-binding proteins (G proteins) belong to a family of regulatory proteins that are crucial for the transduction of signals, which are perceived by a distinct family of cell surface receptors (4). Heterotrimeric G proteins contain three subunits (α, β, and γ) that are linked in the inactive state. Activation of a Gα subunit by a transmembrane receptor leads to exchange of bound GDP with GTP on the Gα subunit, resulting in dissociation of the Gα and the Gβγ dimeric subunits, which can now interact with downstream effectors that subsequently generate changes in cellular responses (for a review, see reference 10).Filamentous fungi have one Gβ- and usually three Gα-encoding genes that belong to three major groups. Encoded proteins in groups I and III are related to the mammalian Gα_i and Gα_s families, respectively, but group II fungal Gα proteins have no mammalian counterpart (1, 4, 14, 22, 33, 53). Interestingly, the corn smut fungus Ustilago maydis contains a unique fourth Gα-encoding gene, and Saccharomyces cerevisiae contains only two Gα proteins (10, 57). Irrespective of the observed numerical variation, Gα proteins regulate a variety of cellular and developmental responses (4). For plant-pathogenic fungi, Gβ-encoding genes have been characterized functionally (9, 14, 22, 27, 31, 48, 52). Apart from the fact that individual Gα-encoding genes and the Gβ-encoding gene have been demonstrated to regulate growth, reproduction, and virulence, comparative functional characterization of all Gα-encoding genes has been reported only for a few plant-pathogenic fungi, including Magnaporthe grisea, Cryphonectria parasitica, and U. maydis (5, 41, 57).Mycosphaerella graminicola (anamorph Septoria tritici) causes septoria tritici blotch disease in bread and durum wheat in areas with high rainfall during the growing season, particularly in Western Europe, where it is considered to be the most important wheat disease (30). It is a ubiquitous phytopathogen with a lifestyle completely different from that of the aforementioned plant-pathogenic fungi. It is a dimorphic pathogen, and therefore the transition from a yeast-like to a filamentous form is important for initiation of infection (45). M. graminicola does not form appressoria but penetrates the leaves through stomata without forming specific infection structures. Furthermore, as a hemibiotroph, it has a biotrophic phase of about 10 days that is followed by a rapid switch to necrotrophy. The necrotic foliar lesions bear anamorphic and teleomorphic fructifications. M. graminicola is the model fungus for the Mycosphaerellaceae and even for the order Dothideales, an extremely large and diverse class of fungi with over 1,000 named species, including major plant pathogens such as the banana leaf streak fungus Mycosphaerella fijiensis (12, 21). Large expressed sequence tag (EST) libraries and the recently released genome sequence have been instrumental for the identification and characterization of genes involved in the development and pathogenicity of M. graminicola (http://genome.jgi-psf.org/Mycgr3/Mycgr3.home.html). Recently, we reported that genes encoding mitogen-activated protein kinases (MAPKs) (MgFus3, MgSlt2, and MgHog1) and the catalytic (MgTpk2) and regulatory (MgBcy1) subunits of protein kinase A (PKA) are essential pathogenicity factors and regulate specific steps during the infection process (8, 43-45). To extend our knowledge about the role of G proteins in the development and pathogenicity of M. graminicola, we functionally analyzed three Gα-encoding genes and one Gβ-encoding gene of M. graminicola, which we designated MgGpa1, MgGpa2, MgGpa3, and MgGpb1, respectively. Our results show the requirement of MgGpa1, MgGpa3, and MgGpb1 for pathogenicity, whereas the latter also negatively regulates cell fusion and anastomosis. Among the G protein-encoding genes characterized in this study, MgGpa3 and MgGpb1 positively regulate the cyclic AMP (cAMP) pathway. MgGpa1 seems to be dispensable for cAMP regulation, whereas MgGpa2 appears to be redundant, for none of the assays rendered altered phenotypes. Our results open new perspectives for studying the regulatory machinery of the cAMP pathway in M. graminicola and other plant-pathogenic fungi.     

Extracellular Matrix Lumican Deposited on the Surface of Neutrophils Promotes Migration by Binding to ��2 Integrin

During inflammation, circulating polymorphonuclear neutrophils (PMNs) receive signals to cross the endothelial barrier and migrate through the extracellular matrix (ECM) to reach the injured site. Migration requires complex and poorly understood interactions of chemokines, chemokine receptors, ECM molecules, integrins, and other receptors. Here we show that the ECM protein lumican regulates PMN migration through interactions with specific integrin receptors. Lumican-deficient (Lum^−/−) mice manifest connective tissue defects, impaired innate immune response, and poor wound healing with reduced PMN infiltration. Lum^−/− PMNs exhibit poor chemotactic migration that is restored with exogenous recombinant lumican and inhibited by anti-lumican antibody, confirming a role for lumican in PMN migration. Treatment of PMNs with antibodies that block β₂, β₁, and α_M integrin subunits inhibits lumican-mediated migration. Furthermore, immunohistochemical and biochemical approaches indicate binding of lumican to β₂, α_M, and α_L integrin subunits. Thus, lumican may regulate PMN migration mediated by MAC-1 (α_M/β₂) and LFA-1 (α_L/β₂), the two major PMN surface integrins. We detected lumican on the surface of peritoneal PMNs and not bone marrow or peripheral blood PMNs. This suggests that PMNs must acquire lumican during or after crossing the endothelial barrier as they exit circulation. We also found that peritoneal PMNs do not express lumican, whereas endothelial cells do. Taken together these observations suggest a novel endothelial lumican-mediated paracrine regulation of neutrophils early on in their migration path.Polymorphonuclear neutrophils (PMNs)³ play a major role in the development of inflammatory responses to host injury and infection. Their functions include destruction of invading bacteria and recruitment of macrophages and lymphocytes to the affected site (1). Circulating PMNs sense injury and pathogen signals, cross the vascular endothelium, and migrate to the target tissue; two series of events control this process. The first leads to the slowing down and adherence of circulating PMNs on the vascular endothelium followed by their transendothelial migration or extravasation and activation (2). The second controls the directional migration of PMNs to the injured site through the endothelial basement membrane, a specialized type of ECM, and subsequently the deeper interstitial ECM, along chemokine and cytokine gradients. Leukocyte-to-leukocyte and leukocyte-to-endothelium interactions are important before extravasation. These are mediated by interactions between selectins and their ligands and by β₂ (MAC-1 and LFA-1) and β₁ (VLA-4–6) integrin interactions with cell adhesion proteins ICAM and PECAM (3). The directional migration of PMNs through the ECM is a complex, multistep process that involves several α and β integrin interactions with ECM proteins. Thus far, a few basement membrane proteins, laminins, entactin, and fibronectin have been identified as specific ligands in regulating migration of PMNs after extravasation (4–6). Additional interstitial ECM proteins and their receptors that modulate PMN migration have yet to be identified. Here we show that the ECM protein lumican is a novel regulator of PMN migration.Lumican is a secreted collagen-binding ECM protein of the corneal, dermal, and tendon stroma, arterial wall, and the intestinal submucosa (7–9). It is a member of the small leucine-rich repeat proteoglycans (10); these were initially investigated in the context of binding collagen and regulating tissue structure and biomechanics (11, 12). A body of literature is beginning to indicate that these proteoglycans interact with cytokines, growth factors, and cell surface receptors to modulate cell adhesion, proliferation, and migration (13–16). Lumican and biglycan, another member of this family of proteoglycans, have been recently shown to regulate host response to pathogen-associated molecular patterns (17, 18). Thus, lumican-deficient (Lum^−/−) mice are hyporesponsive to bacterial lipopolysaccharide (LPS) endotoxins, and Lum^−/− macrophages in culture produce lower levels of pro-inflammatory cytokines in response to LPS (18). Lumican facilitates innate immune response by binding LPS and CD14, the glycerol phosphatidylinositol-linked cell surface adaptor protein that transfers the LPS signal to toll-like receptor 4 (18). In a corneal injury model neutrophil influx is delayed in the Lum^−/− mice (19, 20). Although this may be partly due to impaired innate immune response, it raises the possibility that lumican may have an additional role in neutrophil migration. Here we elucidate a role for lumican in PMN migration. We show that poor chemotactic migration of Lum^−/− PMNs can be rescued by exogenous recombinant lumican (rLum) and blocked specifically with antibodies against lumican, β₂, β₁, and α_M integrins. Our results also show that lumican localizes on the surface of extravasated PMNs through its interactions with β₂ integrins. The likely source of lumican on neutrophils is the vascular endothelium.     

Comparative plastome analysis of Blumea,with implications for genome evolution and phylogeny of Asteroideae

The genus Blumea (Asteroideae, Asteraceae) comprises about 100 species, including herbs, shrubs, and small trees. Previous studies have been unable to resolve taxonomic issues and the phylogeny of the genus Blumea due to the low polymorphism of molecular markers. Therefore, suitable polymorphic regions need to be identified. Here, we de novo assembled plastomes of the three Blumea species B. oxyodonta, B. tenella, and B. balsamifera and compared them with 26 other species of Asteroideae after correction of annotations. These species have quadripartite plastomes with similar gene content, genome organization, and inverted repeat contraction and expansion comprising 113 genes, including 80 protein‐coding, 29 transfer RNA, and 4 ribosomal RNA genes. The comparative analysis of codon usage, amino acid frequency, microsatellite repeats, oligonucleotide repeats, and transition and transversion substitutions has revealed high resemblance among the newly assembled species of Blumea. We identified 10 highly polymorphic regions with nucleotide diversity above 0.02, including rps16‐trnQ, ycf1, ndhF‐rpl32, petN‐psbM, and rpl32‐trnL, and they may be suitable for the development of robust, authentic, and cost‐effective markers for barcoding and inference of the phylogeny of the genus Blumea. Among these highly polymorphic regions, five regions also co‐occurred with oligonucleotide repeats and support use of repeats as a proxy for the identification of polymorphic loci. The phylogenetic analysis revealed a close relationship between Blumea and Pluchea within the tribe Inuleae. At tribe level, our phylogeny supports a sister relationship between Astereae and Anthemideae rooted as Gnaphalieae, Calenduleae, and Senecioneae. These results are contradictory to recent studies which reported a sister relationship between “Senecioneae and Anthemideae” and “Astereae and Gnaphalieae” or a sister relationship between Astereae and Gnaphalieae rooted as Calenduleae, Anthemideae, and then Senecioneae using nuclear genome sequences. The conflicting phylogenetic signals observed at the tribal level between plastidt and nuclear genome data require further investigation.     

Generation and analysis of expressed sequence tags from the mangrove plant, Acanthus ebracteatus Vahl

Salinity is a major abiotic stress that greatly affects plant growth and crop production. Sodium ions in saline soil are toxic to plants because of their adverse effects on potassium nutrition, cytosolic enzyme activities, photosynthesis, and metabolism. It is important to identify genes involved in salinity tolerance from mangrove plants that survive under saline conditions. In this study, a total of 864 randomly selected cDNA clones were isolated and sequenced from the primary cDNA library of Acanthus ebracteatus. Among the 521 readable sequences, 138 of them were assembled into 43 contigs, whereas 383 were singletons. Sequence analyses demonstrated that 349 of these expressed sequence tags showed significant homology to functional proteins, of which 18% are particularly interesting as they correspond to genes involved in stress response. Some of these clones, including putative mannitol dehydrogenase, plastidic aldolase, secretory peroxidase, ascorbate peroxidase, and vacuolar H⁺-ATPase, may be related to osmotic homeostasis, ionic homeostasis, and detoxification.