Unmet social needs negatively affect individual and population health, and better integration of community-based supports and health systems is a promising approach to improve health outcomes and avoid unnecessary health care use. Community-based organizations (CBOs) such as Area Agencies on Aging (AAAs) and Centers for Independent Living (CILs), as providers and coordinators of social services, are well-positioned within their communities to coordinate care and provide for unmet social needs. Partnerships between CBOs and health care entities have clear potential to improve health care outcomes while also reducing expenditures. This paper will present a cross-sectional analysis of a national survey of AAAs, CILS, and other CBOs at two time points  to understand the extent, type, and evolution of CBO engagement with health care providers. In addition, longitudinal analysis (n=374) shows movement at the organization level: 33% of organizations who did not have a contract at T1 but were pursuing one had achieved a contract by T2. This presentation will: describe details of the services delivered, contracting arrangements, and populations served under CBO/health care contracts, as well as challenges experienced by CBOs; examine differences by state and organizational structure; and discuss the implications of state policy on integrated care and contracting.


Mobile health and mobile rehabilitation  services and technologies have attracted considerable interest from healthcare providers, technology vendors, rehabilitation engineers, investors and policy makers in recent years. Successful adoption and use of mHealth/mRehab requires clinician support and engagement, including the ability to identify appropriate use cases and possible barriers to use for themselves and their patients, and acquire adequate knowledge and confidence using mHealth/mRehab interventions. This article reports results from a survey of rehabilitation clinicians in the United States on their attitudes, experience, expectations and concerns regarding mHealth/mRehab interventions and technologies. Over 500 clinicians in physical, occupational, speech, recreation and psychological therapy professions, among others, participated in the survey. Respondents reported that an overwhelming majority of their patients need additional therapy after discharge from inpatient environments, and over half of outpatients need additional therapy between visits. A large majority reported prescribing specific exercises and interventions for patients to work on outside of the clinic. However, only 51% reported being comfortable integrating mRehab technology into their practice; and only 23% feel knowledgeable about rehabilitation technology currently available. Technologies to support mRehab are maturing rapidly. Clinicians recognize the need for mRehab, but their knowledge and confidence prescribing mRehab represents a significant barrier to adoption. Technologies that have transformed education, entertainment and business are now reaching the level of maturity needed to support robust, remote mobile healthcare. As we leverage technology in all facets of our lives, we are now witnessing how the utilization of smart phones, wearable devices, apps and sensors, smart home hubs for automation/control, environmental sensors, cloud computing, and high-speed networks are vastly expanding the foundation for effective mobile care. The term mobile health , is widely understood to refer to the delivery of health care services via mobile communication devices. The Research Plan on Rehabilitation published by the United States National Institute of Health notes that “…mHealth is becoming a significant part of the healthcare … economy. … the use of ICT [Information and Communication Technology] can broaden rehabilitation and healthcare research opportunities for researchers and service opportunities for patients” .A more recent term is mobile rehabilitation (mRehab), which refers to the delivery of rehabilitation services using mobile ICT . The curAlthough potentially game-changing in providing greater access to affordable rehabilitation services, digital health applications for both mHealth and mRehab remain limited by narrow functionality , uncertaPotential barriers to acceptance of mRehab by clinicians include lack of familiarity with technology, complexity and time requirements for use of the technology, practice needed to become proficient, changes required in clinical workflow to incorporate the approach, and the need for practice standards and evidence of effectiveness to govern and justify use of the approach ,14,15.To gain a better understanding of potential barriers and facilitators that may influence adoption of mRehab tools and strategies from the clinical perspective, we conducted a survey of professionals in physical medicine and rehabilitation fields. This article presents findings from this preliminary survey and suggest directions for future work to address barriers identified by survey respondents.With input from our clinician advisors and informed by a review of the available literature on barriers to adoption of digital health interventions, we developed and refined the mRehab survey questionnaire see , consistParticipants were recruited through the researchers’ personal networks at Shepherd Center, Duke University Medical Center, the American Congress of Rehabilitation Medicine, American Physical Therapy Association, American Occupational Therapy Association, American Speech-Hearing Association, and others. Data were collected in January and February 2019 using convenience sampling methods and online data collection on the Survey Monkey web-based platform. Although no protected health information (PHI) was collected in this survey, the Survey Monkey platform does meet the privacy and security requirements of the United States Health Insurance Portability and Accountability Act of 1996 (HIPAA), which establishes essential policies and practices for protecting patient health information from unnecessary and unauthorized access. Efforts were made to ensure that relative balance in the number of respondents among the 4 core clinical therapy professions  by creating unique “collectors” in Survey Monkey and setting limits on the number of respondents to each. A small incentive—a $5.00 Starbucks gift card sent electronically—was offered to respondents to encourage higher levels of completeness in survey responses. The Research Review Committee at Shepherd Center reviewed and approved this research to ensure protection of participants.Response data were analyzed using SPSS version 22 . A total of 505 rehabilitation clinicians across multiple specialties, including physical, occupational, speech therapy and recreation therapy, as well as psychology and other professions, completed the questionnaire . About hMany respondents reported treating multiple patient populations including those with acquired brain injury (ABI), neurodegenerative diseases (NDD), musculoskeletal injury/disorder, cardiovascular disease (CVD), cancer, spinal cord injury (SCI) and other conditions .Similarly, many respondents reported working in multiple clinical environments, including inpatient and outpatient environments, as well as skilled nursing facility, home health and other environments .Respondents reported that more than 70% of their patients need additional therapy after discharge and more than 55% need additional therapy between visits to outpatient programs . The medAlmost all clinicians recognized the potential of mRehab—over 95% indicated mRehab interventions could be effective in supporting post-acute and between-visits therapy interventions for their patients. Over 70% of respondents reported prescribing specific exercises and interventions to their patients to work on outside of the clinic .Despite the perceived need for mRehab interventions, only about half of respondents (51%) reported being comfortable integrating mRehab into their practice and less than a quarter (23%) believe they are knowledgeable about rehabilitation technologies that could be used in their clinical specialty or for their patient populations .The age of respondents was examined as a possible determinant of comfort integrating mRehab into practice and perceived knowledge of available mRehab solutions. Older respondents might be expected to be less comfortable integrating mRehab into practice and less knowledgeable about available technologies. Age was shown not to be a determinant of comfort integrating mRehab into practice or knowledge of mRehab technology. Crosstab analysis using gamma, resulted in very weak relationships between age and comfort, and age and knowledge (gamma coefficients of 0.016 and 0.036) with insignificant p-values .Length of professional service was also examined as a possible determinant of a comfort integrating mRehab into practice and perceived knowledge of available mRehab solutions. Longer time in the profession might cause a clinician to be less likely to deviate from established practice. Crosstab analysis produced gamma coefficients of the strength of the relationship between length of professional service and comfort integrating mRehab into practice (0.051) and perceived knowledge (0.022), with insignificant p-values . Respondents were asked to identify the top three barriers to adoption of mRehab technology into practice. We also asked respondents to select their top three most important use cases for mRehab. We also gave the option of adding an “other” use case. Other use cases identified by respondents included: improving patient engagement and ownership of outcomes (4), improving access to therapy (2), medication management (1), mental health interventions (2), improving compliance especially with seating/positioning and pressure ulcer management (1), and providing data to secure or support funding for therapy.Finally, our survey revealed an already robust rate of adoption of online therapy management platforms by survey respondents. Over 12% respondents are already using a coaching or therapy management platform. Reported uses include patient education (9%), progress tracking (7%), sending reminders, “nudges” (6%) and motivational (5%) messages, care management (4%), assistance with goal setting (3%), and voice or video communication (3%).The growth of technologies to support mHealth and mRehab is both a result and a cause of increasing interest by policymakers, healthcare providers, and patients themselves. Healthcare costs in the United States continue to rise at rates substantially faster than inflation  . This wiThe survey data presented here indicate recognition of considerable need for mRehab technologies and broad acceptance by rehabilitation professionals. Overall, clinicians across all specialties reported that most of their patients need additional therapy after in-patient discharge or between outpatient visits. However, compared to the other professions, medical professionals reported their patients needed the least additional therapy. Physical therapists, occupational therapist, and the speech language pathologists overall indicated that their patients needed somewhat more therapy post-discharge or between outpatient visits. Recreational therapists and mental health professionals reported that their patients needing the most additional therapy. These results may reflect the duties and obligations of the several professions to the patient: medical professionals focus on stabilizing patients in the short term; physical, occupational and speech therapists are dedicated to building strength and skills over a more extended period (weeks or months); and recreation therapists and mental health professionals focus on life-long health, fitness and wellness. Longer time horizons might increase the likelihood that the intervention or therapy will benefit if also practiced in the patient home or community.The two most critical use cases for mRehab interventions and technologies identified by respondents were: 1) supporting patient functioning at home and in the community; and 2) and patient adherence to prescribed exercises and activities. Both use cases were cited by 69% of respondents.Survey respondents also identified substantial barriers to their ability to adopt and implement new mRehab technologies. Two key barriers are: 1) low levels of comfort integrating mRehab into practice and 2) perceived lack of knowledge of available mRehab solutions. Almost half of the respondents reported not feeling comfortable integrating mRehab technologies into their practice, and a large majority (78%) reporting not being knowledgeable about the needed technologies. Additionally, respondents identified the inability of patients to learn and correctly use mRehab technology as the top barrier to adoption and use (cited by 72%).These responses suggest considerable uncertainty due to lack of knowledge of available technologies and insufficient training (for both clinicians and patients) in their use. Additionally, clinicians may need information and guidance to evaluate emerging technologies and understand how technology-based interventions can be incorporated into practice. This uncertainty and need for guidance will likely increase as the pace of development continue accelerate. Education and guidance for patients on proper use of prescribed technologies will also be an ongoing need, placing an additional requirement on clinicians—learning how to train patients in effective use of these innovative technologies.The degree of support or hesitance to utilize mHealth/mRehab interventions and technologies among clinicians in rehabilitation specialties might partly be explained by how international and US-based professional organizations have addressed the opportunities and concerns. The World Health Organization (WHO) views “digital health” solutions as a key tool to strengthen national health systems in order to support the goal of Universal Health Coverage (UHC). According to the WHO: “Digital technologies provide concrete opportunities to tackle health system challenges, and thereby offer the potential to enhance the coverage and quality of health practices and services” .This view is reflected in the World Federation of Occupational Therapists (WFTO), whose Statement of Position on states: “Telehealth is an appropriate delivery model for occupational therapy services when in-person services are not possible, practical, or optimal for delivering care and/or when service delivery via telehealth is mutually acceptable to the client and provider” . In the The caution identified by clinicians responding to our survey might also be reflected in the official positions of these organizations, which emphasize the need to ensure that the intervention and the technology is appropriate to patient needs, competency and context. The WFTO states the concern concisely: “… therapy services via telehealth should be appropriate to the individuals, groups and cultures served, and contextualized to the occupations and interests of clients.” The American Speech-Hearing-Language Association (ASHA) provides a detailed lists of things which need to be considered before adopting or participating in “telepractice”, including: patient privacy, ethical considerations , licensure, reimbursement from insurance plans for services, client selection, and environmental considerations. These types of concerns might partly explain why almost half of the survey sample reported low levels of comfort integrating mRehab technologies into their practice.Additionally, the Technology Acceptance Model (TAM) might partly explain the degree of readiness of rehabilitation clinicians to integrate mRehab interventions into their practice. The model posits that perceived usefulness (PU) and perceived ease of use (PEOU) are the two main factors that influence whether an individual will accept new technology . Each ofLimitations of this research center on the convenience sampling method, which is commonly used when sampling a population that can be difficult to reach. This sampling method requires caution in generalizing results from the sample to the larger population due to potential biases. Despite these limitations, convenience sampling can be effective for exploratory and discovery research to uncover substantive aspects of the research focus and to identify possible trends. Additionally, the present study did not investigate the role of clinician training via their professional organizations, nor the impact of perceived usefulness and ease of use on adoption of mRehab interventions and technology into clinical practice. The questionnaire constitutes only an initial investigation into clinician’s perceptions of opportunities and barriers to using mRehab interventions. As the field of mRehab and supporting technologies continue to mature, these will be critical areas of inquiry. The technologies needed to support mRehab have been maturing at a rapid pace. Meanwhile, clinicians almost universally recognize that many of their patients leave their clinic with unmet rehabilitation needs that could be met outside the clinic. Together these trends suggest accelerating adoption of mRehab technologies. However, obstacles remain. The potential benefit is recognized, but providers need additional knowledge and support to comfortably incorporate these approaches into practice, understandable given the emerging state of the field. Survey findings suggest that more systematic effort is needed to support clinicians’ successful adoption of emerging and highly promising mRehab solutions.


VA offers multiple programs and services to support caregivers of US military Veterans. However, access for rural Veterans and caregivers is challenging due to distance from VA medical facilities. VA Video Connect (VVC) is a remote healthcare platform that enables Veterans to connect directly with VA clinicians through a secure, encrypted video connection. Rural caregivers and Veterans can participate in caregiver services through their own computer or another device from their home, reducing the need for travel to distant VA facilities. In 2018, VA’s Caregiver Support Program and Office of Rural Health developed an implementation pilot to engage eighteen VA Caregiver Support Coordinators (CSCs) in using VVC to monitor and support 180 Veteran/caregiver dyads enrolled in VA’s Program of Comprehensive Assistance for Family Caregivers. The presentation will provide an overview of each phase of implementation, report usability and outcome data from CSCs and caregivers, and discuss implications for broader implementation.


This study sought to assess whether changes in depressive symptoms, general health, and area-level socio-economic status (SES) were associated to changes over time in waist circumference and body mass index (BMI).A total of 2871 adults (18 years or older), living in Adelaide , were observed across three waves of data collection spanning ten years, with clinical measures of waist circumference, height and weight. Participants completed the Centre for Epidemiologic Studies Depression (CES-D) and Short Form 36 health questionnaires . An area-level SES measure, relative location factor, was derived from hedonic regression models using residential property features but blind to location. Growth curve models with latent variables were fitted to data.Waist circumference, BMI and depressive symptoms increased over time. General health and relative location factor decreased. Worsening general health and depressive symptoms predicted worsening waist circumference and BMI trajectories in covariate-adjusted models. Diminishing relative location factor was negatively associated with waist circumference and BMI trajectories in unadjusted models only.Worsening depressive symptoms and general health predict increasing adiposity and suggest the development of unhealthful adiposity might be prevented by attention to negative changes in mental health and overall general health. Waist cII); slope regressed on intercept (βSI); slope regressed on slope (βSS); standard error (SE)). Increasing (worsening) depression was associated with increases in both waist circumference and BMI . Changes in general health and relative location factor were both inversely associated with change in waist circumference  and change in BMI  was associated with increasing waist circumference and BMI. Similarly, worsening relative location factor was associated with increasing waist circumference and BMI.Unadjusted relationships between waist circumference, BMI, depression, general health and relative location factor trajectories are given in Although not the focus of the study, the potential bidirectionality of associations suggested by the literature was supported by the results provided in Results of the fully adjusted growth curve models  and residential built environment features) are presented in Regarding longitudinal relationships in the fully adjusted models, baseline values for depression, general health and the relative location factor were not significantly associated with changes in waist circumference or BMI. However, increasing depression and worsening general health were each statistically significantly associated with increases in waist circumference  and BMI . The decrease in the relative location factor values was not significantly associated with changes in waist circumference or in BMI.Among area and individual level covariates: index of relative socioeconomic disadvantage was statistically significantly inversely associated with baseline values of waist circumference and BMI trajectories; age was directly associated with baseline waist circumference and BMI but inversely related to change in the outcomes over time; similarly, sex  was directly related to baseline waist circumference but inversely associated with change in waist circumference, though at borderline significance (p<0.10) in the waist circumference model including depression; sex was directly associated with baseline BMI only in models including depression, and inversely associated with change in outcomes over time, at p<0.10 for the model involving general health; education (low compared to high) was directly related to baseline waist circumference and BMI, at p<0.10 in the BMI model including general health; and lastly, being a smoker was associated with baseline outcome measures (inverse associations) and change in outcomes over time (positive associations).2, CFI and TLI, RMSEA, SRMR) [Fully adjusted waist circumference and BMI latent growth models were more parsimonious , compared to corresponding intercept-only models in which only the means (intercept and covariates), variances (intercept and covariates) and residual variances are free parameters. Conventional fit indices for SEM  , 60 haveA, SRMR) .This study assessed the independent associations between baseline status and change in depression, general health and relative location factor, and change in waist circumference and BMI, accounting for individual and area level covariates. For our population of predominantly middle-aged adults in Adelaide, we conclude that 1) worsening depressive symptomology is related to increases in waist circumference and BMI, 2) worse baseline general health is associated with greater waist circumference but not BMI at baseline, and worsening general health is related to increases in waist circumference and BMI, and 3) neither baseline status nor change in a resident-specific expression of area-level SES were statistically related to baseline status and change in either waist circumference or BMI, whilst a traditional measure of area-level SES, expressed only at baseline, was inversely related to baseline waist circumference and BMI but not to changes in these measures over time.Our findings on associations between depression and anthropometric measures of adiposity align with the results from previous work in this area , 62, 63.Significant inverse associations between health-related quality of life and BMI have similarly been highlighted elsewhere. Cameron et al. indicated a bi-directional association, although in their study, baseline scores of one variable were used to predict changes over time in scores of the other variable and vice versa . In otheOur findings of negative effects of both area-level SES measures (relative location factor and index of relative socioeconomic disadvantage) on BMI and waist circumference at baseline (inverse relationships or associations), although non-significant for relative location factor in adjusted models, are to some extent consistent with previous literature –29, 66.Both relative location factor measures (baseline and rate of change), were significantly inversely associated with both BMI and waist circumference trajectories in unadjusted models, but the associations became non-significant in adjusted models. These findings align with what other studies reported. In two cross-sectional studies, using residential property values, Drewnowski et al. found an inverse association with BMI values among women , and witIn our study, the index of relative socioeconomic disadvantage, commonly used measure of area-level SES in Australia, had significant negative associations with baseline values but not rates of change for both BMI and waist circumference (non-significant inverse relationships). This is inconsistent with some study findings reported for BMI and for central adiposity. Indeed, Berry et al.  found thOther studies reported findings consistent with ours, although based on the prevalence of obesity and weight gain. Indeed, Drewnowski et al. , 68 repoFeatures of physical and social environments have been linked to general health and mental health  which are, in turn, linked to overweight/obesity and abdominal adiposity. Therefore, studies examining residential environment features, in the context of both BMI and waist circumference changes, should be considered within the same conceptual framework of neighborhoods and health, looking at both individual-level and area-level features simultaneously. Reported studies are limited by the absence of models which account for various pathways involved in the BMI/waist circumference and depressive symptomatology/general health/area-level SES relationships, including the mediation and moderation processes. Such models would help to understand the proximal and distal impacts of both depression and general health  as well as residential environment features  on waist circumference and BMI, after adjustment for individual covariates including socio-demographics.A key distinction of our analysis is that, accounting for other influences, we found no significant associations between any physical built environment feature and baseline or change in waist circumference or BMI. This was unexpected but is well supported by our data and models, and is not untenable given the design limitations of much previous work, for example, cross-sectional studies that have reported inverse associations between BMI and count of parks or proportion of land covered by park space , and posOur study did not aim to identify mediation mechanisms or moderation effects. Potential moderators  could have been tested but we strove to focus on main effects only, not sub-group analyses. This reflects small group sizes and inadequate statistical power for evaluation. Further mediation and/or moderation analyses will be needed to test the effects of neighbourhood factors including the food environment  and public open spaces  on waist circumference and BMI, and the modulating effects of psychological factors. It is important also to investigate group trajectories to determine specific patterns of change (in BMI and waist circumference) and estimate the effects of both depression and general health within devised group trajectories.Strengths of this study include the prospective nature of the data collected and the length of follow-up period, enabling examination of baseline status and change in predictors and outcomes. The use of objective measures is another strength with clinically assessed anthropometric variables and built environment indicators from geographic information systems. Depressive symptomology and general health on the other hand were not measured clinically, but via self-reported responses to questionnaires. While reliable and valid, such measures may bear more uncertainty which would bias model findings to the null. Therefore, relationships reported here between depression and general health in relation to BMI/waist circumference are likely under-reported.The first key limitation of our study is the use of baseline measures for built environment characteristics which do not express how long individuals were exposed to environmental features, or whether the environment changed over the follow-up period. The second key limitation is relative to models’ assumptions. For models’ parameter estimation, we first assumed that both measurement and structural models are well defined. Second, with respect to the measurement models, as frequently done, we assumed that error terms are uncorrelated across waves and error variances are equal over time. Other limitations include the possibility of residual confounding given the omission from models of relevant unmeasured influences at both individual and neighborhood levels  environment features. It is plausible that the former  are more proximal at the individual level in the causal chain, therefore more likely to affect changes in waist circumference and BMI, whereas the latter  have a more distal impact broadly.


Alcohol and high-fat diet are two major risk factors responsible for metabolic diseases, which are manifested as steatohepatitis and liver cancer in the liver, and chronic pancreatitis and pancreatic adenocarcinoma (PDAC) in the pancreas. These metabolic diseases are becoming increasingly prevalent around the globe, and more importantly, their two major etiologies commonly coexist to precipitate the disease processes. To highlight the importance of these metabolic diseases, Japanese Society of Gastroenterology (JSGE) and National Institute on Alcoholism and Alcohol Abuse of National Institute of Health cosponsored the JSGE’s 7th International Forum jointly held with the 12th International Symposium on ALPD and Cirrhosis. Toward the main theme of “Frontiers in ASH, NASH, NBNC-HCC and PDAC”, this platform showcased presentations by 12 invited international and Japanese speakers on brain–gut–liver interactions, emerging mechanisms of ASH and NASH, metabolic reprogramming, and new therapeutic targets for cirrhosis, HCC, and PDAC. This editorial discusses the most recent data on global statistics on how alcohol and obesity impact health and longevity as a prelude to a brief summary of the symposium presentations and discussions, primarily focusing on the first two session themes. Alcohol abuse and high body mass index (BMI) are pressing health issues that globally and significantly contribute to burdens of disease not only in nations of high and middle economic standing but also in nations of poverty. The strongest evidence for this conclusion is found in the Global Burden of Disease 2016 report published by the Institute for Health Metrics and Evaluation at the University of Washington . We seleSimilarly, globalization has had a significant impact on the roles that high-fat diets and soft drinks high in fructose play in determining the death and disability worldwide. These diets and drinks contribute to increased BMI, raising the risk for a host of metabolic diseases including non-alcoholic fatty liver disease (NAFLD). While high BMI as a risk factor was once limited to developed countries, its effect is now evident throughout a larger fraction of the world. High BMI is ranked as the third risk factor globally with an overall 4.6% loss of healthy years, and ranked 3rd and 2nd in high and upper middle-income nations claiming 5.4% and 5.6% reductions, respectively. In low-income countries, this percentage drops to 2.3%, indicating that the extent of “Westernization” of lifestyle appears to predicate this epidemiologic difference. Perhaps of greatest concern is that the percentages in middle- and low-income countries have increased from 4.9% and 1.6% in 2010, respectively, indicating that the number of healthy life years lost due to a high BMI is increasing even in non-affluent nations.Non-alcoholic steatohepatitis (NASH), a severe form of NAFLD is a significant cause of chronic liver disease worldwide. Overtime, the presence of risk factors, such as weight gain, diabetes, hypertension, menopause, and genetic conditions, promotes the development of NASH, liver fibrosis, cirrhosis, and hepatocellular carcinoma (HCC) . ObesityAlcohol and obesity are two independent risk factors for loss of healthy life years and for the development of ASH and NASH for our interest. But interactions among the two are also important. For instance, chronic, excessive alcohol use, as determined by daily intake of > 40 g/kg for men and > 20 g/kg for women, synergistically promotes liver disease in NAFLD patients, particularly in overweight or obese subjects –14. As aAs alcohol use and increased BMI are prevalent and constitute two major risk factors around the world, there is an urgent need to assess cross-interactions of the two by a large prospective multi-ethnic cohort study with accurate assessment of the amount, frequency, and pattern of alcohol intake along with careful qualitative and quantitative measurements of other lifestyle factors such as diet and exercise. Genetic influence on these interactions is also of obvious interest. Such a study should better delineate environmental and genetic factors which determine the predisposition to harmful cross-interactive effects of alcohol and obesity.In light of the global importance of alcohol and obesity-associated metabolic diseases, the 7th JSGE International Forum jointly held with the 12th International Symposium on ALPD and Cirrhosis was a timely and enlightening event for the JSGE community. It showcased 12 invited speakers with the main theme on frontiers in metabolic liver and pancreatic diseases. The space allocated for this editorial is not sufficient to cover all symposium presentations in depth and thus it will review and summarize the essence of the presentations by 5 US speakers on the two selected topics of brain–gut–liver interactions and emerging mechanisms of NASH and ASH.Organ cross talk is a communal and essential mechanism of acute and chronic diseases, particularly metabolic liver diseases. The importance of intestinal microbiota in maintaining the homeostasis of essentially all organs in the body is now well recognized. It is not surprising that excessive or/and unbalanced nutrients or alcohol intake, the primary etiologies of NAFLD and ASH disturb gut flora as a most upstream event. Dysbiosis  alters microbial metabolites  which normally support and protect intestinal epithelium; reduces production of anti-microbial peptides; and enhances paracellular and transcellular translocation of bacteria and pathogen-associated molecular patterns (PAMPs). This stimulates an innate immune response in the intestine and the liver, and early pathogenetic changes in NAFLD and ASH. Proinflammatory activation of hepatic macrophages and hepatic stellate cells initiates PAMP-driven inflammatory and fibrogenic responses in the liver, which are coupled to organelle stress  and activation of cell death pathways in hepatocytes to initiate ASH and NASH. These changes are mirrored in the brain as microglia and astrocyte proinflammatory activation and neurodegeneration via cross talk, yet to be elucidated but being actively investigated.Professor Paolo Sassone-Corsi of University of California Irvine discussed in his opening lecture. This metabolic reprogramming is in part mediated by histone and non-histone acetylation regulated by the NAD-dependent sirtuins . NAD+ level exhibits circadian rhythmicity because the rate-limiting enzyme for the NAD salvage pathway, nicotinamide mononucleotide phosphoribosyltransferase (NAMPT), is transcriptionally upregulated by the circadian clock core transcription factors, CLOCK:BMAL [Both NAFLD and ALD are dictated by metabolic alternations which are closely linked to altered peripheral circadian clock regulation due to the abnormal nutrient or alcohol intake as well as dysbiosis as OCK:BMAL . As suchOCK:BMAL . High-faOCK:BMAL  and thusOCK:BMAL . High-faOCK:BMAL . As gut Bernd Schnabl of University of California, San Diego enlightened the audience on new developments in the understanding of the pathogenetic implications that gut dysbiosis renders for ALD, particularly via altered gut microbial metabolites. Such examples, discovered by a combined application of metagenomic sequencing and metabolomic analysis, include upregulation of bacterial cholylglycine hydrolase which deconjugates bile acids (BA) and reduces intestinal levels of unconjugated BA, leading to suppressed FXR-mediated expression of FGF-15 by ileum, derepression of Cyp7a1, and increased BA synthesis in alcohol-fed mice. Administration of the intestine-restricted FXR agonist or overexpression of FGF-19 (a human FGF-15 ortholog), modulated hepatic genes involved in lipid metabolism and ameliorated ASH, suggesting a causality of dysbiosis-mediated suppression of the BA–FXR–FGF15 signaling [ignaling . He alsoignaling .Gyongyi Szabo of University of Massachusetts Medical Center followed to summarize the pathway of liver inflammation in ASH involving TLR-PAMP-mediated priming and NLRP3 canonical inflammasome-induced IL-β activation triggered by DAMPs such as uric acid [ric acid . She extric acid . Furtherric acid . These dArun Sanyal of Virginia Commonwealth University opened this session by discussing novel treatments of NASH. He emphasized the importance of defining and standardizing the clinical endpoints pursued by clinical trials [l trials . One sucl trials , 35. Howl trials , 35.Vijay Shah of Mayo Clinic discussed therapeutic opportunities for ASH by taking an intriguing approach of exploiting similarities and differences with NASH. ASH and NASH have overlapping histologic and clinical features which are likely caused by common underlying mechanisms. These common mechanisms include gut dysbiosis, hepatocellular organelle stress, inhibited autophagy, altered hepatic lipid metabolism, innate immune activation, and hepatic stellate cell activation [tivation . In additivation . NLRP3-itivation  but its Hidekazu Tsukamoto of University of Southern California; cross talk between mitochondria and autophagy in pancreatitis by Anna Gukovskaya of University of California, Los Angeles; and the role of the vagus nerve in hepatic glucose metabolism and NAFLD progression by Hiroshi Inoue of Kanazawa University. The final session on New Therapeutic Targets for Cirrhosis, HCC, and PDAC included the presentations on neutrophils, the NF-kB p50 subunit and exercise as interventional targets in liver inflammation and cancer by Derek Mann of Newcastle University; Metavert, a new therapeutic for treatment and prevention of metastasis in PDAC by Stephen Pandol of Cedars-Sinai Medical Center; precision medicine for HCC and pancreatic cancer by Shuji Tanaka of Tokyo Medical and Dental University; and epigenetics in liver fibrosis by Jelena Mann of Newcastle University.These two sessions were followed by the session on Metabolic Reprogramming in Liver and Pancreatic Diseases, encompassing the presentations on lipid reprogramming linking liver fibrosis to cancer by The international symposium on alcoholic liver and pancreatic diseases (ALPD) and cirrhosis began in 2006 with a charge by National Institute on Alcoholism and Alcohol Abuse (NIAAA) of US National Institute of Health to pursue a well-defined mission of promoting global exchange of research knowledge and international collaborations concerning ALPD and cirrhosis plaguing the world. Global statistics are staggering: the WHO reports more than 3 million deaths due to alcohol misuse, corresponding to nearly 6% of all deaths in the world. As summarized in the introduction of this editorial, alcohol use and high BMI, which cause ASH and NASH, respectively, are major risk factors for disease and death around the globe, reducing our healthy life span by 5–7%. The symposium aims to face this challenge of the global epidemic by promoting international exchange of cutting-edge basic and translational sciences as witnessed in the 12th symposium in Tokyo. We would like to thank all the speakers who contributed their science to the symposium; the JSGE and Professor Kazuhiko Koike for sponsoring and providing a symposium platform as part of the 104th JSGE General Meeting; and NIAAA for its conference Grant (R13AA020697) enabling the continuation of the symposium.


Randomised clinical trials are pivotal in guiding clinical practice. Trials with surrogate outcomes and industry sponsorship might be less reliable than those with hard outcomes and independent sponsorship. The types of interventions evaluated in randomised clinical trials might not reflect the diversity of those employed in clinical practice.We assessed the types of primary outcome, types of intervention and sponsorship of 360 randomised clinical trials evaluating 416 interventions, published in seven major general medical journals and 10 speciality medical journals in five clinical disciplines.Primary outcomes were surrogate in 223/360 (62%) trials. Neither type of journal nor source of sponsorship was associated with type of primary outcome. Among the interventions evaluated, 233/416 (56%) were drugs, 17/416 (4%) devices and 49/416 (12%) procedures. The majority of trials were non-industry funded . Trials of drug interventions and those with industry sponsorship were more common in specialty than general journals . Industry sponsorship was not associated with results for the primary outcome but was strongly associated with trials of drugs and devices.Within the groups of both general and speciality journals, there were wide ranges in the prevalence of industry funding , but in all cases the prevalence of hard primary outcomes was <40%.Most randomised clinical trials published in influential journals reported surrogate primary outcomes and assessed drug interventions. Trials that evaluated devices and procedures were infrequently published, despite the prominence of each type of intervention in clinical practice. Industry funding was more common for trials published in specialty than general journals but was not associated with more positive results for primary outcomes or with a greater preponderance of surrogate outcomes. Randomised trials are the highest level of evidence in clinical research and are, therefore, pivotal in guiding clinical practice . AccordiThe sponsorship of clinical trials might also influence their reliability. Systematic reviews indicate that industry-sponsored drug research is more likely to report beneficial effects and favourable safety profiles than non-industry-sponsored drug research , 6. ReseClinical practice comprises a range of management strategies. Interventions include medications, medical devices and technologies, and procedures. The relative proportions of these interventions that are applied varies by discipline, but devices and procedures are an integral part of the working lives of most practitioners, and their use affects patient outcomes. Concerns have been expressed that medical devices can enter clinical practice without supporting evidence from clinical trials –11, perhIn the current work, we set out to determine the prevalence of surrogate primary outcomes in clinical trials published in high-impact journals, the prevalence of the types of intervention assessed in such trials and whether there is a higher proportion of surrogate primary outcomes in industry-sponsored trials than non-industry-funded trials. Accordingly, we assessed the types of primary end points, types of intervention assessed and sponsorship in a set of randomised trials published in major internal medicine and specialty journals.The New England Journal of Medicine (NEJM), Lancet, Journal of the American Medical Association (JAMA), The  British Medical Journal, JAMA Internal Medicine, Annals of Internal Medicine and PLoS Medicine. The specialty journals were the two journals with the highest impact factors that publish clinical research in each of five disciplines. For cardiology, we assessed publications in Journal of the American College of Cardiology and Circulation, for infectious diseases those in Lancet Infectious Diseases and Clinical Infectious Diseases, for neurology those in Lancet Neurology and Neurology, for oncology Lancet Oncology and Journal of Clinical Oncology, and for respiratory medicine Lancet Respiratory Medicine and American Journal of Respiratory and Critical Care Medicine.We assessed randomised clinical trials published in 7 general and 10 specialty journals in 2013 and 2014. We focused on the journals that are likely to have the greatest readership and therefore, are most likely to influence clinical practice. The general medical journals were those with the highest impact factors: n = 210 in total) and 15 were assessed for each specialty journal . The number of publications assessed was determined pragmatically. A second investigator (AG) checked the search and collation of publications.One investigator (PG) searched Medline for reports of randomised clinical trials in each journal, collating the most recent publications before 31 December 2014 , trial design, type of intervention and trial results. All data were extracted by one investigator (PG) and checked by a second investigator (AG). In the event of disagreement, a third investigator (MB) provided an assessment and the majority view was recorded.We categorised trial sponsorship as any industry (solely industry funding or mixed industry/non-industry funding) or non-industry. Primary outcomes of the trials were categorised as hard, surrogate or mixed, and single, co-primary or composite. We used the Institute of Medicine definition of surrogate outcomes as “biomarker[s] intended to substitute for a clinical endpoint [and] expected to predict clinical benefit (or harm …) based on epidemiologic, therapeutic, pathophysiologic, or other scientific evidence” . Hard ouWe used descriptive statistics to report the prevalence of types of sponsorship, primary outcome, trial design and trial results, and chi squared or Fisher’s exact test to compare categorical variables between trials with different types of sponsorship and in different types of journal.We assessed 360 trials that collectively reported the effects of 416 interventions Table . We founTable P < 0.001). In specialty journals, 67/150 (45%) trials were industry funded and included a drug intervention, compared to 37/210 (18%) in general journals (P < 0.001). In specialty journals, higher proportions of trials with both surrogate outcomes  and hard outcomes  had industry funding than those in general journals .A higher proportion of trials published in specialty journals than in general journals had industry funding  (Table NEJM and Lancet) also published the lowest proportion of trials of interventions other than drugs, devices and procedures. The proportion of trials with solely surrogate primary outcomes was greater than 40% for each of the general journals (range 43–87%). Conversely, in none of the journals was the proportion of trials with a hard primary outcome greater than 40% (range 7–40%).Finally, we assessed types of outcome, types of interventions and funding of trials published by individual general journals and by the specialty journals within each medical discipline. Table Table The majority of clinical trials published in major general medical and speciality journals in five clinical disciplines had a surrogate primary outcome; 61% of trials had only a surrogate primary outcome, and a further 15% included a surrogate outcome in a mixed primary outcome. Thus, only one quarter of the trials reported a solely hard primary outcome. Since surrogate outcomes may be unreliable in predicting hard outcomes , 4, our The majority of trials we assessed (61%) were not sponsored by industry. Surrogate primary outcomes were present equally frequently in trials funded by industry and other sources. A higher proportion of trials published in specialty journals than general journals had industry funding. Since 86% of industry-funded trials were of either drugs or devices, compared to 44% of trials funded from non-industry sources, it is not surprising that a higher proportion of trials published in specialty journals compared to trials published in general journals were of drugs or devices. Some evidence suggests that industry-funded research disproportionately generates positive results , 15, butMedical devices and procedures are frequently used in medicine, and their widespread use can occur without strong evidence of efficacy and safety , 16. In General medical journals varied widely in the proportions of trials they published that had any industry funding (7–63%) and of the types of intervention assessed. These characteristics are likely co-dependent, as industry funding is more likely to support trials of drugs and devices than trials of health-care delivery or health behaviours. Thus, the two general journals that published the highest proportion of industry-funded trials also published the highest proportion of trials of drugs and devices. Consistently, the proportion of trials with a hard primary outcome published in each of these influential general journals was <30%. Among the specialty journals, although there was also some variability in the proportions of published trials with industry funding, it was in each case more than 33%. With the exception of cardiology, journals in each discipline were strikingly similar in publishing mainly trials of drug interventions (67–79%). Few published trials in each discipline (13–22%) were of interventions other than drugs, devices or procedures. For four of five disciplines, trials with hard outcomes represented <30% of published trials, and in all disciplines such trials were the minority of published trials.Our study has several limitations. Some trials were reported to have both industry and non-industry funding, but we were unable to ascertain whether one source predominated. Some non-industry-funding sources might derive income from commercial sources, but we could not determine this. We reported the characteristics of published trials but could not ascertain whether the results we observed reflect the characteristics of trials submitted for journal review; nonetheless our findings reflect the set of trial results most visible to practitioners. Categorising outcomes as surrogate or hard can sometimes be difficult , but we The majority of trials published in high-impact general and specialty medical journals have surrogate primary outcomes and assess drug interventions. Trials of devices and procedures are infrequently published in such journals, despite the prominence of each type of intervention in clinical practice. Industry funding is more common for trials published in specialty than general journals but is not associated with more positive results for trial primary outcomes or with a greater preponderance of surrogate outcomes.


Existing conceptualizations of successful aging are mainly based on Western cultures, ignoring the inclusion or exploration of culturally-relevant knowledge within the experience of successful aging. Lewis (2011) drew on the experiences of Elders and identified four elements of Eldership (successfully aging elders) in the Bristol Bay region of Alaska: “a) emotional well-being, b) community engagement, c) spirituality, and d) physical health” (p. 544). Given the unique and distinct environmental locations of this study, this presentation builds upon Lewis previous research and will highlight similarities and differences of Alaska Native successful aging between three rural geographic areas of Alaska. 42 Alaska Native Elders were interviewed from the Norton-Sound subregion, 21 Alaska Native Elders from the Aleutian Pribilof Islands, and 26 Elders from the Bristol Bay region. A community-based, exploratory, qualitative research methodology was used to allow for the collaboration of researchers and communities as equal partners. Qualitative interviews explored the participant’s life, influences on aging well, and their aging process. Thematic analysis was used to establish codes and main themes based on the three different cultural regions of Alaska. Results argue for the expansion and emphasize on social components, historical perspectives, and the importance of place , as well as generativity and gerotranscendence. Findings will be used to develop community-specific health promotion and prevention programs to help Elders find meaningful activities that promote health and teach individuals to cope with aging-related changes.


The discussion section should read: “Nutrition plays an important role within the multifactorial susceptibility of this syndrome; however, up to the present no systematic review specifically addressed the effectiveness of nutritional interventions for the treatment of frailty. The systematic reviews identified in the literature on this topic emphasize interventions related to physical activity without any particular focus to nutritional interventions, which were generally analyzed briefly and in a secondary manner.Finally, the full affiliation of Mariana Bordinhon de Moraes and Carolina Fumico Massuda Araujo should read: Department of Public Health, São Paulo State University (UNESP), Botucatu Medical School, SP, Brazil.


Performance-based financing (PBF) both measures and determines payments based on the quality of care delivered and is emerging as a potential tool to improve quality.Comparative case study methodology was used to analyze common challenges and lessons learned in quality of care across seven PBF programs . The eight case studies, across seven PBF programs, compared were commissioned by the USAID-funded Translating Research into Action (TRAction) project (n = 4), USAID’s Health Finance and Government project (n = 3), and from the Global Delivery Initiative (n = 1).The programs show similar design features to assess quality, but significant heterogeneity in their application. The seven programs included 18 unique quality checklists, containing over 1400 quality of care indicators, with an average per checklist of 116 indicators (ranging from 26-228). The quality checklists share a focus on structural components of quality . Process indicators constituted an average of 20% across all checklists (ranging from 8.4% to 61.5%), with the majority measuring the correct application of care protocols for MCH services including child immunization. The sample included only one example of an outcome indicator from Kyrgyzstan. Performance data demonstrated a modest upward improvement over time in checklist scores across schemes, however, achievements plateaued at 60%-70%, with small or rural clinics reporting difficulty achieving payment thresholds due to limited resources and poor infrastructure. Payment allocations (distribution) and thresholds (for payments), data transparency, and approaches to measuring (verification) of quality differ across schemes.Similarities exist in the processes that govern the design of PBF mechanisms, yet substantial heterogeneity in the experiences of implementing quality of care components in PBF programs are evident. This comparison suggests tailoring further the quality component of PBF programs to local and country contexts, and a need to better understand how quality is measured in practice. The growing operational experiences with PBF programs in different settings offer opportunities to learn from best practices, improve ongoing and future programs, and inform research to alleviate current challenges. In many resource-poor settings health care services perform poorly across the key domains that often define quality – safe, effective, timely, efficient, equitable, and people-centered ,2 – and Performance-based financing (PBF) is a strategic purchasing approach that offers providers and health facilities a per-unit payment for targeted tasks or service outcomes ,9. QualiSubstantial heterogeneity exists in how quality is incorporated in the design and implementation of PBF ,16. DiffThe goal of this paper is to systematically document experiences in measuring and paying for quality in donor-supported PBF programs for maternal and child health (MCH) services across seven low- and middle-income countries (LMICs). Our goal is to provide insights into how the quality of care is implemented and formally documented across contexts, designs, and funders. Our sample of PBF schemes differs in their context and approach to PBF, as well as in their source of external financial assistance. We identify similarities and differences across programs, focusing on various key design and implementation aspects, such as the content of the quality of care checklists, reporting and verification, and how quality is featured in the payment formula.We used a comparative case study methodology by conducting a desktop review, hosting key informant interviews, and assessing quality performance data. We analyzed design elements, common challenges, and lessons learned in quality of care across eight case studies of PBF programs .The case studies on the seven PBF programs come from three sources. Five case studies (Democratic Republic of Congo (funded by USAID), Mozambique (CDC), Nigeria (World Bank), and Senegal (World Bank)) were conducted by this study’s authors and commissioned by the USAID-funded Translating Research into Action (TRAction) Project ,20. ThreThe five TRAction-supported cases were purposively selected to achieve a distribution of countries that included: USAID Ending Preventable Child and Maternal Deaths (EPCMD) priority countries whose PBF programs focused on MCH health; variation in the source of PBF funding; variation in the extent to which quality measures were integrated into PBF programs; sufficient availability of program documentation and data on quality of care; and sufficient project duration to be able to measure quality changes.The HFG project's set of three case studies, two of which also cover USAID EPCMD priority countries (Nigeria and Zambia), were selected because the documentation of PBF payment design, implementation duration, and lessons related to maternal health service delivery quality were sufficient to enable robust comparison with the other set of studies .Kreditenstalt fur Wiederaufbau, KfW; and the Norwegian Agency for Development Cooperation, NORAD), and the documentation of program design and outcome elements was sufficient to support its inclusion in our analyses.The Malawi GDI case study was included as it aligned with our selection criteria, in that Malawi is also an EPCMD country, the PBF implementation featured is financed by a unique funder relative to the other cases , followed by qualitative interviews with two to five informants including representatives from the Ministry of Health, donors/funders, PBF implementers, field support staff, and health providers. Key informants were selected using both purposive and snowball sampling. An initial literature review of quality of care in PBF informed the development of qualitative key informant interview guides with input from experts and stakeholders , USAID). The guide was refined for use in each country adapting to context, PBF project, and specific stakeholder's area of expertise and job function. For instance, field support staff were questioned about the implementation challenges of the quality tool and the impact on facilities, whereas PBF designers and donors/funders were asked about tool design and impact on quality scores.http://www.harpnet.org/resource/multi-country-performance-based-incentives-quality-checklist-database/). Reported health facility levels  was recorded directly from the program manual or source material.Data were collected between September 2014 and March 2015 for TRAction case studies, and September-November 2016 for HFG case studies. The GDI case study examines the ongoing Maternal and Neonatal Health (RBF4MNH) in Malawi (project duration: August 2011-December 2017), and includes information from 2010-2015 . We alsoWe conducted a content analysis of the qualitative interviewer notes from TRAction’s completed case studies across seven components: (1) means of quality assessment, (2) verification, (3) quality incentive formula, (4) quality assessment tool design, (5) impact of paying for quality, (6) challenges and (7) lessons learned was performed. We performed secondary comparative analysis using these same dimensions on the HFG the GDI case studies to reveal common themes related to better practices, challenges, and opportunities to improve quality of care in PBF. We grouped data on PBF program components into similarities and differences to highlight key thematic challenges and successes to using PBF to improve quality of care.We relied on a small number of case studies that may not be representative of PBF programs in other contexts. All case studies were purposively selected, and although there is substantial heterogeneity in specific features and implementations of these cases, programs supported by the World Bank’s HRITF often have similar general design features . Second,Our findings are organized by similarities and differences observed across the seven PBF programs. In light of the country contexts, our analysis examined macro-economic figure and MCH outcomes . All programs remain active as of this writing, with the exception of Mozambique and DRC PROSANI, which has been combined with other PBF programs in the country for national scale up.The seven programs included 18 unique quality checklists, containing over 1400 quality of care indicators. On average, the checklists contained 116 indicators, ranging from 26 on the HIV-specific checklist for Mozambique to 228 on the tertiary quality checklist for Nigeria . Process indicators constituted an average of 20% across all checklists (ranging from 8.4% to 61.5%), with the majority measuring the correct application of care protocols for MCH services, including child immunization. The shares of structural and process indicators in programs for which we have multiple versions of revised checklists , remained virtually unchanged post-revision, with the share of process indicators decreasing post-revision by 0.3% , at the expense of additional structural indicators  and maternal health (22%), including antenatal, postnatal and delivery care. A few checklists had a specialty focus, specifically for Malaria prevention and treatment in Senegal, HIV/AIDS care and treatment in Mozambique (mixed level), and non-communicable diseases in Kyrgyzstan (tertiary level).The aggregate quality scores for Nigeria, Mozambique, DRC, and Senegal, Kyrgyzstan demonstrate upward improvement in the median checklist performance over time . This process of adaption was nearly a three-year process due to political interruptions. The adapted tool was tested between January-June 2014 in one ‘pre-pilot' Rayon hospital and scaled after July 2014 to 44 tertiary facilities. Similarly, in Zambia, the ‘pre-pilot’ did not include a unique quality checklist. The pilot started with an adjusted (a modified and simpler) version drawn from the Rwandan health center quality checklist. Refinements to this quality checklist were informed by the pre-pilot results. Conversely in Mozambique, the initial quality checklist was the one already in use and designed by the Ministry of Health, however, as the program scaled up, quality checklists were developed by CDC (funder) and the program implementer  for HIV and MCH-specific quality metrics using other non-PBF checklists as models.All programs revised their quality checklist in the last three years; however most were minimal. Informants stated that checklist reviews were often an annual part of program management, and the revision processes have been described as a “balancing act” between PBF expert guidance and existing quality tools used by country governments. In January 2014, Nigeria introduced a revised checklist, which included additional process-type indicators while maintaining the existing structural-type measures . One rationale for frequent revisions according to informants is that facilities start mastering components on the original checklist and may hit the ceiling for improvement. The revision allows for further improvement in targeted services, thereby ensuring that facilities remain engaged and motivated to continually improve. Informants suggested a critical need for monitoring the implementation of quality checklists, including the length, frequency of verification, and the resources required to complete them. is defined in the notes of Senegal represents the sole use of a deflator scheme and can decrease the quantity of payment earned continuously from 100% to 0% based on the score a facility receives on the quality checklist. Zambia initially had the payment formula as a deflator; however, early program experience showed that individual-level bonuses earned were reportedly too low to increase worker motivation. After several consultations between the government and the funder, the quality deflator became an inflator, and eventually had conditionality of 61% achievement applied to it.The PBF implementations exhibit high variability in bonus allocation between facility re-investment and health care provider  and Kyrgyzstan totaling US$ 6.3 million USD, for only quality, from Q2 2014 to Q4 2017 . For all other programs, the only financial data available at the time of this writing is the overall program budget across multiple years.Two programs provided health facilities with an initial investment in infrastructure and staff to ensure commencement of the PBF program with the required minimum standards for delivering quality care. In Zambia, implementation began with the provision of a package of reproductive health commodities and equipment to ensure that every facility could provide an acceptable level of quality for MCH services. A similar package was rolled out, including infrastructural upgrades, prior to the introduction of Malawi's PBF program.Four programs have an online PBF data portal that reports quality checklist performance . Other programs do not have online portals and manage performance data through internal spreadsheets. While the online PBF portals have made great strides in enhancing data transparency, informants reported that these portals are rarely utilized at the health facility level, but rather by central level planning units, funders, and researchers. Much of the data available through the data portals is aggregated by region or by section of the quality checklist, rather than offering performance per indicator. In every case study, informants reported that health providers and community groups rarely receive their facility performance data and are not included in discussions on how to improve performance.Across all programs, most indicators are measured via the checklist, whereby a verifier observes an indicator at a health facility and checks it off (79%), . Typically, the programs only employ one or two supplemental means of assessment in addition to the checklist. Other methods include facility (5%) and patient register reviews (7%), direct observation of patient-provider interactions (8%), and staff assessments (<1%). There is also ex-post verification, which is the random checking of performance values after the payment is completed. Typically, there are penalties for discrepancies larger than 10%. This verification method is being deployed in Nigeria and Kyrgyzstan.Our findings indicate considerable heterogeneity in the design and implementation of quality of care components in select PBF programs. Payment allocations (distribution), data transparency, and measuring quality appear to differ across schemes, while the process of checklist design and revision, positive performance gains, payment formulas, and indicator typology are shared features. While the similarities and difference amongst program design and implementation serve as an important contribution to helping improve and re-design programs, the core finding of this paper is that PBF program information is burdensome to access, understand, and leverage for learning and comparison.The current evidence gaps in understanding how PBF programs work mechanically and on-a-ground-level results directly from the dearth of information that is publicly available. For all of the case studies, program documents were obtained only through direct request and follow-up with the funder. This documentation differed significantly across programs and funders, particularly when comparing manuals, which are intended to have a shared format. Routine implementation documentation and noted discrepancies between design and execution are completely absent, even internally for many programs. Evaluations of the programs are spaced by years and take significant time to be published and released. Moreover, the formal evaluations provide little information about the actual implementation, with the focus being on impact.Although great strides to increase data transparency has improved access to PBF data for HRITF-supported programs, few offer any analysis of this data, and in even fewer instances is this data used by the beneficiaries and verifiers, where it could be leveraged to strength programs.A final glaring gap in the PBF information sphere is financial data. With regards to the topic of our analysis, the payments for quality remain elusive. While some programs, notably Nigeria and Kyrgyzstan, publish aggregate quarterly payment information on the public portal, how the payments are calculated, distributed amongst PBF facilities, and most importantly, how the money is spent overall and directly tied to the improvement in quality is measured on the checklist is critical to understanding whether the payment side of PBF has any effect on quality.While the amount paid for quality is not available, our analysis provides insights into the payment formulas. PBF programs reviewed here favor incorporating quality as an inflator to quantity bonuses. However, the allocation (distribution) of payments and threshold of performance on the checklists differ. The experience of Senegal concerning the accountability and enforcement of the deflation approach was positive, however, most informants reported that inflators are more aligned with work culture and preference of health facility staff and managers. Payment thresholds may favor well-performing or well-equipped facilities. Conversely, this may demotivate smaller, lower-performing facilities that are unlikely to meet the threshold (as the case of Mozambique suggests), as well as higher-performing facilities who have no incentive to improve beyond just above the threshold. Some programs address this issue by graduating payment thresholds so that greater performance continues to increase payment incrementally. Periodic checklist revisions also help to address the problem of complacency.Another shared challenge is the length and overt focus on structural quality components. The focus of the checklists on structural attributes is likely an acknowledgment that, in many LMICs, health facilities do not achieve a minimal level of infrastructure, supplies, and cleanliness. However, the process and outcome aspects of quality are increasingly recognized as important ,28 and eOur finding that quality checklists are lengthy is echoed by a recent study assessing 68 quality of care checklists which found that checklists contained on average 126 indicators, ranging from 26 to 220 . Key infEnhanced role of patient feedback would be a positive shift in assessing quality, also to raise the awareness and responsiveness of providers to patient experiences. Moreover, there is a need for innovation to collect these kinds of measures at low cost. Enhanced engagement of the community in knowing and understanding facility quality performance could support a more participatory process to improve quality of care in PBF programs. In Kyrgyzstan, although it requires the facility to report at least patient feedback surveys, it does not specify a minimum score reporting minimum satisfaction, the payment is made for the completion.Finally, this analysis points to the need to work more closely with continuous quality improvement (QI) and quality assurance (QA) programs when designing PBF programs. We know that other countries have concurrent QI/QA projects in the same facilities as PBF. Indeed, at least some of our sample countries – Mozambique, Nigeria, Malawi – have QI/QA efforts under way in the same provinces or districts, if not in the same facilities. The challenge ahead lies in the opportunity to creatively test and combine efforts between PBF and QI/QA processes to reduce redundancy and improve quality of care using multiple approaches.PBF holds appeal as a tool to improve the quality of care in health facilities and to focus decision-makers' attention on current quality shortfalls as well as toward performance-based payments. The growing operational experiences with PBF programs in different settings offer opportunities to learn from best practices and mistakes, improve ongoing and future programs, and inform research to alleviate challenges in current programs, such as how to shift toward process and outcomes quality while containing the administrative burden of reporting and verifying performance.


Between 1 and 5% of children in industrialized countries are conceived through Assisted Reproductive Technologies (ART). As infertility and the use of ART may be associated with adverse perinatal outcomes, care plans specific to these pregnancies are needed. We conducted a systematic review to examine the existing care plans specific to women pregnant following Assisted Reproductive Technologies (ART).MEDLINE, Embase and the Cochrane Library were searched by a senior information specialist. The population of interest included women becoming pregnant with ART , Intracytoplasmic Sperm Injection (ICSI), and surrogacy). All proposed care plans were sought that pertained to any aspect of care during pregnancy and delivery. Only Clinical Practice Guidelines (CPGs) addressing the recommendations and plans for the care of ART pregnant women were included. The search was restricted to the publication dates 2007 to June 12, 2017 when the search was run. The search was not restricted by language, however only English and French language guidelines were considered for inclusion.After screening 2078 citations, a total of ten CPGs were included. The following key clinical messages were prevalent: (1) although there was no supporting evidence, antenatal care for ART pregnancies should be provided by specialist with knowledge in obstetrics; (2) high-order multiple pregnancies are the greatest risk of ART and selective reduction options should be discussed; (3) there is some evidence of increased risk of congenital abnormalities and prenatal genetic and anatomic screening is recommended, especially in IVF-ICSI pregnancies; (4) due to a lack of or conflicting evidence, treatment of venous thromboembolism, antithrombotic therapy, treatment for hypothyroidism, and women with positive thyroid antibodies is recommended to be the same as in spontaneous pregnancies; and lastly (5) since an increased level of distress is a recognized feature in these pregnancies, psychosocial care and counselling should be considered.There is a lack of CPGs specific to ART pregnancies. While we identified a small number of recommendations for ART pregnancies, specific interventions and models of care aiming at decreasing adverse maternal and perinatal outcomes following ART should be developed, implemented, and evaluated.The online version of this article (10.1186/s12978-019-0667-z) contains supplementary material, which is available to authorized users. Advances in infertility treatments have helped many couples to achieve a pregnancy. Some of these pregnancies may have a higher risk of complications for the mothers and the babies. The cause of infertility, the type of treatment, or both could play a role in these adverse events. Despite previous advances in the care of women who are expecting, there are few clinical practice guidelines specific to pregnant women who conceive with infertility treatment. Thus, we conducted a systematic review of current clinical practice guidelines to identify gaps in knowledge, including recommendations for clinical care and optimal maternity care provider and setting for women who conceived following infertility treatments. Only 10 guidelines were identified, and the quality of the evidence varied, with only one guideline considered of high quality. They recommend that antenatal care for these pregnancies should be provided by specialist with knowledge in obstetrics. In the case of a higher order multiple pregnancy, the parents should receive information about the risk/benefits of selective pregnancy reduction. Since some advanced infertility treatments may be associated with congenital abnormalities, prenatal genetic screening should be offered. The treatment of thromboembolic diseases and thyroid problems should be the same as for pregnancies conceived spontaneously. Finally, the stress associated with these pregnancies is recognized, and as such psychosocial support should be provided. We conclude that there is a lack of specific guidelines for pregnant women following infertility treatment, and new guidelines should be developed to decrease complications during pregnancy for this population.Infertility has been declared as an emerging public health priority in developed countries . It is eSome studies suggest that ART pregnancies are associated with adverse maternal and perinatal outcomes, including preeclampsia, placenta previa, caesarean delivery, preterm birth, low birth weight, and congenital malformations, even among singleton pregnancies –7. The rThe objective of this systematic review was to identify the recommended care plans for women becoming pregnant with ART which are currently discussed in existing CPGs. This review focuses upon care given to women pregnant with the involvement of ART during pregnancy and delivery.http://hdl.handle.net/10393/36555).This review has been reported with guidance from the PRISMA reporting guideline  and follCriteria to identify eligible publications for the current review were established using the PICOS (Population-Intervention-Comparators-Outcomes-Study design) framework.The population of interest included women becoming pregnant with involvement of ART , In Vitro Fertilization (IVF), Intracytoplasmic Sperm Injection (ICSI), and surrogacy).All proposed care plans were sought that pertained to any aspect of care for these women during pregnancy and delivery. This included women in both low risk  and high risk settings .Any CPGs addressing the recommendations and plans for the care of ART pregnant women were included. Information of interest included the following: recommendations related to different types of maternity care providers  and location of care ; details of the care plans and/or individual elements recommended  the number and types of ultrasounds during pregnancy, prenatal screening, and so forth); underlying evidence supporting the recommendation ; citations of studies cited as informing the recommended care plans.Only CPGs were included. Primary studies, abstracts, letters, commentaries, and non-guideline reviews were excluded. There were no restrictions imposed on the setting, or geographic location. The search was not restricted by language, however only English and French language guidelines were included.Grey Matters: a practical tool for search health-related grey literature (https://www.cadth.ca/resources/finding-evidence/grey-matters) and targeted specialty societies. All searches were undertaken on June 12, 2017.The search strategies were developed and tested through an iterative process by an experienced medical information specialist (BS) in consultation with the review team. The strategies were peer reviewed by another senior information specialist prior to execution using the PRESS Checklist . Using tStrategies utilized a combination of controlled vocabulary  and keywords . A guidelines/care pathway filter was applied and vocabulary and syntax were adjusted across the two databases. The search was restricted to the publication dates 2007 to the present. Animal-only, opinion pieces and conference abstracts were removed from the results.Specific details regarding the strategies appear in Additional file Search results were de-duplicated in Reference Manager  before uReferences that did not contain an abstract were screened based on the title, and those determined to be clearly not relevant were excluded. If there was any indication that the title may be relevant, or it was unclear, it was passed through to full-text screeningData extraction forms were developed in Microsoft Excel 2007 and pilot tested on one included guideline. One reviewer extracted all data and a second reviewer verified all of the information collected. For all included CPGs, the following study characteristics were extracted: authorship list; guideline funders and sponsoring society; CPG type (new versus update of an existing CPG); date of publication; journal of publication/website; and country/language of publication. Other guideline information that were extracted included the following clinical details: recommendations related to different types of maternity care providers , location of care ; details of the care plans and/or individual elements recommended ; underlying evidence ; citations of studies cited as informing the recommended care plans.Quality assessment was performed on each clinical research guideline using the Appraisal of Guidelines for Research & Evaluation (AGREE)-II tool . This toFor the current review, the checklist was implemented in DSR, and three reviewers independently assessed the quality of each included guideline using this checklist. Three reviewers were used to increase the validity of the overall findings, as suggested by the AGREE-II Next Steps Consortium . For anyRecommendations from the included CPGs were summarized narratively according to the category of recommendations, which were chosen to be (1) models of care; (2) risks of ART; (3) surveillance, screening, and diagnostic testing in pregnancy; (4) treating conditions in pregnancy; and lastly (5) psychosocial care and counseling. Within each of these categories, we summarized recommendations described by at least one of the included CPGs, summarized the number of CPGs stating these recommendations, and indicated the assigned grade of evidence (where available). Within each of the categories of care, recommendations related to sub-aspects of care were grouped and contrasted where differences in recommendations were identified.The search across databases produced a total of 2173 records. After de-duplication and adding the records identified from the grey literature search and bibliographic screening of the included guidelines, 2078 unique records were assessed based on title and abstract. A total of 138 records were evaluated at full-text, and 10 guidelines were included . CPGs that scored low in this domain did not provide sufficient information on the target population of interest or a clear description of the health questions covered by the guideline.With respect to the stakeholder involvement domain, scores ranged from 13 to 87% (median 29%). Guidelines typically specified the names and geographic location of the development group, but failed to specify discipline or content expertise, their institution, or a description of the member’s role in the guideline development group. Only one guideline  specificConcerning the rigour of development domain, scores ranged from 3 to 85% (median 40%). Excluding the CPG by the ESHRE, the range was 3 to 59%. In general CPGs were associated with a lack of reporting of several key details including (i) the methodology used for study selection; (ii) the methods used to formulate recommendations; (iii) the approach to how the external review was performed; and (iv) a description of the procedure for updating the guideline. None of the included CPGs provided the literature search strategies used or a link to the search strategies used.In regard to the clarity of presentation domain, scores ranged from 17 to 89% (median 78%). One guideline received a low score ; after eWith respect to the applicability domain, scores ranged from 6 to 57%  . OverallWith reference to the editorial independence domain, scores ranged from 0 to 97% (median 4%). Funding information was not provided in most CPGs, and aside from generic statements that “disclosure statements have been received from all contributors”, there was no further information about any competing interests of the CPG development group members.Narrative summaries with table-based presentations Tables  and 3 arOne CPG reviewed the models of care in Australia and New Zealand, and referral within and between models . This guThe ACOG guideline discussed the perinatal risks associated with ART . Multi-fTwo SOGC guidelines discussed surveillance, screening and/or diagnostic testing for these women as there are several known risks  associated with pregnancy achieved with ART , 19. AltSeveral well-designed observational studies cited by the SOGC guidelines reported a higher prevalence of congenital malformations (Hazard Ratio (HR) 1.20; 95%CI 1.07–1.35), genital organ malformations , and congenital defects, including septal heart defects (adjusted Odds Ratio (aOR) 2.1; 95%CI 1.1–4.0), esophageal atresia , and anorectal atresia  compared to spontaneously conceived infants , 35. ThiStudies have evaluated several different maternal serum levels , Estradiol (uE3), Pregnancy associated plasma protein-A (PAPP-A), Human chorionic gonadotropin (HCG), etc) during the first and second trimesters of pregnancy. In observational studies cited by the CPG, there has been conflicting evidence that there are differences in some of these serum levels between pregnancies through IVF and non-IVF –38. As sAlthough the incidence of chromosomal abnormalities in births and induced terminations following IVF (0.7%) has been shown to be similar to those in spontaneous conceived pregnancies (0.2%), it has been shown to be significantly higher among those who became pregnant with IVF-ICSI (1.0%) . FurtherThe SOGC and ACCP CPGs focused on venous thromboembolism (VTE) and antithrombotic therapy in pregnancy and on how to diagnose and treat VTE in pregnancy and postpartum , 27. OneTwo CPGs focused on women with thyroid disease, specifically hypothyroidism, and how it should be treated in pregnancy , 24. AltA guideline from the ESHRE  providedGerman guidelines provided information for psychosocial counseling in the area of gamete donation, specific to donor insemination, as this is the only legal form of gamete donation in Germany . There aFew existing CPGs for women pregnant following ART were identified. A total of 10 guidelines were included, with a focus on models of care, risks of ART, screening in pregnant women, care of women with conditions not specific to those pregnant using ART, and psychosocial counselling for those involved in ART. The associated degree of rigor based on formal quality assessments using the AGREE-II tool was found to be both variable and limited; only one CPG, the ESHRE guideline, referenced a full publication , which pRecommendations within these guidelines related to the population were often based on observational studies and expert opinion. Many of the recommendations were indicated to be the same as for the care suggested for women who conceive spontaneously. This was either due to a lack of evidence specific to women who conceived with ART, conflicting evidence, or because the evidence suggested that there was little or no difference between these women. Additionally, the recommendations from the ACCP CPG were based on some evidence on women who were undergoing ART treatment and not yet pregnant, however, this evidence was combined with studies that included women who were followed through pregnancy.Several fundamental points of care can be drawn from the CPGs that were reviewed. One of the main differences of care for women becoming pregnant using ART (relative to those conceiving spontaneously) was for those who became pregnant with IVF-ICSI, because of a higher risk of birth defects , 35. In Important gaps were noticed. Clear indications for directing women pregnant using ART to low- versus high-risk antenatal care do not exist. Furthermore, consensus regarding ideal antenatal care  of these women is lacking in both low-risk and high-risk settings. Although it is recognized that there is a higher incidence of mono-chorionic twinning with IVF than the general population, none of the guidelines addressed the use of early ultrasound to determine twin chorionicity. In relation to evidence-base recommendations known to decrease adverse pregnancy outcomes in women at high risk, none of the identified CPGs considered folic acid supplementation to decrease the risk of congenital anomalies in ART pregnancies, or the use of low-dose aspirin to decrease the risk of preeclampsia. Moreover, recent guidelines specific to these two recommendations in the general obstetrical population, did not identify ART pregnancies as a high risk population who could benefit from an adjusted dose of folic acid , or low-There is evidence that supports an increased risk of adverse maternal and perinatal outcomes in pregnancies conceived using ART. The underlying cause of infertility may play a role, and even within ART, there appears to be different levels of risk depending on the technology used. As this quality of evidence grows and improves, CPGs specific to this population need to be re-evaluated. Although the quality of most included guidelines were deemed to require modifications , it is recommended that women who conceive using ART should be followed by health care providers with a recognized postgraduate qualification in obstetrics, be offered appropriate screening and diagnostic tests, and have access to psychosocial counselling throughout the entire process. The benefit of current recommendations known to decrease the risk of congenital malformations and preeclampsia in the general obstetrical population should be evaluated in ART pregnancies.Additional file 1:Search Strategy for Pregnancy using ART – Guidelines/Care Plans (DOCX 18 kb)Additional file 2:Excluded studies with reasons (DOCX 38 kb)


The numbers of older persons experiencing homelessness (OPEH) is on the rise globally Yet housing and shelter options that support the varied and complex needs of this population are scarce. In order to understand effective solutions for housing OPEH, it is critical to explore promising practices that support aging in the right place for OPEH. In an effort to inform this critical gap, 100 OPEH and service providers were purposefully selected and invited to attend one of three World Café workshops held in three major urban cities in Canada: Vancouver, Calgary, and Montréal. Participants engaged in facilitated discussions aimed at supporting knowledge exchange and generating dialogue about gaps, opportunities and promising local housing options. Thematic analyses of audiotaped deliberations revealed three themes: 1) The limited nature of current housing options and programs in each locality; 2) The importance of supporting integrative housing models that increase access to formal health and social support staff, transportation, and income supports; and 3) The significance of supporting sustainability, by conducting regular program evaluations, increasing public awareness of homelessness issues, and involving multi-sector stakeholders. Findings highlight how meeting the unique health and psychosocial needs of OPEH requires a nuanced understanding of the development, design, and sustainability of effective housing options. World Café dialogues revealed that identifying and sustaining existing promising practice models provides an avenue to supporting aging in the right place for OPEH.