Risk adjustment in aging societies

Background In Switzerland, age is the predominant driver of solidarity transfers in risk adjustment (RA). Concerns have been voiced regarding growing imbalances in cost sharing between young and old insured due to demographic changes (larger fraction of elderly >65 years and rise in average age). Particularly young adults aged 19–25 with limited incomes have to shoulder increasing solidarity burdens. Between 1996 and 2011, monthly intergenerational solidarity payments for young adults have doubled from CHF 87 to CHF 182, which corresponds to the highest absolute transfer increase of all age groups. Results By constructing models for age-specific RA growth and for calculating the lifetime sum of RA transfers we investigated the causes and consequences of demographic changes on RA payments. The models suggest that the main driver for RA increases in the past was below average health care expenditure (HCE) growth in young adults, which was only half as high (average 2% per year) compared with older adults (average 4% per year). Shifts in age group distributions were only accountable for 2% of the CHF 95 rise in RA payments. Despite rising risk adjustment debts for young insured the balance of lifetime transfers remains positive as long as HCE growth rates are greater than the discount rate used in this model (3%). Moreover, the life-cycle model predicts that the lifetime rate of return on RA payments may even be further increased by demographic changes. Nevertheless, continued growth of RA contributions may overwhelm vulnerable age groups such as young adults. We therefore propose methods to limit the burden of social health insurance for specific age groups (e.g. young adults in Switzerland) by capping solidarity payments. Conclusions Taken together, our mathematical modelling framework helps to gain a better understanding of how demographic changes interact with risk adjustment and how redistribution of funds between age groups can be controlled without inducing further selection incentives. Those methods can help to construct more equitable systems of health financing in light of population aging.

Exercise efficiency relates with mitochondrial content and function in older adults

Chronic aerobic exercise has been shown to increase exercise efficiency, thus allowing less energy expenditure for a similar amount of work. The extent to which skeletal muscle mitochondria play a role in this is not fully understood, particularly in an elderly population. The purpose of this study was to determine the relationship of exercise efficiency with mitochondrial content and function. We hypothesized that the greater the mitochondrial content and/or function, the greater would be the efficiencies. Thirty-eight sedentary (S, n = 23, 10F/13M) or athletic (A, n = 15, 6F/9M) older adults (66.8 ± 0.8 years) participated in this cross sectional study. V˙O2peak was measured with a cycle ergometer graded exercise protocol (GXT). Gross efficiency (GE, %) and net efficiency (NE, %) were estimated during a 1-h submaximal test (55% V˙O2peak). Delta efficiency (DE, %) was calculated from the GXT. Mitochondrial function was measured as ATPmax (mmol/L/s) during a PCr recovery protocol with (31)P-MR spectroscopy. Muscle biopsies were acquired for determination of mitochondrial volume density (MitoVd, %). Efficiencies were 17% (GE), 14% (NE), and 16% (DE) higher in A than S. MitoVD was 29% higher in A and ATPmax was 24% higher in A than in S. All efficiencies positively correlated with both ATPmax and MitoVd. Chronically trained older individuals had greater mitochondrial content and function, as well as greater exercise efficiencies. GE, NE, and DE were related to both mitochondrial content and function. This suggests a possible role of mitochondria in improving exercise efficiency in elderly athletic populations and allowing conservation of energy at moderate workloads.

Outcomes associated with chemotherapy in elderly patients with early stage operable breast cancer

Background. Various clinical trials have proved the efficacy of adjuvant chemotherapy in women with breast cancer. Chemotherapy efficacy and guidelines for its use differ by stage of tumor and age of the patient with no clear recommendations for patients aged 70 and above. Objective. To examine the clinical and economic outcomes associated with chemotherapy use in and to examine the disparities in treatment and survival in elderly patients with early stage operable breast cancer by age and axillary node status. Methods. We studied a cohort of 23,110 node positive and 31,572 node negative women aged 65 and over diagnosed with incident American Joint Committee on Cancer (AJCC) stage I, II or IIIa breast cancer between January 1, 1991 and December 31, 2002 using SEER-Medicare data. Total patient costs were estimated using the phase of care approach and adjusted cost estimates were obtained from regression analysis using a 3% discount rate. Cox proportional hazard ratio of mortality was used to determine the effectiveness of chemotherapy. Propensity score approach was also used to minimize the bias associated with receipt of chemotherapy. To assess disparity in treatment, multivariate logistic regression analyses were performed to assess the relative odds of receiving surgery, chemotherapy and radiation after BCS for African Americans compared to Whites. Results. Regression adjusted cost estimates for all node positive patients receiving chemotherapy was approximately $2,300 and was significantly higher (p<0.05) than for patients not receiving chemotherapy. Mortality was significantly lower in node positive and node negative women aged 65-74 years receiving chemotherapy. There was a significant difference between African American and White women in receiving BCS and radiation after BCS; however this difference was explained by patient demographics, tumor characteristics and socioeconomic status (SES). African American node positive women were 21% less likely to receive chemotherapy than White women (OR, 0.79; CI, 0.68-0.92) in multivariate analysis. Conclusion. Chemotherapy is associated with increased survival in patients aged 65-74 and total costs attributable to chemotherapy differ by phase and age of the patient. Underutilization of systemic adjuvant chemotherapy in African American women requires attention and may serve as potential areas for appropriate intervention.^

A review of economic analysis in the vaccination program; decision making and governance: Adivisory Committee on Immunization Practices (ACIP)

The Advisory Committee on Immunization Practices (ACIP) develops written recommendations for the routine administration of vaccines to children and adults in the U.S. civilian population. The ACIP is the only entity in the federal government that makes such recommendations. ACIP elaborates on selection of its members and rules out concerns regarding its integrity, but fails to provide information about the importance of economic analysis in vaccine selection. ACIP recommendations can have large health and economic consequences. Emphasis on economic evaluation in health is a likely response to severe pressures of the federal and state health budget. This study describes the economic aspects considered by the ACIP while sanctioning a vaccine, and reviews the economic evaluations (our economic data) provided for vaccine deliberations. A five year study period from 2004 to 2009 is adopted. Publicly available data from ACIP web database is used. Drummond et al. (2005) checklist serves as a guide to assess the quality of economic evaluations presented. Drummond et al.'s checklist is a comprehensive hence it is unrealistic to expect every ACIP deliberation to meet all of their criteria. For practical purposes we have selected seven criteria that we judge to be significant criteria provided by Drummond et al. Twenty-four data points were obtained in a five year period. Our results show that out of the total twenty-four data point‘s (economic evaluations) only five data points received a score of six; that is six items on the list of seven were met. None of the data points received a perfect score of seven. Seven of the twenty-four data points received a score of five. A minimum of a two score was received by only one of the economic analyses. The type of economic evaluation along with the model criteria and ICER/QALY criteria met at 0.875 (87.5%). These three criteria were met at the highest rate among the seven criteria studied. Our study findings demonstrate that the perspective criteria met at 0.583 (58.3%) followed by source and sensitivity analysis criteria both tied at 0.541 (54.1%). The discount factor was met at 0.250 (25.0%).^ Economic analysis is not a novel concept to the ACIP. It has been practiced and presented at these meetings on a regular basis for more than five years. ACIP‘s stated goal is to utilize good quality epidemiologic, clinical and economic analyses to help policy makers choose among alternatives presented and thus achieve a better informed decision. As seen in our study the economic analyses over the years are inconsistent. The large variability coupled with lack of a standardized format may compromise the utility of the economic information for decision-making. While making recommendations, the ACIP takes into account all available information about a vaccine. Thus it is vital that standardized high quality economic information is provided at the ACIP meetings. Our study may provide a call for the ACIP to further investigate deficiencies within the system and thereby to improve economic evaluation data presented. ^

Policy analysis of Texas Senate Bill 532 and the regulation of nurse practitioners in the convenience care model

Background. Retail clinics, also called convenience care clinics, have become a rapidly growing trend since their initial development in 2000. These clinics are coupled within a larger retail operation and are generally located in "big-box" discount stores such as Wal-mart or Target, grocery stores such as Publix or H-E-B, or in retail pharmacies such as CVS or Walgreen's (Deloitte Center for Health Solutions, 2008). Care is typically provided by nurse practitioners. Research indicates that this new health care delivery system reduces cost, raises quality, and provides a means of access to the uninsured population (e.g., Deloitte Center for Health Solutions, 2008; Convenient Care Association, 2008a, 2008b, 2008c; Hansen-Turton, Miller, Nash, Ryan, Counts, 2007; Salinsky, 2009; Scott, 2006; Ahmed & Fincham, 2010). Some healthcare analysts even suggest that retail clinics offer a feasible solution to the shortage of primary care physicians facing the nation (AHRQ Health Care Innovations Exchange, 2010). ^ The development and performance of retail clinics is heavily dependent upon individual state policies regulating NPs. Texas currently has one of the most highly regulated practice environments for NPs (Stout & Elton, 2007; Hammonds, 2008). In September 2009, Texas passed Senate Bill 532 addressing the scope of practice of nurse practitioners in the convenience care model. In comparison to other states, this law still heavily regulates nurse practitioners. However, little research has been conducted to evaluate the impact of state laws regulating nurse practitioners on the development and performance of retail clinics. ^ Objectives. (1). To describe the potential impact that SB 532 has on retail clinic performance. (2). To discuss the effectiveness, efficiency, and equity of the convenience care model. (3). To describe possible alternatives to Texas' nurse practitioner scope of practice guidelines as delineated in Texas Senate Bill 532. (4). To describe the type of nurse practitioner state regulation (i.e. independent, light, moderate, or heavy) that best promotes the convenience care model. ^ Methods. State regulations governing nurse practitioners can be characterized as independent, light, moderate, and heavy. Four state NP regulatory types and retail clinic performance were compared and contrasted to that of Texas regulations using Dunn and Aday's theoretical models for conducting policy analysis and evaluating healthcare systems. Criteria for measurement included effectiveness, efficiency, and equity. Comparison states were Arizona (Independent), Minnesota (Light), Massachusetts (Moderate), and Florida (Heavy). ^ Results. A comparative states analysis of Texas SB 532 and alternative NP scope of practice guidelines among the four states: Arizona, Florida, Massachusetts, and Minnesota, indicated that SB 532 has minimal potential to affect the shortage of primary care providers in the state. Although SB 532 may increase the number of NPs a physician may supervise, NPs are still heavily restricted in their scope of practice and limited in their ability to act as primary care providers. Arizona's example of independent NP practice provided the best alternative to affect the shortage of PCPs in Texas as evidenced by a lower uninsured rate and less ED visits per 1,000 population. A survey of comparison states suggests that retail clinics thrive in states that more heavily restrict NP scope of practice as opposed to those that are more permissive, with the exception of Arizona. An analysis of effectiveness, efficiency, and equity of the convenience care model indicates that retail clinics perform well in the areas of effectiveness and efficiency; but, fall short in the area of equity. ^ Conclusion. Texas Senate 532 represents an incremental step towards addressing the problem of a shortage of PCPs in the state. A comparative policy analysis of the other four states with varying degrees of NP scope of practice indicate that a more aggressive policy allowing for independent NP practice will be needed to achieve positive changes in health outcomes. Retail clinics pose a temporary solution to the shortage of PCPs and will need to expand their locations to poorer regions and incorporate some chronic care to obtain measurable health outcomes. ^

La cultura política : un objeto compartido

La denominación "cultura política" se ha constituido en objeto de estudio de diversas disciplinas sociales. Particularmente la historia de las ideas y la sociología política han convergido en este campo con el objeto de reconstruir redes de relaciones significativas entre el mundo simbólico y la vida política - social. Los itinerarios seguidos por ambas, así como propuestas y debates de autores de amplia difusión académica, nos muestra tanto el enriquecimiento, como las limitaciones, con que la producción en torno a los denominados "giro cultural", "lingüístico", "antropológico" y "sociológico", ha pretendido avanzar en la interpretación de significados con los que se teje la trama política.

Paul Veyne; "Cómo se escribe la historia. Foucault revoluciona la historia". Madrid, Alianza, 1984.

Fil: Fares, Celina. Universidad Nacional de Cuyo. Facultad de Ciencias Políticas y Sociales

Democracia y derechos de primera generación - Polimodal : proyecto pedagógico con modalidad a distancia para la terminalidad de estudios de EGB3 y Educación Polimodal EDITEP

El libro introduce al lector a la problemática actual de los derechos humanos y el ejercicio de la ciudadanía. Se abordan cuestiones como las diversas "generaciones" de derechos humanos, las luchas, declaraciones y universalización de los derechos civiles y políticos. También se incursiona en las violaciones de los derechos humanos en Argentina. Incluye actividades didácticas individuales y grupales. Se editó como material de aprendizaje destinado al personal de seguridad pública de la Provincia de Mendoza en el marco del proyecto pedagógico con modalidad a distancia para la terminalidad de estudios de EGB3 y Educación Polimodal –EDITEP–, implementado a partir de la firma del Convenio entre la Universidad Nacional de Cuyo y el Gobierno de la Provincia de Mendoza, en octubre de 2003.

Democracia y derechos de segunda y tercera generación - Polimodal : proyecto pedagógico con modalidad a distancia para la terminalidad de estudios de EGB3 y Educación Polimodal EDITEP

Este libro es un material didáctico sobre la actuación del Estado y la regulación jurídica emitida con el fin de delimitar y/o promover los derechos de segunda y tercera generación. Busca que el lector comprenda nociones y problemas fundamentales de la relación: "democracia y derechos humanos", en su proceso histórico y en relación con el presente; que analice críticamente las dimensiones y las características de los procesos de construcción de los derechos humanos de segunda y tercera generación y de la democracia en el contexto nacional, a partir de las problemáticas planteadas y de su propia experiencia de vida; y que valore el compromiso de los ciudadanos en el desempeño de roles sociales y laborales que hacen al mejoramiento de la calidad democrática y al respeto y cumplimiento de los derechos humanos. Se editó como material de aprendizaje destinado al personal de seguridad pública de la Provincia de Mendoza en el marco del proyecto pedagógico con modalidad a distancia para la terminalidad de estudios de EGB3 y Educación Polimodal –EDITEP–, implementado a partir de la firma del Convenio entre la Universidad Nacional de Cuyo y el Gobierno de la Provincia de Mendoza, en octubre de 2003.

Identidades hispanas en EE.UU.

Este artículo analiza el tema de la identidad hispana / latina en EE.UU. como resultado de fuerzas históricas y políticas en juego desde el siglo XVI, despejando el tema de conceptos y prejuicios raciales o étnicos que tienden a justificar actitudes discriminatorias basadas en conceptos esencialistas. La categoría de “hispanos" que nace de varios encuentros ha significado el agrupamiento en EE.UU. de pueblos en su mayoría no-sajones, y dicha agrupación lleva a preguntarse ¿qué es ser “hispano" o “latino"? El artículo propone que la identidad hispana en EE.UU. surge como una manera de responder de manera coherente a una historia política que construye identidades en base a términos raciales. En suma, la raza y las identidades que ella sostiene nacen de procesos históricos y políticos y no constituyen una categoría “natural" dada. Como resultado de estos procesos, los grupos que se formen alrededor de la raza, y no de nacionalidades o culturas, en el esquema político norteamericano, tienen más posibilidades de que su voz se escuche a nivel nacional.

Reconstruyendo imaginarios sobre democracia : a propósito de las elecciones a partir de la crisis del 2001

El trabajo aborda la relación democracia y ciudadanía desde la dimensión subjetiva de la política e indaga las representaciones mentales del imaginario político sobre participación y representación ciudadana a partir de los procesos electorales. El objetivo es rescatar las significaciones que sostienen o transforman la institucionalidad democrática. La crisis del 2001 en Argentina generó nuevas formas de participación y un redimensionamiento de la democracia. Los resultados del trabajo atribuyen la escasa calidad democrática a la dirigencia política aunque abren la posibilidad de un mayor compromiso, participación y autonomía ciudadana y recuperación de lo político, como inescindible de lo social.

Trabajo Social

El debate profesional siempre es bienvenido y de algún modo es un giro en el quehacer de la educación, más en el ámbito de la educación universitaria. Todo debate se transforma en mayor o menor medida la labor cotidiana y, generalmente, hace emerger nuevos campos de análisis e intervención. La presente revista es un abono a este debate que hace tiempo es una constante en el Trabajo Social, no sólo a nivel nacional sino también internacional. Proceso que convoca a revisar las estructuras de las profesiones y, sobre todo, la pertinencia social del ejercicio y la formación profesional con el desarrollo de la visa social, política y científica de nuestras sociedades.

Sociología

Desde el año 2002, los docentes y graduados de la Carrera de Sociología de la Facultad de Ciencias Políticas y Sociales contamos con la Revista Confluencia como una valiosa herramienta para la divulgación de nuestras producciones Este espacio ha ido dejando testimonio tanto de los abordajes teórico-metodológicos como de los objetos de análisis que los docentes e investigadores de la carrera han elegido en cada coyuntura particular. En esta oportunidad nos complace presentar los artículos de la Revista Confluencia de Sociología 2010, ellos son el resultado de arduas jornadas de trabajo que se sintetizan en las páginas que siguen. La tarea de dar a conocer estas producciones ha sido gratificante. Creemos que Confluencia es una instancia que fortalece nuestra carrera, aprecia el trabajo de nuestros profesionales y, sobre todo, ha constituido, y sigue haciéndolo, un espacio de convivencia plural de la Sociología mendocina.

Ciencia Política y Administración Pública

Mas allá de las diferentes perspectivas teóricas o los aspectos prácticos que tratan, los trabajos incluidos en esta nueva presentación de la Revista Confluencia reafirman los objetivos de las publicaciones de nuestra facultad: la pretensión de servir a la difusión de los conocimientos que se producen en ella y a la vez permitir el intercambio y el debate entre docentes, investigadores, graduados y alumnos que dé cuenta de la pluralidad de miradas y las enriquezca, sin olvidar el deseo de que lleguen más allá de las fronteras académicas y puedan producir un impacto positivo en la sociedadad en que vivimos.

Prólogo

Fil: Fares, Celina. Universidad Nacional de Cuyo. Facultad de Ciencias Políticas y Sociales