Practice-Level Variation in Outpatient Cardiac Care and Association With Outcomes.

BACKGROUND: Utilization of cardiac services varies across regions and hospitals, yet little is known regarding variation in the intensity of outpatient cardiac care across cardiology physician practices or the association with clinical endpoints, an area of potential importance to promote efficient care. METHODS AND RESULTS: We included 7 160 732 Medicare beneficiaries who received services from 5635 cardiology practices in 2012. Beneficiaries were assigned to practices providing the plurality of office visits, and practices were ranked and assigned to quartiles using the ratio of observed to predicted annual payments per beneficiary for common cardiac services (outpatient intensity index). The median (interquartile range) outpatient intensity index was 1.00 (0.81-1.24). Mean payments for beneficiaries attributed to practices in the highest (Q4) and lowest (Q1) quartile of outpatient intensity were: all cardiac payments (Q4 $1272 vs Q1 $581; ratio, 2.2); cardiac catheterization (Q4 $215 vs Q1 $64; ratio, 3.4); myocardial perfusion imaging (Q4 $253 vs Q1 $83; ratio, 3.0); and electrophysiology device procedures (Q4 $353 vs Q1 $142; ratio, 2.5). The adjusted odds ratios (95% CI) for 1 incremental quartile of outpatient intensity for each outcome was: cardiac surgical/procedural hospitalization (1.09 [1.09, 1.10]); cardiac medical hospitalization (1.00 [0.99, 1.00]); noncardiac hospitalization (0.99 [0.99, 0.99]); and death at 1 year (1.00 [0.99, 1.00]). CONCLUSION: Substantial variation in the intensity of outpatient care exists at the cardiology practice level, and higher intensity is not associated with reduced mortality or hospitalizations. Outpatient cardiac care is a potentially important target for efforts to improve efficiency in the Medicare population.

Duty of care and slippery floors

Reflects on the scope of a shop owner's duty of care under the Occupiers' Liability Act 1957 to keep floors clear of spillages. Reviews the principles formulated by the Court of Appeal in Ward v Tesco Stores Ltd, including the evidential burden to show the discharge of the duty, and the approach adopted in subsequent cases. Discusses the High Court ruling in Piccolo v Larkstock Ltd (t/a Chiltern Flowers) on whether a small florist on Marylebone Station concourse was obliged to keep the floor dry and petal-free at all times and notes the importance of a proper system to safeguard customers.

Managing time: integration of care and paid work amongst low income families and the role of the United Kingdom’s tax credit system

Under the New Labour Governments in the UK, successive reforms of the tax and benefit system sought to improve the financial benefits of paid work. Drawing on two waves of qualitative interviews with low-income working families this article examines the role of the UK tax credit system in shaping decisions about employment and unpaid care work. The article suggests that the financial support provided for lone parent participants by the tax credit system enhanced their temporal autonomy, permitting participation in paid work to align more closely with temporally situated notions of parental responsibility for caring. For couple families however, parental perceptions of responsibility for pre-school children, along with childcare constraints and the structure of the tax credit system served to constrain the autonomy of the main carer and implicitly encourage a gendered specialisation in caring or employment.

Specific Newborn Individualized Developmental Care and Assessment Program movements are associated with acute pain in preterm infants in the neonatal intensive care unit

The Newborn Individualized Developmental Care and Assessment Program (NIDCAP) is widely used in neonatal intensive care units and comprises 85 discrete infant behaviors, some of which may communicate infant distress. The objective of this study was to identify developmentally relevant movements indicative of pain in preterm infants.