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Concept: Contract


BACKGROUND: Systematic reviews have been challenged to consider effects on disadvantaged groups. A priori specification of subgroup analyses is recommended to increase the credibility of these analyses. This study aimed to develop and assess inter-rater agreement for an algorithm for systematic review authors to predict whether differences in effect measures are likely for disadvantaged populations relative to advantaged populations (only relative effect measures were addressed). METHODS: A health equity plausibility algorithm was developed using clinimetric methods with three items based on literature review, key informant interviews and methodology studies. The three items dealt with the plausibility of differences in relative effects across sex or socioeconomic status (SES) due to: 1) patient characteristics; 2) intervention delivery (i.e., implementation); and 3) comparators. Thirty-five respondents (consisting of clinicians, methodologists and research users) assessed the likelihood of differences across sex and SES for ten systematic reviews with these questions. We assessed inter-rater reliability using Fleiss multi-rater kappa. RESULTS: The proportion agreement was 66% for patient characteristics (95% confidence interval: 61%-71%), 67% for intervention delivery (95% confidence interval: 62% to 72%) and 55% for the comparator (95% confidence interval: 50% to 60%). Inter-rater kappa, assessed with Fleiss kappa, ranged from 0 to 0.199, representing very low agreement beyond chance. CONCLUSIONS: Users of systematic reviews rated that important differences in relative effects across sex and socioeconomic status were plausible for a range of individual and population-level interventions. However, there was very low inter-rater agreement for these assessments. There is an unmet need for discussion of plausibility of differential effects in systematic reviews. Increased consideration of external validity and applicability to different populations and settings is warranted in systematic reviews to meet this need.

Concepts: Evidence-based medicine, Assessment, Interval finite element, Meta-analysis, Cohen's kappa, Inter-rater reliability, Contract, Fleiss' kappa


Intergroup conflicts are ubiquitous-they occur, for instance, between (work)groups, departments, organizations, political parties, or nations. Such conflicts are commonly addressed through negotiations, in which representatives negotiate on behalf of their constituency. Intergroup negotiations are complex, as representatives need to navigate between the interests of their own constituency and the other party. This implies that negotiation success requires careful processing of information about both parties' interests. Here, we examine how representative negotiators' motivation to engage in such thorough information processing is influenced by their position in the group. Whereas prototypical representatives feel secure about their membership, peripheral representatives have a less certain position. We propose that peripheral representatives are therefore more attentive and responsive to information that may be relevant to the negotiation than prototypical representatives, but only when they are accountable to their constituents. Data from 4 experiments showed that peripheral representatives reported higher information-processing motivation (Experiment 1), bought and recalled more information (Experiment 2), exhibited greater sensitivity to emotional expressions of the outgroup representative (Experiment 3), and attained more integrative (“win-win”) agreements (Experiment 4) than prototypical representatives, but only when they were accountable. The findings are discussed in relation to theorizing on group dynamics, motivated information processing, emotion, and intergroup conflict, and practical implications are considered. (PsycINFO Database Record © 2012 APA, all rights reserved).

Concepts: Mediation, Dispute resolution, Negotiation, Win-win game, Contract


As physicians seek innovative practice models, one that is gaining ground is for practices to contract with patients to pay directly for some or all services-often called cash-only, retainer, boutique, concierge, or direct primary care or specialty care practices. Such descriptions do not reflect the variability found in practices. For the purposes of this paper, the American College of Physicians (ACP) defines a direct patient contracting practice (DPCP) as any practice that directly contracts with patients to pay out-of-pocket for some or all of the services provided by the practice, in lieu of or in addition to traditional insurance arrangements, and/or charges an administrative fee to patients, sometimes called a retainer or concierge fee, often in return for a promise of more personalized and accessible care. This definition encompasses the practice types previously described. The move to DPCPs is based on the premise that access and quality of care will be improved without third-party payers imposing themselves between the patient and the physician. Yet concerns have been raised that DPCPs may cause access issues for patients that cannot afford to pay directly for care. This ACP position paper, initiated and written by its Medical Practice and Quality Committee and approved by the Board of Regents on 25 July 2015, assesses the impact of DPCPs on access, cost, and quality; discusses principles from the ACP Ethics Manual, Sixth Edition, that should apply to all practice types; and makes recommendations to mitigate any adverse effect on underserved patients.

Concepts: Medicine, Patient, Hospital, Physician, Doctor-patient relationship, Contract


Many cellular processes are driven by cytoskeletal assemblies. It remains unclear how cytoskeletal filaments and motor proteins organize into cellular scale structures and how molecular properties of cytoskeletal components affect the large scale behaviors of these systems. Here we investigate the self-organization of stabilized microtubules in Xenopus oocyte extracts and find that they can form macroscopic networks that spontaneously contract. We propose that these contractions are driven by the clustering of microtubule minus ends by dynein. Based on this idea, we construct an active fluid theory of network contractions which predicts a dependence of the timescale of contraction on initial network geometry, a development of density inhomogeneities during contraction, a constant final network density, and a strong influence of dynein inhibition on the rate of contraction, all in quantitative agreement with experiments. These results demonstrate that the motor-driven clustering of filament ends is a generic mechanism leading to contraction.

Concepts: Eukaryote, Cytoskeleton, Mitosis, Dynein, Kinesin, Tubulin, Microtubule, Contract


To examine the extent, and nature, of impact on junior doctors' career decisions, of a proposed new contract and the uncertainty surrounding it.

Concepts: Decision making, National Health Service, Impact factor, Contract, Contractual term


Trade poses risks and opportunities to public health nutrition. This paper discusses the potential food-related public health risks of a radical new kind of trade agreement: the Trans Pacific Partnership agreement (TPP). Under negotiation since 2010, the TPP involves Australia, Brunei, Canada, Chile, Japan, Malaysia, Mexico, New Zealand, Peru, Singapore, the USA, and Vietnam. Here, we review the international evidence on the relationships between trade agreements and diet-related health and, where available, documents and leaked text from the TPP negotiations. Similar to other recent bilateral or regional trade agreements, we find that the TPP would propose tariffs reductions, foreign investment liberalisation and intellectual property protection that extend beyond provisions in the multilateral World Trade Organization agreements. The TPP is also likely to include strong investor protections, introducing major changes to domestic regulatory regimes to enable greater industry involvement in policy making and new avenues for appeal. Transnational food corporations would be able to sue governments if they try to introduce health policies that food companies claim violate their privileges in the TPP; even the potential threat of litigation could greatly curb governments' ability to protect public health. Hence, we find that the TPP, emblematic of a new generation of 21st century trade policy, could potentially yield greater risks to health than prior trade agreements. Because the text of the TPP is secret until the countries involved commit to the agreement, it is essential for public health concerns to be articulated during the negotiation process. Unless the potential health consequences of each part of the text are fully examined and taken into account, and binding language is incorporated in the TPP to safeguard regulatory policy space for health, the TPP could be detrimental to public health nutrition. Health advocates and health-related policymakers must be proactive in their engagement with the trade negotiations.

Concepts: Policy, International trade, Negotiation, Contract, World Trade Organization, General Agreement on Tariffs and Trade, North American Free Trade Agreement, Customs union


Health system reforms in England are opening broad areas of clinical practice to new providers of care. As part of these reforms, new entrants - including private companies - have been allowed into the primary care market under ‘alternative provider of medical services’ contracting mechanisms since 2004. The characteristics and performance of general practices working under new alternative provider contracts are not well described. We sought to compare the quality of care provided by new entrant providers to that provided by the traditional model of general practice.

Concepts: Health care, Medicine, Health, Clinical trial, Medical ethics, Contract, Common law, Privately held company


Strategic purchasing is one of the key policy instruments to achieve the universal health coverage (UHC) goals of improved and equitable access and financial risk protection. Given favourable outcomes of Universal Coverage Scheme (UCS), this study synthesized strategic purchasing experiences in the National Health Security Office (NHSO) responsible for the UCS in contributing to achieving UHC goals. The UCS applied the purchaser-provider split concept where NHSO, as a purchaser, is in a good position to enforce accountability by public and private providers to the UCS beneficiaries, through active purchasing. A comprehensive benefit package resulted in high level of financial risk protection as reflected by low incidence of catastrophic health spending and impoverished households. The NHSO contracted the District Health System (DHS) network, to provide outpatient, health promotion and disease prevention services to the whole district population, based on an annual age-adjusted capitation payment. In most cases, the DHS was the only provider in a district without competitors. Geographical monopoly hampered the NHSO to introduce a competitive contractual agreement, but a durable, mutually dependent relationship based on trust was gradually evolved, while accreditation is an important channel for quality improvement. Strategic purchasing services from DHS achieved a pro-poor utilization due to geographical proximity, where travel time and costs were minimal. Inpatient services paid by Diagnostic Related Group within a global budget ceiling, which is estimated based on unit costs, admission rates and admission profiles, contained cost effectively. To prevent potential under-provisions of the services, some high cost interventions were unbundled from closed end payment and paid on an agreed fee schedule. Executing monopsonistic purchasing power by NHSO brought down price of services given assured quality. Cost saving resulted in more patients served within a finite annual budget.

Concepts: Medicine, Universal health care, Risk, Prevention, Cost, Finance, Contract, Gentlemen's agreement


On August 8, 33 weeks into the longest, largest, and most widespread Ebola outbreak on record, the World Health Organization (WHO) declared the epidemic to be a Public Health Emergency of International Concern (PHEIC). This declaration was not made lightly. A PHEIC is an instrument of the International Health Regulations (IHR) - a legally binding agreement made by 196 countries on containment of major international health threats. The August 8 statement made by WHO Director-General Margaret Chan followed advice from the independent IHR Emergency Committee. Reviewing all the available evidence, the committee concluded that further international spread of Ebola could . . .

Concepts: Public health, Epidemiology, English-language films, Pandemic, World Health Organization, Contract, Gentlemen's agreement, Margaret Chan


In the absence of theoretical or empirical agreement on how to establish and maintain engagement in instructor-led health care simulation debriefings, we organize a set of promising practices we have identified in closely related fields and our own work. We argue that certain practices create a psychologically safe context for learning, a so-called safe container. Establishing a safe container, in turn, allows learners to engage actively in simulation plus debriefings despite possible disruptions to that engagement such as unrealistic aspects of the simulation, potential threats to their professional identity, or frank discussion of mistakes. Establishing a psychologically safe context includes the practices of (1) clarifying expectations, (2) establishing a “fiction contract” with participants, (3) attending to logistic details, and (4) declaring and enacting a commitment to respecting learners and concern for their psychological safety. As instructors collaborate with learners to perform these practices, consistency between what instructors say and do may also impact learners' engagement.

Concepts: Health care, Psychology, Cognitive science, Management, Learning, Developmental psychology, Engagement, Contract