Association between provider specialty and healthcare costs and glycemic control for patients with diabetes

Aims: To analyze the association between provider, healthcare costs, and glycemic control for patients with diabetes mellitus (DM).

Materials and methods: This cross-sectional study identified adults with type 1 or 2?DM (T1D, T2D) in the Optum database. The main independent variable was provider (endocrinologist or primary care). Regression analysis compared total medical and pharmacy costs, adjusting for health status and other patient differences, by provider.

Results: For all patients, HbA1C improvement was greater, and medical costs significantly lower with an endocrinologist rather than a primary care provider. The largest HbA1C improvement (4%) occurred for insulin-dependent patients seen by endocrinologists. Significant medical savings with endocrinologist management occurred within the Medicare Advantage population in every sub-group of patients, with 14% lower costs ($4,767) for patients with T1D, 11% lower costs ($3,160) for patients with macro- and microvascular complications, and 10% lower costs ($2,237) for insulin-dependent patients. Within the commercial insurance population, medical costs were reduced by ≥9% in every sub-group of patients, with a 20% reduction ($8,450) for patients with micro- and macrovascular complications. Overall total costs (medical and pharmacy) were 8% ($1,541) higher for patients receiving endocrinologist rather than primary care, although endocrinologist care resulted in a 9% reduction (–$3,710) in costs for Medicare Advantage patients with T1D. Total medical costs (excluding pharmacy costs) may be a more accurate indicator of costs associated with patients in various stages of DM.

Limitations: There was insufficient data to develop risk-adjustment payments for pharmacy costs based on disease severity. The cross-sectional design identifies associations and not cause–effect relationships.

Conclusion: DM management by an endocrinologist was associated with greater HbA1C improvement and significantly lower medical costs. Total costs were higher with an endocrinologist, but for patients with T1D lower costs were seen, ranging from 2–9% regardless of insurance type.     

Families at leisure outdoors: well-being through adventure

ABSTRACT

This study investigates families who choose to co-participate in outdoor adventure holidays, and explores how they benefit from these shared experiences. In so doing, it seeks to determine the role of adventure tourism in developing and enhancing family well-being (FWB). Hyper-modern family life for many is powered by technological hardware, each room in the house replete with on-line pleasures, distractions and identities. In response to this dystopia, some families opt to take adventure holidays together. However, scholarship concerning collective experiences of adventurous leisure, in this case as families, is limited. Using a qualitative whole family approach, 15 (adventure tourist) families were interviewed, totalling 62 interviewees (29 adults and 33 children under 18 years old), in their home environments. Four key themes related to FWB emerged. First, families extended their active lifestyles to adventure holidays and repeatedly mentioned the health and fitness benefits gained from these experiences. Second, adventure holidays facilitated unmediated time together for families. Third, parents harboured ideals of positive personal development for their children in these adventure settings. Fourth, making memories during adventure holidays, and recollecting these post-trip, were integral to family bonding. Further research should consider non-traditional families, and various socio-economic and cultural groups in this context.     

Sequential decisions with tests

We consider a principal-agent problem where the principal wishes to be endorsed by a sequence of agents, but cannot truthfully reveal type. In the standard “herding” model, the agents learn from each other's decisions, which can lead to cascades on a given decision when later agents' private information is swamped. We augment the standard model to allow the principal to subject herself to a test designed to provide public information about her type. She must decide how tough a test to attempt from a continuum of test types, which involves trading off the higher probability of passing an easier test against the greater impact from passing a tougher test. We find that the principal will always choose to be tested, and will prefer a tough test to a neutral or easy one.     

Turkmenistan: From Communism to Nationalism by Gradual Economic Reform

Turkmenistan's economic performance during the first decade after independence is interesting because it is an extreme case, regularly ranking last among all the former centrally planned economies by transition indicators measuring speed of reform or degree of economic liberalization. This paper analyses the evolution of the economic system and Turkmenistan's economic development since 1991. The country's abundant resource endowment provided favourable initial conditions for pursuing an agenda that gave a low priority to economic reform, while emphasizing the country's neutrality and minimizing internal political change. Nevertheless, in 1997 the unreformed economy suffered a deep decline and, although it has enjoyed some recovery since 1999, the overall performance of GDP since independence is one of the worst among all transition economies. Although the government had achieved its external and internal political goals, the economic strategy appeared to be unsustainable.     

Telling and selling the value of diversity and inclusion—External consultants' discursive strategies and practices

On the basis of a qualitative study of a subgroup of diversity professionals, external diversity and inclusion (D&I) consultants, we explore D&I consultants' discursive strategies and practices situated within organisational structures, relations, and interactions of power and knowledge. Theoretically, the research reveals how D&I consultants' own discursive strategies interact with existing organisational and societal discourses of diversity, incrementally shaping their continual evolution. A classification is developed, which sets out four approaches taken by consultants with regard to their discursive strategies in relation to clients. The findings suggest that HR practitioners need to work in tandem with external consultants to develop strategies to improve the status and legitimacy of diversity work if the field is to progress the organisational D&I agenda.     

The optimal choice of pre-launch reviewer

We develop a framework in which: (i) a firm can have a new product tested publicly before launch; and (ii) tests vary in toughness, holding expertise fixed. Price flexibility boosts the positive impact on consumer beliefs of passing a tough test and mitigates the negative impact of failing a soft test. As a result, profits are convex in toughness: the firm selects either the toughest or softest test available. The toughest test is optimal when consumers start with an unfavorable prior and receive sufficiently uninformative private signals (an “innovative” product); the softest test is optimal when signals are sufficiently informative.     

Possibilities for remote participation in trade unions: mobilising women activists

This paper argues that trade union activism within the new era of information and communication technologies (ICTs) offers the potential for unions to become more inclusive of under‐represented groups. Traditional conceptions of activism, participation and democracy within trade unions require physical presence at meetings at times and in spaces incompatible with caring responsibilities and atypical hours of work. This restricts the participation of women and other ‘atypical’ workers in trade unions. The paper explores the complexities of electronic forms of union activism in practice, indicating that while some positive features are experienced, there are also a range of obstacles, barriers and possible negative consequences.     

How do managerial techniques evolve over time? The distortion of “facilitation” in healthcare service improvement

When applied to solving real-world problems in the public sector, managerial techniques are likely to evolve over time in response to the context of their implementation. The temporal dynamics of this evolution and its underlying processes, however, remain under-researched. To address this gap, we present a qualitative longitudinal case study of a UK-based knowledge mobilization programme utilizing “facilitation” as a service improvement approach. We describe the processes underpinning the distortion of facilitation over time and argue that an uncritical and uncontrolled adaptation of managerial techniques may mask the unsustainable nature of the resulting improvement outcomes captured by conventional performance measurement.