Approximately four million adults in the United States are homebound, and many of them cannot access office-based primary care. Home-based medical care can improve outcomes and reduce health care costs, but this care operates in a quality measurement desert, having been largely left out of the national conversation on care quality. To address this shortcoming, two of the authors created the National Home-Based Primary and Palliative Care Network, an organization whose members include exemplary home-based medical practices, professional societies, and patient advocacy groups. This article describes the current status of home-based medical care in the United States and offers a brief narrative of a fictional homebound patient and the health events and fragmented care she faces. The article then describes the network's quality-of-care framework, which includes ten quality-of-care domains, thirty-two standards, and twenty quality indicators that are being tested in the field. The same two authors also developed a practice-based registry that will be used for quality-of-care benchmarking, practice-based quality improvement, performance reporting, and comparative effectiveness research. Together, these steps should help bring home-based medical care further into the mainstream of US health care.

Background It is unclear whether lack of follow-up after screening FOBT in older adults is due to screening patients whose comorbidity or preferences do not permit follow-up versus failure to complete follow-up in healthy patients. Methods Prospective cohort study of 2,410 patients ≥ 70 years screened with FOBT at 4 VA’s between 1/1/01-12/31/01. Main outcome was receipt of follow-up within 1 year of FOBT based on national VA and Medicare data. For patients with positive FOBT results, age and Charlson comorbidity scores were evaluated as potential predictors of receiving complete colon evaluation (colonoscopy or sigmoidoscopy plus barium enema) and medical records were reviewed to determine reasons for lack of follow-up. Results 212 (9%) patients had positive FOBT results; 42% received complete colon evaluation within 1 year. Age and comorbidity were not associated with receipt of complete follow-up, which was similar among patients 70–74 years with Charlson=0 compared with patients ≥ 80 years with Charlson≥1 (48% vs 41%; P=0.28). VA site, number of positive FOBT cards, and number of VA outpatient visits were predictors. Of 122 patients who did not receive follow-up within 1 year, 38% had documentation that comorbidity or preferences did not permit follow-up, and over the next 5 years 76% never received follow-up. Conclusions While follow-up after positive FOBT results was low regardless of age or comorbidity, screening patients in whom complete evaluation would not be pursued substantially contributes to lack of follow-up. Efforts to improve follow-up should address the full chain of decision-making, including decisions to screen and decisions to follow-up.

Tropical forests are an important source of atmospheric methane (CH 4 ), and recent work suggests that CH 4 fluxes from humid tropical environments are driven by variations in CH 4 production, rather than by bacterial CH 4 oxidation. Competition for acetate between methanogenic archaea and Fe(III)-reducing bacteria is one of the principal controls on CH 4 flux in many Fe-rich anoxic environments. Upland humid tropical forests are also abundant in Fe and are characterized by high organic matter inputs, steep soil oxygen (O 2 ) gradients, and fluctuating redox conditions, yielding concomitant methanogenesis and bacterial Fe(III) reduction. However, whether Fe(III)-reducing bacteria coexist with methanogens or competitively suppress methanogenic acetate use in wet tropical soils is uncertain. To address this question, we conducted a process-based laboratory experiment to determine if competition for acetate between methanogens and Fe(III)-reducing bacteria influenced CH 4 production and C isotope composition in humid tropical forest soils. We collected soils from a poor to moderately drained upland rain forest and incubated them with combinations of 13 C-bicarbonate, 13 C-methyl labeled acetate ( 13 CH 3 COO À ), poorly crystalline Fe(III), or fluoroacetate. CH 4 production showed a greater proportional increase than Fe 2 1 production after competition for acetate was alleviated, suggesting that Fe(III)-reducing bacteria were suppressing methanogenesis. Methanogenesis increased by approximately 67 times while Fe 2 1 production only doubled after the addition of 13 CH 3 COO À . Large increases in both CH 4 and Fe 2 1 production also indicate that the two process were acetate limited, suggesting that acetate may be a key substrate for anoxic carbon (C) metabolism in humid tropical forest soils. C isotope analysis suggests that competition for acetate was not the only factor driving CH 4 production, as 13 C partitioning did not vary significantly between 13 CH 3 COO À and 13 CH 3 COO À 1 Fe(III) treatments. This suggests that dissimilatory Fe(III)-reduction suppressed both hydrogenotrophic and aceticlastic methanogenesis. These findings have implications for understanding the CH 4 biogeochemistry of highly weathered wet tropical soils, where CH 4 efflux is driven largely by CH 4 production.

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