Accountable care-a way to align health care payments with patient-focused reform goals-is currently being pursued in the United States, but its principles are also being applied in many other countries. In this article we review experiences with such reforms to offer a globally applicable definition of an accountable care system and propose a conceptual framework for characterizing and assessing accountable care reforms. The framework consists of five components: population, outcomes, metrics and learning, payments and incentives, and coordinated delivery. We describe how the framework applies to accountable care reforms that are already being implemented in Spain and Singapore. We also describe how it can be used to map progress through increasingly sophisticated levels of reforms. We recommend that policy makers pursuing accountable care reforms emphasize the following steps: highlight population health and wellness instead of just treating illness; pay for outcomes instead of activities; create a more favorable environment for collaboration and coordinated care; and promote interoperable data systems.

Background Regions within England, Scotland and Wales show variation in rate of adoption of biosimilar infliximab and etanercept. Objectives This study aims to examine how local decisions and practices in regions within England, Scotland and Wales might explain initial variation in market dynamics of biosimilar and originator infliximab and etanercept. Methods Market data provided by the National Health Service (NHS) on biosimilar and originator infliximab and etanercept uptake were analysed for the 10 historical regions of England, 14 health boards in Scotland and 7 health boards in Wales (2015)(2016)(2017)(2018). Findings were discussed in ten semi-structured interviews: on a national level with an industry representative (1), on a regional level with NHS employees in England (6), Scotland (1) and Wales (1), and on a local level with a representative of a clinical commissioning group in England (1). Results Tenders for infliximab and etanercept in England, Scotland and Wales have consistently resulted in a biosimilar as the best value biological. Early and late biosimilar adopters are seen, with overall convergence towards high biosimilar market shares over time. Qualitative results suggest that biosimilar adoption was positively influenced by (a) a price difference between biosimilar and originator product making it worthwhile to switch patients; (b) a good relationship between commissioner and provider in England resulting in gain share agreements; (c) leadership on biosimilars in regional NHS offices in England or Scottish and Welsh health boards; (d) key opinion leaders or leading hospitals that start using biosimilars early and gain experience. Conclusions This study has shown that the savings potential drives biosimilar use. Regions with a proactive attitude, good stakeholder relationships, and clinician engagement were identified as early adopters.Steven Simoens and Isabelle Huys: Joint last authors.

Objective This survey examined the current management of continuous ambulatory peritoneal dialysis (CAPD) peritonitis and the effectiveness of the various antibiotic protocols in use. Design The information required was elicited via a postal questionnaire. Setting The questionnaire was posted to each renal dialysis unit offering CAPD throughout the North and South Thames National Health Service regions. Patients All patients using CAPD at each responding unit were eligible for inclusion. Main Outcome Measures Each unit provided details of their CAPD peritonitis episodes for 1997. Each unit's empirical treatment regimen for CAPD peritonitis was sought in addition to response rates. Also requested were numbers for peritonitis episodes, recurrences, and negative cultures, plus the peritonitis rate per patient-month. Results Thirteen units returned the questionnaire (87% of the survey population). Nine of the 13 units were using vancomycin regimens, with the remainder using cephalosporin regimens. The results were compared to the audit standards of the British Renal Association. Seventy percent of units reached the 80% mark for response rate; similar results were achieved with both the vancomycin and cephalosporin regimens. Ninety-two percent achieved the suggested peritonitis rate of 1 episode every 18 patient-months; 30% achieved the culture-negative rate of 10%. The average recurrence rate was 19%. Conclusion The units contacted achieved most of the standards suggested by the British Renal Association; however, wide variations did exist. Recent guidelines have suggested avoiding vancomycin-based regimens in order to reduce the incidence of vancomycin resistance. The suggested regimen of a cephalosporin with an aminoglycoside seems to represent a suitable alternative.

Described is a new method for single-hand tying of the Surgeon's or Friction Knot, which is essentially a modification of the basic knot-tying technique, involving the formation of an inside loop. It is recommended for obtaining secure knots with synthetic suture materials.