IMPORTANCE Low-value care is prevalent in the United States, yet little is known about the downstream health care use triggered by low-value services. Measurement of such care cascades is essential to understanding the full consequences of low-value care.OBJECTIVE To describe cascades (tests, treatments, visits, hospitalizations, and new diagnoses) after a common low-value service, preoperative electrocardiogram (EKG) for patients undergoing cataract surgery. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years or older without known heart disease who were continuously enrolled between

There is increasing concern globally about the enormity of the threats posed by antimicrobial resistance (AMR) to human, animal, plant and environmental health. A proliferation of international, national and institutional reports on the problems posed by AMR and the need for antibiotic stewardship have galvanised attention on the global stage. However, the AMR community increasingly laments a lack of action, often identified as an ‘implementation gap’. At a policy level, the design of internationally salient solutions that are able to address AMR’s interconnected biological and social (historical, political, economic and cultural) dimensions is not straightforward. This multidisciplinary paper responds by asking two basic questions: (A) Is a universal approach to AMR policy and antibiotic stewardship possible? (B) If yes, what hallmarks characterise ‘good’ antibiotic policy? Our multistage analysis revealed four central challenges facing current international antibiotic policy: metrics, prioritisation, implementation and inequality. In response to this diagnosis, we propose three hallmarks that can support robust international antibiotic policy. Emerging hallmarks for good antibiotic policies are: Structural, Equitable and Tracked. We describe these hallmarks and propose their consideration should aid the design and evaluation of international antibiotic policies with maximal benefit at both local and international scales.

This article uses quantitative and qualitative approaches to review 75 years of international policy reports on antimicrobial resistance (AMR). Our review of 248 policy reports and expert consultation revealed waves of political attention and repeated reframings of AMR as a policy object. AMR emerged as an object of international policy-making during the 1990s. Until then, AMR was primarily defined as a challenge of human and agricultural domains within the Global North that could be overcome via ‘rational’ drug use and selective restrictions. While a growing number of reports jointly addressed human and agricultural AMR selection, international organisations (IOs) initially focused on whistleblowing and reviewing data. Since 2000, there has been a marked shift in the ecological and geographic focus of AMR risk scenarios. The Global South and One Health (OH) emerged as foci of AMR reports. Using the deterritorialised language of OH to frame AMR as a Southern risk made global stewardship meaningful to donors and legitimised pressure on low-income and middle-income countries to adopt Northern stewardship and surveillance frameworks. It also enabled IOs to move from whistleblowing to managing governance frameworks for antibiotic stewardship. Although the environmental OH domain remains neglected, realisation of the complexity of necessary interventions has increased the range of topics targeted by international action plans. Investment nonetheless continues to focus on biomedical innovation and tends to leave aside broader socioeconomic issues. Better knowledge of how AMR framings have evolved is key to broadening participation in international stewardship going forward.

An extensive body of scholarship focuses on cultural diversity in health care, and this has resulted in a plethora of strategies to “manage” cultural difference. This work has often been patient-oriented (i.e., focused on the differences of the person being cared for), rather than relational in character. In this study, we aimed to explore how the difference was relational and coproduced in the accounts of cancer care professionals and patients with cancer who were from migrant backgrounds. Drawing on eight focus groups with 57 cancer care professionals and one-on-one interviews with 43 cancer patients from migrant backgrounds, we explore social relations, including intrusion and feelings of discomfort, moral logics of rights and obligation, and the practice of defaulting to difference. We argue, on the basis of these accounts, for the importance of approaching difference as relational and that this could lead to a more reflexive means for overcoming “differences” in therapeutic settings.

Background: Long-term nursing home residents have complex needs that often require services from acute care settings. The accountable care organization (ACO) model provides an opportunity to improve care by creating payment incentives for more coordinated, higher quality care. Objectives: To assess the extent of nursing home participation in ACOs, and the characteristics of residents and their nursing homes connected to ACOs. Research Design: This was a cross-sectional study. Subjects: Medicare nursing home residents identified from 2014 Minimum Data Set assessments. Residents were attributed to ACOs based on Medicare methods. Measures: Individuals’ demographics, clinical characteristics, health care utilization, and nursing home characteristics. Results: Among 660,780 nursing home residents, a quarter of them were attributed to ACOs. ACO residents had only small differences from non-ACO residents: age 85 years and older (47.1% vs. 45.3%), % black (10.5% vs. 12.7%), % dual eligible (74.3% vs. 75.8%), and emergency department visits (55.1 vs. 57.3 per 100). Of the 14,868 nursing homes with study residents, few were ACO providers (N=222, 1.6% of total residents) yet many had at least one ACO resident (N=8077, 76.4% of total residents); one-fifth had at least 20 (N=2839, 33.4% of total residents). ACO-provider homes were more likely than other homes to have a 5-star rating, be hospital-based and have Medicare as the primary payer. Conclusions: With a quarter of long-term nursing home residents attributed to an ACO, and one-fifth of nursing homes caring for a large number of ACO residents, outcomes and spending in this setting are important for ACOs to consider when designing patient care strategies.

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