ObjectivesThe Centers for Medicare and Medicaid Services funded the development of a computed tomography (CT) quality measure for use in pay-for-performance programs, which balances automated assessments of radiation dose with image quality to incentivize dose reduction without compromising the diagnostic utility of the tests. However, no existing quantitative method for assessing CT image quality has been validated against radiologists' image quality assessments on a large number of CT examinations. Thus to develop an automated measure of image quality, we tested the relationship between radiologists' subjective ratings of image quality with measurements of radiation dose and image noise.Materials and MethodsBoard-certified, posttraining, clinically active radiologists rated the image quality of 200 diagnostic CT examinations from a set of 734, representing 14 CT categories. Examinations with significant distractions, motion, or artifact were excluded. Radiologists rated diagnostic image quality as excellent, adequate, marginally acceptable, or poor; the latter 2 were considered unacceptable for rendering diagnoses. We quantified the relationship between ratings and image noise and radiation dose, by category, by analyzing the odds of an acceptable rating per standard deviation (SD) increase in noise or geometric SD (gSD) in dose.ResultsOne hundred twenty-five radiologists contributed 24,800 ratings. Most (89%) were acceptable. The odds of an examination being rated acceptable statistically significantly increased per gSD increase in dose and decreased per SD increase in noise for most categories, including routine dose head, chest, and abdomen-pelvis, which together comprise 60% of examinations performed in routine practice. For routine dose abdomen-pelvis, the most common category, each gSD increase in dose raised the odds of an acceptable rating (2.33; 95% confidence interval, 1.98-3.24), whereas each SD increase in noise decreased the odds (0.90; 0.79-0.99). For only 2 CT categories, high-dose head and neck/cervical spine, neither dose nor noise was associated with ratings.ConclusionsRadiation dose and image noise correlate with radiologists' image quality assessments for most CT categories, making them suitable as automated metrics in quality programs incentivizing reduction of excessive radiation doses.

Concerns regarding both the limited generalizability and the slow pace of traditional randomized trials have led to calls for greater use of real‐world evidence (RWE) in the evaluation of new treatments or products. The RWE label has been used to refer to a variety of departures from the methods of traditional randomized controlled trials. Recognizing this complexity and potential confusion, the National Academies of Science, Engineering, and Medicine convened a series of workshops to clarify and address questions regarding the use of RWE to evaluate new medical treatments. Those workshops identified three specific dimensions in which RWE studies might differ from traditional clinical trials: use of real‐world data (data extracted from health system records or data captured by mobile devices), delivery of real‐world treatment (open‐label treatments delivered in community settings by community practitioners), and real‐world treatment assignment (including nonrandomized comparisons and variations on random assignment such as before‐after or stepped‐wedge designs). For any RWE study, decisions regarding each of these dimensions depends on the specific research question, characteristics of the potential study settings, and characteristics of the settings where study results would be applied.

This Viewpoint discusses the challenges to detecting sepsis in patients early in the disease course and suggests ways to improve the diagnosis and outcomes of sepsis in the inpatient or community setting.

Background Lack of standardization in CT protocol choice contributes to radiation dose variation. Purpose To create a framework to assess radiation doses within broad CT categories defined according to body region and clinical imaging indication and to cluster indications according to the dose required for sufficient image quality. Materials and Methods This was a retrospective study using Digital Imaging and Communications in Medicine metadata. CT examinations in adults from January 1, 2016 to December 31, 2019 from the University of California San Francisco International CT Dose Registry were grouped into 19 categories according to body region and required radiation dose levels. Five body regions had a single dose range (ie, extremities, neck, thoracolumbar spine, combined chest and abdomen, and combined thoracolumbar spine). Five additional regions were subdivided according to dose. Head, chest, cardiac, and abdomen each had low, routine, and high dose categories; combined head and neck had routine and high dose categories. For each category, the median and 75th percentile (ie, diagnostic reference level [DRL]) were determined for dose-length product, and the variation in dose within categories versus across categories was calculated and compared using an analysis of variance. Relative median and DRL (95% CI) doses comparing high dose versus low dose categories were calculated. Results Among 4.5 million examinations, the median and DRL doses varied approximately 10 times between categories compared with between indications within categories. For head, chest, abdomen, and cardiac (3 266 546 examinations [72%]), the relative median doses were higher in examinations assigned to the high dose categories than in examinations assigned to the low dose categories, suggesting the assignment of indications to the broad categories is valid (head, 3.4-fold higher [95% CI: 3.4, 3.5]; chest, 9.6 [95% CI: 9.3, 10.0]; abdomen, 2.4 [95% CI: 2.4, 2.5]; and cardiac, 18.1 [95% CI: 17.7, 18.6]). Results were similar for DRL doses (all P < .001). Conclusion Broad categories based on image quality requirements are a suitable framework for simplifying radiation dose assessment, according to expected variation between and within categories. © RSNA, 2021 See also the editorial by Mahesh in this issue.

Health Services Research (HSR) is one of the most highly cited health services journals and a major destination for publishing research in our field. The effort of our reviewers is a major reason for HSR’s excellence. During the past two years, HSR has relied on 961 reviewers to evaluate original submissions. In many cases, these same reviewers have contributed to evaluating revisions that have resulted from their original reviews. We are grateful for the contributions that each of our reviewers has made to improve the papers they read and hope that authors recognize these reviewers’ feedback as a gift that fuels improvement within our community. Based on a discussion within our editorial team, we have decided to apply specific criteria to identify those reviewers who have been exceptional in the volume and quality of their reviews for HSR during the past two years. The individuals listed below were rated in the top 5% of reviewers in this time period. We congratulate them for being selected as “Outstanding Reviewers for Health Services Research in 2019.” Going forward, we expect to honor a new cohort of reviewers in a similar fashion on an annual basis. Margarita Alegria Laurence Baker Michael Barnett Michel Boudreaux Amanda Brewster M. Kate Bundorf Michael Chernew Sandra Decker Kelly Devers Christopher Forrest Floyd Fowler Mark Friedberg Melissa Garrido Lillian Gelberg Teresa Gibson Marsha Gold Carole Roan Gresenz J. Lee Hargraves Laura Hatfield Arthur Hong Marco Huesch Orna Intrator Laura Keohane R. Tamara Konetzka Richard Kronick Anthony LoSasso Matthew Maciejewski Leo Morales Karoline Mortensen Dana Mukamel Amol Navathe Daniel Polsky Gregory Pope Shelby Reed Zirui Song Joanne Spetz David Stevenson Michael Stoto Denise Tyler Marko Vujicic Pete Welch Christopher Whaley Brad Wright Carolyn Zhu Stephen Zuckerman

Health Services ResearchVolume 55, Issue 2 p. 151-152 FROM THE EDITORS’ DESK From the Editor’s Desk Andrew B. Bindman MD, Corresponding Author Andrew B. Bindman MD [email protected] orcid.org/0000-0002-6161-0609 Departments of Medicine and Epidemiology & Biostatistics, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California Correspondence Andrew B. Bindman, MD, Departments of Medicine and Epidemiology & Biostatistics, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA. Email: [email protected]Search for more papers by this authorPatrick S. Romano MD, MPH, Patrick S. Romano MD, MPH orcid.org/0000-0001-6749-3979 Divisions of General Medicine and General Pediatrics, Center for Healthcare Policy and Research, University of California Davis, Sacramento, CaliforniaSearch for more papers by this author Andrew B. Bindman MD, Corresponding Author Andrew B. Bindman MD [email protected] orcid.org/0000-0002-6161-0609 Departments of Medicine and Epidemiology & Biostatistics, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, California Correspondence Andrew B. Bindman, MD, Departments of Medicine and Epidemiology & Biostatistics, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA. Email: [email protected]Search for more papers by this authorPatrick S. Romano MD, MPH, Patrick S. Romano MD, MPH orcid.org/0000-0001-6749-3979 Divisions of General Medicine and General Pediatrics, Center for Healthcare Policy and Research, University of California Davis, Sacramento, CaliforniaSearch for more papers by this author First published: 02 January 2020 https://doi.org/10.1111/1475-6773.13253Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume55, Issue2April 2020Pages 151-152 RelatedInformation

INTRODUCTION:There is limited research on difficulties with activities of daily living (I/ADLs) among older adults living alone with cognitive impairment, including differences by race/ethnicity.METHODS:For U.S. Health and Retirement Study (2000-2014) participants aged 55+ living alone with cognitive impairment (4,666 individuals; 9,091 observations), we evaluated I/ADL difficulty and help.RESULTS:Among 4.3 million adults aged 55+ living alone with cognitive impairment, an estimated 46% reported an I/ADL difficulty; 72% reported not receiving help with an I/ADL. Women reported more difficulty than men. Compared to white women, black women were 22% more likely to report a difficulty without help, and Latina women were 36% more likely to report a difficulty with help. Among men, racial/ethnic differences in outcomes were not significant. Patterns of difficulty without help by race/ethnicity were similar among Medicaid beneficiaries.DISCUSSION:Findings call for targeted efforts to support older adults living alone with cognitive impairment.

Primary care in England is largely governmentfunded. Although private (paid for directly by the patient) primary care services have increased in recent years, the vast majority of England’s population remain registered with an NHS general practice, which is their sole or main provider of primary care. These general practices are largely funded through capitation payments from the government, with only a small proportion of income coming from other sources such as NHS quality incentive schemes and NHS fee-for-service activities. During this time of turbulence with radical changes implemented in a very short period of time, this system of funding has provided financial stability for general practices, something that is not the case for many primary care practices in the USA or elsewhere.

The article discusses the financial impact of the coronavirus disease 2019 (COVID-19) pandemic on the U S health care system Topics explored include the challenges brought by the significant increase in the demand for COVID-19-related health services to hospitals, the way some health systems opted to lay off health care workers to reduce expenses, and the Public Health and Social Services Emergency Fund allotted to hospitals and physicians following the issuance of shelter-in-place orders

The democratic nominee for president, former Vice President Joe Biden, has made the availability of a public option (a Medicarelike health plan operated by the federal government) a central component of his health care platform. One goal of this policy is to lower costs for consumers who purchase coverage in health insurance marketplaces. Biden would also increase population coverage by making his public option available at no cost to income-eligible adults in the 12 states that have still not expanded Medicaid as a part of the Affordable Care Act. In the states that have already expanded Medicaid to low-income adults, he would allow these states to convert their expansion population to the federal public option, provided the state maintains its contribution toward the cost at the level it had been through the state’s Medicaid program. Although Biden envisions a federal public option as an alternative to a state’s Medicaid program for its expansion population, states themselves might want to also consider the benefits of using a state or local public Medicaid managed care plan to improve the quality of care throughout their programs.

With the election of Joe Biden, the US will have a president who actively embraces the Affordable Care Act (ACA). During his campaign, Biden competed against progressive Democratic candidates who advocated for a Medicarefor-all plan, as well as an incumbent president who promoted less government involvement in health care. President-elect Biden plans to use the ACA as the basis for expanding health care coverage. This approach extends a policy he supported as vice president to Barack Obama and reflects his political approach of using incrementalism as a means to advance policy objectives. However, despite Biden’s victory in the presidential race, he will face considerable challenges in his ability to follow through on his plan. First, there is the issue of whether the ACA will remain intact long enough for Biden to build upon it. On November 10, 2020, the US Supreme Court heard arguments in the case of California v Texas. In this case, Texas, with the support of the Trump administration, questions the legitimacy of the ACA following the elimination in 2019 of the financial penalty associated with the individual mandate. Although the Supreme Court has twice previously affirmed the legitimacy of the law, a major wild card is that with the replacement of former Justice Ruth Bader Ginsburg with newly appointed Justice Amy Coney Barrett, the Court is more conservative in its political orientation than it had been when considering the earlier cases. However, Justice Barrett raised the possibility during her confirmation hearing that even if the individual mandate is found to be illegitimate, the rest of the law could remain intact. During the Court proceedings, other conservative justices made similar comments. A decision from the Court is expected by June 2021. Second, even if the Supreme Court upholds most or all of the ACA, many of the changes Biden envisions to build upon it will require Congress to pass legislation. For example, Biden wants to increase federal financial support to help individuals purchase health insurance and create a federal public option to increase competition and provide a source of free coverage for individuals who are income eligible for Medicaid but living in a state that has not expanded Medicaid coverage. Even though these policies are substantially less disruptive than a Medicare-for-all plan, a provision for a public option failed to pass in the US Senate when the Democrats held a majority under Obama. As this issue of JAMA went to press, control of the Senate hinged on the outcomes of 2 Senate runoff elections in Georgia on January 5. If the Democrats have won both races and gained control of the Senate, that still will not guarantee that Biden will be able to pass his legislative agenda because the traditional threshold for passing legislation in the Senate is 60 votes. Biden could recommend that a Democratic majority leader use the same budgetary maneuver called reconciliation that was invoked during the passage of the ACA. In such a case, only a simple majority of senators is needed for passage—but even then, it would only take 1 Democratic senator to defect for the legislation to fail. The legislative path is significantly more challenging if Republicans have won at least 1 of the runoff Senate races, which would result in Republicans maintaining control of that chamber. Biden has a history of working on legislation across the political aisle, but the stakes will be higher with him in the role of president. Senate Republicans may be unwilling to negotiate a compromise that could be perceived as a political win for Democrats. If Biden is unable to navigate a legislative change in the ACA, his alternatives for achieving an expansion in health care coverage are to issue executive orders, to promote regulatory changes within federal executive agencies, or to support states’ efforts aligned with this goal. Trump used these same policy levers to sabotage the ACA after he failed to convince Congress to repeal the law. For example, he used executive orders and regulatory changes to erode private insurance coverage by decreasing the duration of the federal health insurance marketplace’s open enrollment period, curtailing the resources dedicated to advertising the open enrollment period, and reducing the availability of navigators to help News & Analysis

Changes under way in the healthcare environment have the potential to accelerate the pace at which evidence is incorporated into practice.Motivated by new payment models that hold clinicians accountable for cost and quality, healthcare organisations in the US are developing their capacity to become learning healthcare systems that are able to generate, adopt and apply evidence to support quality improvement and high-value care.The pace at which healthcare organisations will make progress will depend on whether they perceive a return on their investments, the availability of internal and external resources to help them make this transformation, and the external pressures on them to be accountable for managing the cost and quality of their patient care.

An estimated one-third of older US adults with cognitive impairment live alone. Little is known about this vulnerable population's potentially unmet needs for care, including differences by race/ethnicity. We identified older adults living alone with cognitive impairment or probable dementia in the 2014 U.S. Health and Retirement Study (HRS) using cognitive scores and proxy interviews. We applied the Crimmins et al (2011) probabilistic algorithm to classify respondents as living with dementia, cognitive impairment without dementia (CIND), or no cognitive impairment. We estimated the prevalence of a) self-reported limitations in any of six activities of daily living (ADLs) or five instrumental activities (IADLs), and b) unmet need, defined as having at least one I/ADL limitation for which no help was reported. HRS survey weights were applied to reflect the United States (US) community dwelling population age ≥ 55 years in 2014. Weighted estimates indicated 1.1 million US adults (unweighted n=278) aged 55+ lived alone with probable dementia, and another 3.7 million lived alone with CIND (unweighted n=884; Table 1). A larger share of older adults living alone with dementia/CIND belonged to a racial/ethnic minority group compared to those with no cognitive impairment. Nearly half (45%) of older adults living alone with dementia/CIND had ≥1 I/ADL, compared to 23% of those living alone with no cognitive impairment. Older adults living alone with dementia/CIND were more likely to have ≥1 unmet need for I/ADL assistance compared to those without cognitive impairment (32% vs 19%). Unmet needs for assistance were reported by 41% of African Americans, 39% of Latinos, and 26% of whites living alone with dementia/CIND (Table 3).