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We explored whether financial incentives have a role in patients' decisions to accept (purchase) a continuous positive airway pressure (CPAP) device in a healthcare system that requires cost sharing. Longitudinal interventional study. The group receiving financial incentive (n = 137, 50.8±10.6 years, apnea/hypopnea index (AHI) 38.7±19.9 events/hr) and the control group (n = 121, 50.9±10.3 years, AHI 39.9±22) underwent attendant titration and a two-week adaptation to CPAP. Patients in the control group had a co-payment of $330-660; the financial incentive group paid a subsidized price of $55. CPAP acceptance was 43% greater (p = 0.02) in the financial incentive group. CPAP acceptance among the low socioeconomic strata (n = 113) (adjusting for age, gender, BMI, tobacco smoking) was enhanced by financial incentive (OR, 95% CI) (3.43, 1.09-10.85), age (1.1, 1.03-1.17), AHI (>30 vs. <30) (4.87, 1.56-15.2), and by family/friends who had positive experience with CPAP (4.29, 1.05-17.51). Among average/high-income patients (n = 145) CPAP acceptance was affected by AHI (>30 vs. <30) (3.16, 1.14-8.75), living with a partner (8.82, 1.03-75.8) but not by the financial incentive. At one-year follow-up CPAP adherence was similar in the financial incentive and control groups, 35% and 39%, respectively (p = 0.82). Adherence rate was sensitive to education (+yr) (1.28, 1.06-1.55) and AHI (>30 vs. <30) (5.25, 1.34-18.5). Minimizing cost sharing reduces a barrier for CPAP acceptance among low socioeconomic status patients. Thus, financial incentive should be applied as a policy to encourage CPAP treatment, especially among low socioeconomic strata patients.

To investigate determinants of health-care utilization in patients with obstructive sleep apnea syndrome (OSAS). Case-control prospective study with OSAS patients and a control group. We compared 218 patients with OSAS to those of age-, gender-, geographically-, and family physician-matched control subjects from the general population, matched 1:1 (χ2 = 0.999). All participants were members of Clalit Health Care Services, a health maintenance organization in the southern region of Israel. All OSAS patients underwent nocturnal polysomnography studies. Indexes of health-care utilization 2 years prior to the polysomnography were analyzed. Health-care utilization was 1.7-fold higher (p < 0.001) in the OSAS patients due to more hospitalization days (p < 0.001), consultations (p < 0.001), and cost for drugs (p < 0.05), particularly those for the cardiovascular system. In comparison to men, women consumed significantly more health-care resources (p < 0.001). OSAS patients ≤ 65 of age years consumed 2.2-fold more health-care resources than control subjects (p < 0.001). Polysomnography findings and OSAS severity and body mass index (BMI) did not predict health-care utilization, using multivariate logistic regression analysis. Age > 65 (odds ratio [OR], 2.2; p < 0.04) and female gender (OR, 2.0; p < 0.05) were the leading elements predicting the most costly OSAS patients. Arbitrarily dividing the OSAS group by cost of health-care utilization, the upper 25% (n = 55) of patients who were the “most costly” consumed sevenfold more health-care resources than the lower 75% of the patients. This was due to higher comorbidity, ie, 10 to 30% more hypertension, ischemic heart disease, diabetes mellitus, and pulmonary disease. OSAS patients are heavy users of health-care resources. Age > 65 years and female gender were the leading elements predicting the most costly OSAS patients, and not necessarily patients with a high BMI and classic OSAS severity indexes.

Objectives This study analyzes the effect of outsourcing healthcare on career soldiers in the Israel Defense Forces (IDF) in different settings, so as to develop a model for predicting per capita medical costs. Methods Demographic information and data on healthcare utilization and costs were gathered from three computerized billing database systems: The IDF Medical Corps; a civilian hospital; and a healthcare fund, providing services to 3,746; 3,971; and 6,400 career soldiers, respectively. Visits to primary care physicians and specialists, laboratory and imaging exams, number of sick-leave days, and hospitalization days, were totaled for men and women separately for each type of clinic. A uniform cost was assigned to each type of treatment to create an average annual per capita cost for medical services of career soldiers. Results Significantly more visits were recorded to primary care physician and to specialists, as well as imaging examinations by Leumit Healthcare Services (LHS), than visits and tests in hospitals or in military clinics (p<0.001). The number of referrals to emergency rooms and sick-leave days were lowest in the LHS as compared to the hospital and military clinics (p<0.001). The medical cost per capita/year was lowest in LHS as well. Conclusions Outsourcing primary care for career soldiers to a civilian healthcare fund represents a major cost effective change, lowest consumption and lower cost of medical care. Co-ayment should be integrated into every agreement with the medical corps.

Many signal transduction pathways involve heterotrimeric G proteins. The accepted model for activation of heterotrimeric G proteins states that the protein dissociates to the free G sub( alpha ) (GTP)-bound subunit and free G sub( beta gamma ) dimer. On GTP hydrolysis, G sub( alpha ) (GDP) then reassociates with G sub( beta gamma ) [Gilman, A. G. (1987) Annu. Rev. Biochem. 56, 615-649]. We reexamined this hypothesis, by using the mating G protein of the yeast Saccharomyces cerevisiae encoded by the genes GPA1, STE4, and STE18. In the absence of mating pheromone, the G sub( alpha ) (Gpa1) subunit represses the mating pathway. On activation by binding of pheromone to a serpentine receptor, the G sub( beta gamma ) (Ste4, Ste18) dimer transmits the signal to a mitogen-activated protein kinase cascade, leading to gene activation, arrest in the G sub(1) stage of the cell cycle, production of shmoos (mating projections), and cell fusion. We found that a Ste4-Gpa1 fusion protein transmitted the pheromone signal and activated the mating pathway as effectively as when Ste4 (G sub( beta )) and Gpa1 (G sub( alpha )) were coexpressed as separate proteins. Hence, dissociation of this G protein is not required for its activation. Rather, a conformational change in the heterotrimeric complex is likely to be involved in signal transduction.

Many signal transduction pathways involve heterotrimeric G proteins. The accepted model for activation of heterotrimeric G proteins states that the protein dissociates to the free Gα(GTP)-bound subunit and free Gβ γdimer. On GTP hydrolysis, Gα(GDP) then reassociates with Gβ γ[Gilman, A. G. (1987) Annu. Rev. Biochem. 56, 615-649]. We reexamined this hypothesis, by using the mating G protein of the yeast Saccharomyces cerevisiae encoded by the genes GPA1, STE4, and STE18. In the absence of mating pheromone, the Gα(Gpa1) subunit represses the mating pathway. On activation by binding of pheromone to a serpentine receptor, the Gβ γ(Ste4, Ste18) dimer transmits the signal to a mitogen-activated protein kinase cascade, leading to gene activation, arrest in the G1stage of the cell cycle, production of shmoos (mating projections), and cell fusion. We found that a Ste4-Gpa1 fusion protein transmitted the pheromone signal and activated the mating pathway as effectively as when Ste4 (Gβ) and Gpa1 (Gα) were coexpressed as separate proteins. Hence, dissociation of this G protein is not required for its activation. Rather, a conformational change in the heterotrimeric complex is likely to be involved in signal transduction.

The morbidity and mortality benefits of blood pressure (BP) control for the elderly is well documented. The cognitive consequences of hypertension control in this population, however, are still under debate. We aim to study the association between BP and cognitive performance in the elderly. Specifically, we explore 1) the possibility that BP is differentially associated with various cognitive domains; and 2) the utility of analyzing both BP and cognitive scores as continuous variables to unravel possible nonlinear associations. Four hundred ninety-five community living 70 to 85 year olds completed eight cognitive tests that measured memory, concentration, visual retention, verbal fluency, and the mini-mental state examination (MMSE). The performance of each test was analyzed first by comparing four groups (normotensives, normalized hypertensives, untreated hypertensives, and treated but uncontrolled hypertensives). Then, using BP values as continuous variables, linear, U-curve, and J-curve associations were estimated. On all cognitive tests, except for verbal fluency, normotensives performed poorest, treated but uncontrolled hypertensives achieved the highest scores. The MMSE scores and the lighter concentration task were linearly related to BP; J-curve association was observed between memory and visual retention; prolonged concentration was related to pulse pressure alone. Low BP, as observed among the normotensive subjects, was associated with poor cognitive performance. Mild hypertension appeared to enhance cognitive functioning among the subjects of this study. Moreover, we found support for the hypothesis that the association between BP and different dimensions of cognition take on different patterns.