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\"A chronicle of one of the most unusual series of events in the history of medicine, this book tells the story a group of men and women clinicians, administrators, frontline workers, trustees, and leaders blessed with vision, courage, and a relentless determination to improve. It is the story of a medical center transformed. Ultimately, it is the story of a new and possibly better way to take on the challenge we face in the United States today to provide superb medical care to our people while at the same time controlling costs\"--Provided by publisher.

Patient-centeredness-the idea that care should be designed around patients' needs, preferences, circumstances, and well-being-is a central tenet of health care delivery. For CEOs of health care organizations, patient-centered care is also quickly becoming a business imperative, with payments tied to performance on measures of patient satisfaction and engagement. In A CEO Checklist for High-Value Health Care, we, as executives of eleven leading health care delivery institutions, outlined ten key strategies for reducing costs and waste while improving outcomes. In this article we describe how implementation of these strategies benefits both health care organizations and patients. For example, Kaiser Permanente's Healthy Bones Program resulted in a 30 percent reduction in hip fracture rates for at-risk patients. And at Virginia Mason Health System in Seattle, nurses reorganized care patterns and increased the time they spent on direct patient care to 90 percent. Our experiences show that patient-engaged care can be delivered in ways that simultaneously improve quality and reduce costs. Adapted from the source document.

Cycles of incarceration, drug abuse, and poverty undermine ongoing public health efforts to reduce overdose deaths and the spread of infectious disease in vulnerable populations. Jail diversion programs aim to divert low-level drug offenders toward community care resources, avoiding criminal justice costs and disruptions in treatment for HIV, hepatitis C virus (HCV), and drug abuse. We sought to assess the health benefits and cost-effectiveness of a jail diversion program for low-level drug offenders. We developed a microsimulation model, calibrated to King County, Washington, that captured the spread of HIV and HCV infections and incarceration and treatment systems as well as preexisting interventions such as needle and syringe programs and opiate agonist therapy. We considered an adult population of people who inject drugs (PWID), people who use drugs but do not inject (PWUD), men who have sex with men, and lower-risk heterosexuals. We projected discounted lifetime costs and quality-adjusted life years (QALYs) over a 10-year time horizon with and without a jail diversion program and calculated resulting incremental cost-effectiveness ratios (ICERs) from the health system and societal perspectives. We also tracked HIV and HCV infections, overdose deaths, and jail population size. Over 10 years, the program was estimated to reduce HIV and HCV incidence by 3.4% (95% CI 2.7%-4.0%) and 3.3% (95% CI 3.1%-3.4%), respectively, overdose deaths among PWID by 10.0% (95% CI 9.8%-10.8%), and jail population size by 6.3% (95% CI 5.9%-6.7%). When considering healthcare costs only, the program cost $25,500/QALY gained (95% CI $12,600-$48,600). Including savings from reduced incarceration (societal perspective) improved the ICER to $6,200/QALY gained (95% CI, cost-saving $24,300). Sensitivity analysis indicated that cost-effectiveness depends on diversion program participants accessing community programs such as needle and syringe programs, treatment for substance use disorder, and HIV and HCV treatment, as well as diversion program cost. A limitation of the analysis is data availability, as fewer data are available for diversion programs than for more established interventions aimed at people with substance use disorder. Additionally, like any model of a complex system, our model relies on simplifying assumptions: For example, we simplified pathways in the healthcare and criminal justice systems, modeled an average efficacy for substance use disorder treatment, and did not include costs associated with homelessness, unemployment, and breakdown in family structure. We found that diversion programs for low-level drug offenders are likely to be cost-effective, generating savings in the criminal justice system while only moderately increasing healthcare costs. Such programs can reduce incarceration and its associated costs, and also avert overdose deaths and improve quality of life for PWID, PWUD, and the broader population (through reduced HIV and HCV transmission).

Decision aids are evidence-based sources of health information that can help patients make informed treatment decisions. However, little is known about how decision aids affect health care use when they are implemented outside of randomized controlled clinical trials. We conducted an observational study to examine the associations between introducing decision aids for hip and knee osteoarthritis and rates of joint replacement surgery and costs in a large health system in Washington State. Consistent with prior randomized trials, our introduction of decision aids was associated with 26 percent fewer hip replacement surgeries, 38 percent fewer knee replacements, and 12-21 percent lower costs over six months. These findings support the concept that patient decision aids for some health conditions, for which treatment decisions are highly sensitive to both patients' and physicians' preferences, may reduce rates of elective surgery and lower costs. [PUBLICATION ABSTRACT]

The aim of this study was to assess the effects of an arginine-based immunonutrition intervention for patients undergoing elective colorectal surgery on postsurgical utilization and cost outcomes. This analysis was based on data from two Washington State databases: Surgical Care and Outcomes Assessment Program (SCOAP) linked to the Comprehensive Hospital Abstract Reporting System (CHARS). The sample (N=722) comprises adult patients who underwent elective colorectal surgery with anastomosis in a Washington State hospital that participated in the Strong for Surgery (S4S) initiative between January 1, 2012, and December 31, 2013. A generalized linear model was used to predict the outcomes, adjusting for demographic characteristics and patient health conditions within a multivariate regression framework. Findings from this study demonstrated significantly fewer readmissions and hospital days for the intervention group during the 180 d after index hospitalization. Clinical benefits included decreased risk for infections and venous thromboembolism. There was a similar pattern toward lower total costs in the immunonutrition patient group; however, these were not statistically different compared with the control group at any time point. Savings in the immunonutrition group were substantial—mean total costs per patient were less by ∼$2500 at index hospitalization, $3500 less through 30 d of follow-up, and $5300 less over 180 d compared with the control group. These findings suggest that arginine-based immunonutrition should be thoroughly evaluated for incorporation into clinical practice for patients undergoing elective surgery. Moreover, there is a need to assess the effects of the intervention in other hospitals both within and outside Washington. •Clinical benefits of arginine-based immunonutrition included decreased risk for infections and venous thromboembolism.•Significantly fewer readmissions and hospital days were reported for the immunonutrition group during the 180 d after index hospitalization.•Arginine-based immunonutrition should be thoroughly evaluated for incorporation into clinical practice for patients undergoing elective surgery.

Power system models of electric systems are crucial in system planning for operations, economics, and expansion analyses. However, as these models contain critical infrastructure data, they are not publicly available. This poses challenges in future expansion scenarios and evaluating technological advancements in an electric grid. Synthetic models are realistic power system models, both topologically and operationally. However, since the electrical network is typically produced using statistical data and often uses machine learning, it does not contain propriety information. This allows researchers to evaluate system behavior under various operating conditions and as test cases for emerging technologies. These test cases are particularly important in highly evolving electric grids and areas of high renewable energy integration such as Alaska. Currently, no publicly available benchmark power system models of rural Alaskan island microgrids exist. This paper presents a rural Alaskan microgrid synthetic power system model and the methodology adopted to develop the model. The performance of the developed synthetic grid was assessed through steady state and positive-sequence dynamic simulations under various operating conditions.

While industrial emissions research has historically focused on energy-intensive sectors like steel, cement, and chemicals, this study addresses a critical gap by examining barriers across all the manufacturing industry in the U.S. Sectors like food processing, retail, plastics, and transportation face unique challenges distinct from heavy industry, operating on thin margins with limited bargaining power while experiencing heightened consumer and stakeholder pressure for improved environmental responsibility. Through structured interview data collection process and using quantitative ratings and qualitative analysis, this research identifies and categorizes emission reduction barriers across four key themes: financial, technical, organizational, and regulatory. Unlike energy-intensive industries that may pursue hydrogen or carbon capture technologies, discrete manufacturing industry like automotive, electrical and electronics, and machine manufacturers typically focus on energy efficiency, electrification of thermal processes, and alternate fuel switching, solutions better aligned with their lower-temperature processes and distributed facility profiles. The study’s primary contribution lies in documenting specific barrier manifestations within organizations and identifying proven mitigation strategies that companies have successfully implemented or observed among peers.

Studies of African immigrant health in the U.S. have traditionally focused on infectious diseases. However, the rising burden of non-communicable diseases (NCDs) indicates the increasing importance of general preventive health care. As part of a series of community health events designed for African-born individuals in King County, Washington, we administered key informant interviews (KIIs) with 16 health event participants, medical professionals, and community leaders to identify barriers and facilitators to use of preventive health care among African-born individuals. We used descriptive thematic analysis to organize barriers according to the socio-ecological model. Within the individual domain, KII participants identified lack of knowledge and awareness of preventive health benefits as barriers to engagement in care. Within the interpersonal domain, language and cultural differences frequently complicated relationships with health care providers. Within the societal and policy domains, healthcare costs, lack of insurance, and structural racism were also reported as major barriers. Participants identified community outreach with culturally competent and respectful providers as key elements of interventions to improve uptake. In conclusion, African immigrant communities face several barriers, ranging from individual to policy levels, to accessing health services, resulting in substantial unmet need for chronic disease prevention and treatment. Community-centered and -led care may help facilitate uptake and engagement in care.

Dynamic and Adaptive solar systems demonstrate a greater potential to enhance the satisfaction of occupants, in terms of indoor environment quality and the energy efficiency of the buildings, than conventional shading solutions. This study has evaluated Dynamic and Adaptive Photovoltaic Shading Systems (DAPVSSs) through a comprehensive analysis of six shading designs in which their energy production and the comfort of occupants were considered. Energy generation, thermal comfort, daylight, and glare control have been assessed in this study, considering multiple orientations throughout the seasons, and a variety of tools, such as Rhino 6.0, Grasshopper, ClimateStudio 2.1, and Ladybug, have been exploited for these purposes. The results showed that the prototypes that were geometrically more complex, designs 5 and 6 in particular, had approximately 485 kWh higher energy production and energy savings for cooling and 48% better glare control than the other simplified configurations while maintaining the minimum daylight as the threshold (min DF: 2%) due to adaptive and control methodologies. Design 6 demonstrated optimal balanced performance for all the aforementioned criteria, achieving 587 kWh/year energy production while maintaining the daylight factor within the 2.1–2.9% optimal range and ensuring visual comfort compliance during 94% of occupied hours. This research has established a framework that can be used to make well-informed design decisions that could balance energy production, occupants’ wellbeing, and architectural integration, while advancing sustainable building envelope technologies.

Achieving national goals for increased college completion in a time of scarce resources will require the postsecondary institutions that enroll the majority of undergraduates—community colleges and less-selective public universities—to graduate more students at a lower cost. Davis Jenkins and Olga Rodríguez examine research on how these \"broad-access\" institutions can do so without sacrificing access or quality. Research indicates that the strategies broad-access institutions have relied on in the past to cut costs—using part-time instructors and increasing student-faculty ratios—may in fact reduce productivity and efficiency. The limited evidence available suggests that some of the most popular strategies for improving student success are not cost-effective. New strategies to cut costs and improve college success are therefore imperative. Some believe that redesigning courses to make use of instructional technologies will lead to better outcomes at lower cost, although the evidence is mixed. Recently, a growing number of institutions are going beyond redesigning courses and instead changing the way they organize programs and supports along the student's \"pathway\" through college. These efforts are promising, but their effects on cost per completion are not yet certain. Meager funding has so far hampered efforts by policy makers to fund colleges based on outcomes rather than how many students they enroll, but some states are beginning to increase the share of appropriations tied to outcomes. Jenkins and Rodríquez argue that as policy makers push colleges to lower the cost per graduate, they must avoid providing incentives to lower academic standards. They encourage policy makers to capitalize on recent research on the economic value of postsecondary education to measure quality, and urge colleges and universities to redouble efforts to define learning outcomes and measure student mastery.