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Abbreviations: CI, confidence interval; HMOs, Health Maintenance Organizations; MDS, Minimum Data Set; RCTs, randomized controlled trials Provenance: Not commissioned; externally peer-reviewed Summary Points * Nursing home residents are a highly vulnerable population, and nursing home care quality has been a persistent focus of public concern. * There is considerable evidence from observational studies that public funding of care delivered in for-profit facilities is inferior to care delivered in public or nonprofit facilities. * The past decade has seen many industrialized countries increasing governmental payment for care of frail seniors in for-profit nursing homes, leading to questions about whether this leads to inferior care. * Many of Bradford Hill's guidelines for causation can be found in published studies supporting a causal link between for-profit ownership and inferior care. * The precautionary principle should be applied when developing policy for this frail and vulnerable population. Introduction Nursing homes, also called residential long-term care facilities or aged care homes, are regulated institutions providing around-the-clock medical and social care to (mainly) older people who are unable to live independently due to physical and/or mental disability. Because of the vulnerability of this population and frequent media reports of scandals across many industrialized countries [1], nursing home care quality has been a persistent focus of public concern.

The extent to which physicians lead, own, and govern accountable care organizations (ACOs) is unknown. However, physicians' involvement in ACOs will influence how clinicians and patients perceive the ACO model, how effective these organizations are at improving quality and costs, and how future ACOs will be organized. From October 2012 to May 2013 we fielded the National Survey of Accountable Care Organizations, the first such survey of public and private ACOs. We found that 51 percent of ACOs were physician-led, with another 33 percent jointly led by physicians and hospitals. In 78 percent of ACOs, physicians constituted a majority of the governing board, and physicians owned 40 percent of ACOs. The broad reach of physician leadership has important implications for the future evolution of ACOs. It seems likely that the challenge of fundamentally changing care delivery as the country moves away from fee-for-service payment will not be accomplished without strong, effective leadership from physicians.

Objectives. To describe a new database containing detailed annual information on firearm-related laws in place in each of the 50 US states from 1991 to 2016 and to summarize key trends in firearm-related laws during this time period. Methods. Using Thomson Reuters Westlaw data to access historical state statutes and session laws, we developed a database indicating the presence or absence of each of 133 provisions of firearm laws in each state over the 26-year period. These provisions covered 14 aspects of state policies, including regulation of the process by which firearm transfers take place, ammunition, firearm possession, firearm storage, firearm trafficking, and liability of firearm manufacturers. Results. An examination of trends in state firearm laws via this database revealed that although the number of laws nearly doubled during the study period, there was substantial heterogeneity across states, leading to a widening disparity in the number of firearm laws. Conclusions. This database can help advance firearm policy research by providing 26 years of comprehensive policy data that will allow longitudinal panel study designs that minimize the limitations present in many previous studies.

Mobile phones significantly improve access to healthcare, public health services, and disease surveillance globally. However, challenges related to reachability and accessibility persist, especially when individuals change or drop telephone numbers affecting continuity in public health interventions such as HIV follow-ups and vaccine reminders. We explored trends in phone ownership, changes in mobile phone numbers, associated factors, and the time it takes to better understand how these might affect the ability of phone-based public health services to reach targeted recipients. We used data from the Rakai Community Cohort Study, a population-based prospective open cohort in rural Uganda. Between 2010 and 2020, data on phone ownership and individuals’ phone numbers were collected for six consecutive visits. We assessed trends in phone ownership using descriptive statistics. Factors associated with the number of times individuals changed their phone numbers were assessed using a Poisson multivariable regression model. We used Anderson Gill Cox proportional hazards regression to evaluate the time-to-change of phone numbers. In total 41,922 participants contributed 97,034 visits. A majority (61.8%) of participants owned a mobile phone at some point from 2010 to 2020. Phone ownership increased over the study period from 51.2% in 2010 to 68.2% in 2020 ( p  < 0.001). Phone ownership was lower among women participants (versus men; adjPR = 0.81; 95% CI 0.78–0.83) and younger persons < 25 years (versus ≥ 25 years; adjPR = 0.69; 95% CI 0.65–0.72), but there were no differences by HIV serostatus. The rate of change in phone numbers was significantly lower among women participants (adjusted prevalence ratio [adjIRR] = 0.88; 0.83–0.95) and those with secondary education or above (versus primary or none; adjIRR = 0.92; 95% CI 0.87–0.98). In contrast, it was higher among young persons aged 15-24-years old (versus 45 + years; adjIRR = 2.52; 95% CI 2.13–2.76), those living in lake Victoria fishing communities (versus trading centers, adjIRR = 1.28; 95% CI 1.17–1.40), persons with lower SES (versus higher SES; adjIRR:1.30; 95% CI 1.19–1.42), and persons living with HIV (versus HIV negative participants; adjIRR = 1.11; 95% CI 1.03–1.20). In this Ugandan cohort, mobile phone ownership increased over time, although by 2020 nearly 30% of the population still did not own a phone, and participants frequently changed phone numbers. Being a man, living with HIV, and lower socioeconomic status were all associated with changing phone numbers, a community peer system to maintain contact with these groups may be required to supplement phone-based initiatives.

In recent years, policymakers have paid particular attention to the emergence of a robust for-profit hospice sector and increased hospice use by nursing home residents. Previous research has explored financial incentives for nursing home-hospice use, but there has been limited research on nursing home-hospice partnerships and none on the extent of nursing home-hospice common ownership. To describe trends in nursing home-hospice contracting and common ownership and to identify potential tradeoffs in care provided by nursing homes and hospice agencies that share common ownership. Retrospective cohort study of nursing home-hospice patients between 2005 and 2015. Between 2005 and 2015, the number of hospice agencies and nursing homes with common ownership grew substantially, now representing almost 1-in-5 providers in each sector. Relative to individuals using hospice in nursing homes without common ownership, adjusted analyses found that individuals receiving hospice from a commonly owned agency had a greater likelihood of having stays of 90 days or more [odds ratio (OR)=1.06; 95% confidence interval (CI), 1.02-1.10], having a stay resulting in a live discharge (OR=1.06; 95% CI, 1.02-1.11), and having at least 1 registered nurse/licensed practical nurse visit during the last 3 days of life (OR=1.17; 95% CI, 1.05-1.29); these individuals also had a lower mean visit hours per day (-0.07; P=0.003). Common ownership between hospice agencies and nursing homes is an emerging trend that reflects a broader push toward consolidation in the health care sector. Our analyses highlight potential concerns relevant to Medicare payment policy and are a first step toward improving our understanding of these trends and their implications.

Understanding the impacts of climate change on people and the environment requires an understanding of the dynamics of both climate and land use/land cover changes. A range of future climate scenarios is available for the conterminous United States that have been developed based on widely used international greenhouse gas emissions storylines. Climate scenarios derived from these emissions storylines have not been matched with logically consistent land use/cover maps for the United States. This gap is a critical barrier to conducting effective integrated assessments. This study develops novel national scenarios of housing density and impervious surface cover that are logically consistent with emissions storylines. Analysis of these scenarios suggests that combinations of climate and land use/cover can be important in determining environmental conditions regulated under the Clean Air and Clean Water Acts. We found significant differences in patterns of habitat loss and the distribution of potentially impaired watersheds among scenarios, indicating that compact development patterns can reduce habitat loss and the number of impaired watersheds. These scenarios are also associated with lower global greenhouse gas emissions and, consequently, the potential to reduce both the drivers of anthropogenic climate change and the impacts of changing conditions. The residential housing and impervious surface datasets provide a substantial first step toward comprehensive national land use/land cover scenarios, which have broad applicability for integrated assessments as these data and tools are publicly available.

The main aim of this study was to replicate methodology used to estimate the size of the UK pet cat and dog populations in 2006 and the proportion of households owning cats/dogs in 2007, to produce updated data to compare trends in ownership and population sizes. A cross-sectional study design was used to collect telephone interview data from 3155 households in the UK. 2011 UK human census data were used to predict the size of the cat and dog populations owned by households in the UK in 2011. Of the households, 23 per cent (714/3155) owned one or more cats and 30 per cent (940/3155) owned one or more dogs. There was some overlap in pet ownership with 7 per cent (210/3155) of households owning both one or more cats and one or more dogs. There was a small but significant decrease in the proportion of households that owned one or more cats in 2011 compared with 2007, with no change in the proportion owning dogs. However, overall, the total number of cats and dogs that were estimated to be owned by UK households did not change significantly between 2006 and 2011. The estimated size (and 95% CIs) of the pet cat and dog populations in the UK in 2011 was 10,114,764 cats (9,138,603–11,090,924) and 11,599,824 dogs (10,708,070–12,491,578).

The COVID-19 pandemic has been one of the most globally disruptive social events in recent history, bringing widespread lockdowns, restrictions on movement, remote work, mass vaccination campaigns, and millions of deaths worldwide. These unprecedented circumstances have reshaped many aspects of social life, including perceptions of safety and firearm ownership. This study examines changes in reported gun ownership before and during the COVID-19 pandemic in the United States, using binary logistic regression analyses of General Social Survey (GSS) data from 2018 and 2021. Analysis revealed that reported gun ownership remained stable at approximately 35% in both years. However, the demographic and social profile of gun owners shifted significantly. Demographic factors such as sex, US birth, marital status, and income consistently predicted ownership in both years, while race, middle-class identification, and political party affiliation emerged as significant predictors only during the pandemic, with Democrats becoming significantly less likely to report gun ownership. The results demonstrate how social crises can reshape the composition of firearm owners rather than overall rates, with implications for public policy and safety.

This paper develops an empirical agent-based model to assess the impacts of Brexit on Scottish cattle farms. We first identify several trends and processes among Scottish cattle farms that were ongoing before Brexit: the lack of succession, the rise of leisure farming, the trend to diversify and industrialise, and, finally, the phenomenon of the “disappearing middle”, characterised by the decline of medium-sized farms and the polarization of farm sizes. We then study the potential impact of Brexit amid the local context and those ongoing social processes. We find that the impact of Brexit is indeed subject to pre-Brexit conditions. For example, whether industrialization is present locally can significantly alter the impact of Brexit. The impact of Brexit also varies by location: we find a clear divide between constituencies in the north (highland and islands), the middle (the central belt) and the south. Finally, we argue that policy analysis of Brexit should consider the heterogeneous social context and the complex social processes under which Brexit occurs. Rather than fitting the world into simple system models and ignoring the evidence when it does not fit, we need to develop policy analysis frameworks that can incorporate real world complexities, so that we can assess the impacts of major events and policy changes in a more meaningful way.

Analyses of ownership in the US hospice sector have focused on the growth of for-profit hospice care and on aggregate differences in patient populations and service use patterns between for-profit and not-for-profit agencies. Such comparisons, although useful, do not offer insights about the types of organizations within the hospice sector, including the emergence of multiagency chains. Using Medicare cost report data for the period 2000-11, we tracked the evolution of the US hospice industry. We not only describe the market's composition by profit status but also provide new information about the roles of regional and national chains. Almost half of all Medicare hospice enrollees in 2011 received hospice services from a multiagency chain. A handful of companies play a prominent role, although the presence of smaller for-profit and not-for-profit hospice chains also has grown in recent years. By focusing on the role of the diverse organizations that provide hospice care, our analyses can help inform efforts to monitor and assure quality of care, to assess payment adequacy and options for reform, and to facilitate greater transparency and accountability within the hospice marketplace.