The IRYSS-COPD appropriateness study: objectives, methodology, and description of the prospective cohort

Background: Patients with chronic obstructive pulmonary disease (COPD) often experience exacerbations of the disease that require hospitalization. Current guidelines offer little guidance for identifying patients whose clinical situation is appropriate for admission to the hospital, and properly developed and validated severity scores for COPD exacerbations are lacking. To address these important gaps in clinical care, we created the IRYSS-COPD Appropriateness Study. Methods/Design: The RAND/UCLA Appropriateness Methodology was used to identify appropriate and inappropriate scenarios for hospital admission for patients experiencing COPD exacerbations. These scenarios were then applied to a prospective cohort of patients attending the emergency departments (ED) of 16 participating hospitals. Information was recorded during the time the patient was evaluated in the ED, at the time a decision was made to admit the patient to the hospital or discharge home, and during follow-up after admission or discharge home. While complete data were generally available at the time of ED admission, data were often missing at the time of decision making. Predefined assumptions were used to impute much of the missing data. Discussion: The IRYSS-COPD Appropriateness Study will validate the appropriateness criteria developed by the RAND/UCLA Appropriateness Methodology and thus better delineate the requirements for admission or discharge of patients experiencing exacerbations of COPD. The study will also provide a better understanding of the determinants of outcomes of COPD exacerbations, and evaluate the equity and variability in access and outcomes in these patients.

Development of appropriateness explicit criteria for cataract extraction by phacoemulsification

Background: Consensus development techniques were used in the late 1980s to create explicit criteria for the appropriateness of cataract extraction. We developed a new appropriateness of indications tool for cataract following the RAND method. We tested the validity of our panel results. Methods: Criteria were developed using a modified Delphi panel judgment process. A panel of 12 ophthalmologists was assembled. Ratings were analyzed regarding the level of agreement among panelists. We studied the influence of all variables on the final panel score using linear and logistic regression models. The explicit criteria developed were summarized by classification and regression tree analysis. Results: Of the 765 indications evaluated by the main panel in the second round, 32.9% were found appropriate, 30.1% uncertain, and 37% inappropriate. Agreement was found in 53% of the indications and disagreement in 0.9%. Seven variables were considered to create the indications and divided into three groups: simple cataract, with diabetic retinopathy, or with other ocular pathologies. The preoperative visual acuity in the cataractous eye and visual function were the variables that best explained the panel scoring. The panel results were synthesized and presented in three decision trees. Misclassification error in the decision trees, as compared with the panel original criteria, was 5.3%. Conclusion: The parameters tested showed acceptable validity for an evaluation tool. These results support the use of this indication algorithm as a screening tool for assessing the appropriateness of cataract extraction in field studies and for the development of practice guidelines.

Anisotropic expansion and SNIa: An open issue

We review the appropriateness of using SNIa observations to detect potential signatures of anisotropic expansion in the Universe. We focus on Union2 and SNLS3 SNIa datasets and use the hemispherical comparison method to detect possible anisotropic features. Unlike some previous works where nondiagonal elements of the covariance matrix were neglected, we use the full covariance matrix of the SNIa data, thus obtaining more realistic and not underestimated errors. As a matter of fact, the significance of previously claimed detections of a preferred direction in the Union2 dataset completely disappears once we include the effects of using the full covariance matrix. Moreover, we also find that such apreferred direction is aligned with the orthogonal direction of the SDSS observational plane and this suggests a clear indication that the SDSS subsample of the Union2 dataset introduces a significant bias, making the detected preferred direction unphysical. We thus find that current SNIa surveys are inappropriate to test anisotropic features due to their highly non-homogeneous angular distribution in the sky. In addition, after removal of the highest in homogeneous sub-samples, the number of SNIa is too low. Finally, we take advantage of the particular distribution of SNLS SNIa sub- sample in the SNLS3 data set, in which the observations were taken along four different directions. We fit each direction independently and find consistent results at the 1 sigma level. Although the likelihoods peak at relatively different values of Omega(m), the low number of data along each direction gives rise to large errors so that the likelihoods are sufficiently broad as to overlap within 1 sigma. (C) 2014 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http:// creativecommons. org/licenses/by/4.0/).