Potentially avoidable 30-day hospital readmissions in medical patients: derivation and validation of a prediction model

IMPORTANCE Because effective interventions to reduce hospital readmissions are often expensive to implement, a score to predict potentially avoidable readmissions may help target the patients most likely to benefit. OBJECTIVE To derive and internally validate a prediction model for potentially avoidable 30-day hospital readmissions in medical patients using administrative and clinical data readily available prior to discharge. DESIGN Retrospective cohort study. SETTING Academic medical center in Boston, Massachusetts. PARTICIPANTS All patient discharges from any medical services between July 1, 2009, and June 30, 2010. MAIN OUTCOME MEASURES Potentially avoidable 30-day readmissions to 3 hospitals of the Partners HealthCare network were identified using a validated computerized algorithm based on administrative data (SQLape). A simple score was developed using multivariable logistic regression, with two-thirds of the sample randomly selected as the derivation cohort and one-third as the validation cohort. RESULTS Among 10 731 eligible discharges, 2398 discharges (22.3%) were followed by a 30-day readmission, of which 879 (8.5% of all discharges) were identified as potentially avoidable. The prediction score identified 7 independent factors, referred to as the HOSPITAL score: h emoglobin at discharge, discharge from an o ncology service, s odium level at discharge, p rocedure during the index admission, i ndex t ype of admission, number of a dmissions during the last 12 months, and l ength of stay. In the validation set, 26.7% of the patients were classified as high risk, with an estimated potentially avoidable readmission risk of 18.0% (observed, 18.2%). The HOSPITAL score had fair discriminatory power (C statistic, 0.71) and had good calibration. CONCLUSIONS AND RELEVANCE This simple prediction model identifies before discharge the risk of potentially avoidable 30-day readmission in medical patients. This score has potential to easily identify patients who may need more intensive transitional care interventions.

"Deal of the day” platforms: what drives consumer loyalty?

Maintaining a loyal customer base is challenging for “Deal of the Day” (DoD) platforms. DoD providers market and sell deals on products and services, yet it is the merchants who ultimately deliver those to consumers. Low entry and switching costs drive competition in this market. However, research on the determinants of user loyalty in the DoD context is limited. This study uses Grounded Theory and Structural Equation Modeling to explore the phenomenon of DoD platform loyalty. Particularly, monetary benefits, signal-to-noise ratio, perceived risk, and service friendliness during a merchant encounter emerge as powerful determinants of loyalty in this novel context.

REE and Hf distribution among mineral phases in the CV-CK clan : a way to explain present-day Hf isotopic variations in chondrites

Chondrites are among the most primitive objects in the Solar System and constitute the main building blocks of telluric planets. Among the radiochronometers currently used for dating geological events, Sm–Nd and Lu–Hf are both composed of refractory, lithophile element. They are thought to behave similarly as the parent elements (Sm and Lu) are generally less incompatible than the daughter elements (Nd and Hf) during geological processes. As such, their respective average isotopic compositions for the solar system should be well defined by the average of chondrites, called Chondritic Uniform Reservoir (CHUR). However, while the Sm–Nd isotopic system shows an actual spread of less than 4% in the average chondritic record, the Lu–Hf system shows a larger variation range of 28% [Bouvier A., Vervoort J. D. and Patchett P. J. (2008) The Lu–Hf and Sm–Nd isotopic composition of CHUR: Constraints from unequilibrated chondrites and implications for the bulk composition of terrestrial planets. Earth Planet. Sci. Lett.273, 48–57]. To better understand the contrast between Sm–Nd and Lu–Hf systems, the REE and Hf distribution among mineral phases during metamorphism of Karoonda (CK) and Vigarano-type (CV) carbonaceous chondrites has been examined. Mineral modes were determined from elemental mapping on a set of five CK chondrites (from types 3–6) and one CV3 chondrite. Trace-element patterns are obtained for the first time in all the chondrite-forming minerals of a given class (CK chondrites) as well as one CV3 sample. This study reveals that REE are distributed among both phosphates and silicates. Only 30–50% of Sm and Nd are stored in phosphates (at least in chondrites types 3–5); as such, they are not mobilized during early stages of metamorphism. The remaining fraction of Sm and Nd is distributed among the same mineral phases; these elements are therefore not decoupled during metamorphism. Of the whole-rock total of Lu, the fraction held in phosphate decreases significantly as the degree of metamorphism increases (30% for types 3 and 4, less than 5% in type 6). In contrast to Lu, Hf is mainly hosted by silicates with little contribution from phosphates throughout the CK metamorphic sequence. A significant part of Sm and Nd are stored in phosphates in types 3–5, and these elements behave similarly during CK chondrite metamorphism. That explains the robustness of the Sm/Nd ratios in chondrites through metamorphism, and the slight discrepancies observed in the present-day isotopic Nd values in chondrites. On the contrary, Lu and Hf are borne by several different minerals and consequently they are redistributed during metamorphism–induced recrystallization. The Lu/Hf ratios are therefore significantly disturbed during chondrites metamorphism, leading to the high discrepancies observed in present-day Hf isotopic values in chondrites.

Multiprofessional collaboration in teaching practices in all-day-schools in Switzerland

Multiprofessional collaboration in settings of extended education has been an important research topic in the past 40 years and has been discussed as a means to improve educational achievement, foster professional development, and support teachers in their everyday work. Several recent studies in multiprofessional settings found that collaboration practices often remain on a student-centered, time-limited, and superficial level of exchange, whereas higher forms of collaboration are very rare (Dizinger, Fussangel, Kasper, 2011). Furthermore there exists an obvious research gap on collaboration in Swiss all-day schools (Jutzi&Thomann, 2012). In this study we analyzed practices of multiprofessional collaboration in school-based and community-based extracurricular activities of all-day schools in Switzerland. The aim of this qualitative study of 10 all-day schools was to answer the following questions: (a) What forms of collaboration (informal/formal) are used between the different professionals? and (b) Are there different types of all-day schools with regard to distinctive and consistent types of collaboration? We conducted 18 problem-centered interviews (with the principals/heads of the all-day schools) and 10 focus group discussions (teams). In the process of data evaluation, we applied the method of qualitative content analysis. The results show that multiprofessional collabo ration is taking place in all of the all-day schools examined in the study. However, the collaborative practices differ in their level of intensity, design, and purpose.

Conditions promoting good multiprofessional collaboration practices in Swiss all-day schools

Multiprofessional collaboration in all-day schools refers to teamwork and coordination that takes place between professionals with different vocational backgrounds. In Switzerland, all-day schoolscomprise regular school instruction and school-based extracurricular activities. Nevertheless, multiprofessional collaboration can also refer to collaboration between education professionals in all-day schools and professionals outside the school in a community-based setting of extracurricular activities. A synthesis of the literature shows that collaboration inside and outside the school setting is promoted by conditions in three areas: structural characteristics of the institution, characteristics of the team, and interpersonal processes (Schüpbach, Jutzi & Thomann 2012). In view of these findings, it was the aim of this study to analyze conditions of good collaboration practices in all-day schools in Switzerland. This qualitative study examined 10 all-day schools in five different cantons in the German-speaking part of Switzerland that showed good collaboration practice. In the course of this study, we conducted 18 problem-centered interviews and 10 focus group discussions. In the process of data evaluation, we applied the method of qualitative content analy sis. The findings show that all of the three areas of conditions promoting good collaboration proved to be relevant in the whole sample of all-day schools. Nevertheless, for the three different types of collaboration found? The school- oriented, the mixed/in termediate, and the social environment-oriented type? We identified different conditions of good collaboration practice.

The quasi 16-day wave in mesospheric water vapor during boreal winter 2011/2012

This study investigates the characteristics of the quasi 16-day wave in the mesosphere during boreal winter 2011/2012 using observations of water vapor from ground-based microwave radiometers and satellite data. The ground-based microwave radiometers are located in Seoul (South Korea, 37° N), Bern (Switzerland, 47° N) and Sodankylä (Finland, 67° N). The quasi 16-day wave is observed in the mesosphere at all three locations, while the dominant period increases with latitude from 15 days at Seoul to 20 days at Sodankylä. The observed evolution of the quasi 16-day wave confirms that the wave activity is strongly decreased during a sudden stratospheric warming that occurred in mid-January 2012. Using satellite data from the Microwave Limb Sounder on the Aura satellite, we examine the zonal characteristics of the quasi 16-day wave and conclude that the observed waves above the mid-latitudinal stations Seoul and Bern are eastward-propagating s=−1 planetary waves with periods of 15 to 16 days, while the observed oscillation above the polar station Sodankylä is a standing oscillation with a period of approximately 20 days. The strongest relative wave amplitudes in water vapor during the investigated time period are approximately 15%. The wave activity varies strongly along a latitude circle. The activity of the quasi 16-day wave in mesospheric water vapor during boreal winter 2011/2012 is strongest over Northern Europe, the North Atlantic ocean and North-West Canada. The region of highest wave activity seems to be related to the position of the polar vortex. We conclude that the classic approach to characterize planetary waves zonally averaged along a latitude circle is not sufficient to explain the local observations because of the strong longitudinal dependence of the wave activity.

Adaption of cardio-respiratory balance during day-rest compared to deep sleep—An indicator for quality of life?

Heart rate and breathing rate fluctuations represent interacting physiological oscillations. These interactions are commonly studied using respiratory sinus arrhythmia (RSA) of heart rate variability (HRV) or analyzing cardiorespiratory synchronization. Earlier work has focused on a third type of relationship, the temporal ratio of respiration rate and heart rate (HRR). Each method seems to reveal a specific aspect of cardiorespiratory interaction and may be suitable for assessing states of arousal and relaxation of the organism. We used HRR in a study with 87 healthy subjects to determine the ability to relax during 5 day-resting periods in comparison to deep sleep relaxation. The degree to which a person during waking state could relax was compared to somatic complaints, health-related quality of life, anxiety and depression. Our results show, that HRR is barely connected to balance (LF/HF) in HRV, but significantly correlates to the perception of general health and mental well-being as well as to depression. If relaxation, as expressed in HRR, during day-resting is near to deep sleep relaxation, the subjects felt healthier, indicated better mental well-being and less depressive moods.

The quasi 16-day wave in mesospheric water vapor during boreal winter 2011/2012

This study investigates the characteristics of the quasi 16-day wave in the mesosphere during boreal winter 2011/2012 using observations of water vapor from ground-based microwave radiometers and satellite data. The ground-based microwave radiometers are located in Seoul (South Korea, 37° N), Bern (Switzerland, 47° N) and Sodankylä (Finland, 67° N). The quasi 16-day wave is observed in the mesosphere at all three locations, while the dominant period increases with latitude from 15 days at Seoul to 20 days at Sodankylä. The observed evolution of the quasi 16-day wave confirms that the wave activity is strongly decreased during a sudden stratospheric warming that occurred in mid-January 2012. Using satellite data from the Microwave Limb Sounder on the Aura satellite, we examine the zonal characteristics of the quasi 16-day wave and conclude that the observed waves above the midlatitudinal stations Seoul and Bern are eastward-propagating s = −1 planetary waves with periods of 15 to 16 days, while the observed oscillation above the polar station Sodankylä is a standing wave with a period of approximately 20 days. The strongest relative wave amplitudes in water vapor during the investigated time period are approximately 15%. The wave activity varies strongly along a latitude circle. The activity of the quasi 16-day wave in mesospheric water vapor during boreal winter 2011/2012 is strongest over northern Europe, the North Atlantic Ocean and northwestern Canada. The region of highest wave activity seems to be related to the position of the polar vortex. We conclude that the classic approach to characterize planetary waves zonally averaged along a latitude circle is not sufficient to explain the local observations because of the strong longitudinal dependence of the wave activity.

CONSTRAINING THE ATMOSPHERIC COMPOSITION OF THE DAY-NIGHT TERMINATORS OF HD 189733b: ATMOSPHERIC RETRIEVAL WITH AEROSOLS

A number of observations have shown that Rayleigh scattering by aerosols dominates the transmission spectrum of HD 189733b at wavelengths shortward of 1 μm. In this study, we retrieve a range of aerosol distributions consistent with transmission spectroscopy between 0.3-24 μm that were recently re-analyzed by Pont et al. To constrain the particle size and the optical depth of the aerosol layer, we investigate the degeneracies between aerosol composition, temperature, planetary radius, and molecular abundances that prevent unique solutions for transit spectroscopy. Assuming that the aerosol is composed of MgSiO3, we suggest that a vertically uniform aerosol layer over all pressures with a monodisperse particle size smaller than about 0.1 μm and an optical depth in the range 0.002-0.02 at 1 μm provides statistically meaningful solutions for the day/night terminator regions of HD 189733b. Generally, we find that a uniform aerosol layer provide adequate fits to the data if the optical depth is less than 0.1 and the particle size is smaller than 0.1 μm, irrespective of the atmospheric temperature, planetary radius, aerosol composition, and gaseous molecules. Strong constraints on the aerosol properties are provided by spectra at wavelengths shortward of 1 μm as well as longward of 8 μm, if the aerosol material has absorption features in this region. We show that these are the optimal wavelengths for quantifying the effects of aerosols, which may guide the design of future space observations. The present investigation indicates that the current data offer sufficient information to constrain some of the aerosol properties of HD189733b, but the chemistry in the terminator regions remains uncertain.