Specialized managed care for children with cystic fibrosis: Resource use patterns and rate design for a high cost Medicaid population

Objective. This research study had two goals: (1) to describe resource consumption patterns for Medi-Cal children with cystic fibrosis, and (2) to explore the feasibility from a rate design perspective of developing specialized managed care plans for such a special needs population.^ Background. Children with special health care needs (CSHN) comprise about 2% of the California Medicaid pediatric population. CSHN have rare but serious health problems, such as cystic fibrosis. Medicaid programs, including Medi-Cal, are enrolling more and more beneficiaries in managed care to control costs. CSHN, however, do not fit the wellness model underlying most managed care plans. Child health advocates believe that both efficiency and quality will suffer if CSHN are removed from regionalized special care centers and scattered among general purpose plans. They believe that CSHN should be "carved out" from enrollment in general plans. One alternative is the Specialized Managed Care Plan, tailored for CSHN.^ Methods. The study population consisted of children under age 21 with CF who were eligible for Medi-Cal and California Children's Services program (CCS) during 1991. Health Care Financing Administration (HCFA) Medicaid Tape-to-Tape data were analyzed as part of a California Children's Hospital Association (CCHA) project.^ Results. Mean Medi-Cal expenditures per month enrolled were $2,302 for 457 CF children, compared to about \$1,270 for all 47,000 CCS special needs children and roughly $60 for almost 2.6 million ``regular needs'' children. For CF children, inpatient care (80\%) and outpatient drugs (9\%) were the major cost drivers, with {\it all\/} outpatient visits comprising only 2\% of expenditures. About one-third of CF children were eligible due to AFDC (Aid to Families with Dependent Children). Age group explained about 17\% of all expenditure variation. Regression analysis was used to select the best capitation rate structure (rate cells by age and eligibility group). Sensitivity analysis estimated moderate financial risk for a statewide plan (360 enrollees), but severe risk for single county implementation due to small numbers of children.^ Conclusions. Study results support the carve out of CSHN due to unique expenditure patterns. The Specialized Managed Care Plan concept appears feasible from a rate design perspective given sufficient enrollees. ^

User-definable resource bounds analysis for logic programs

We present a static analysis that infers both upper and lower bounds on the usage that a logic program makes of a set of user-definable resources. The inferred bounds will in general be functions of input data sizes. A resource in our approach is a quite general, user-defined notion which associates a basic cost function with elementary operations. The analysis then derives the related (upper- and lower-bound) resource usage functions for all predicates in the program. We also present an assertion language which is used to define both such resources and resourcerelated properties that the system can then check based on the results of the analysis. We have performed some preliminary experiments with some concrete resources such as execution steps, bytes sent or received by an application, number of files left open, number of accesses to a datábase, number of calis to a procedure, number of asserts/retracts, etc. Applications of our analysis include resource consumption verification and debugging (including for mobile code), resource control in parallel/distributed computing, and resource-oriented specialization.

Some techniques for automated, resource-aware distributed and mobile computing in a multi-paradigm programming system

Distributed parallel execution systems speed up applications by splitting tasks into processes whose execution is assigned to different receiving nodes in a high-bandwidth network. On the distributing side, a fundamental problem is grouping and scheduling such tasks such that each one involves sufñcient computational cost when compared to the task creation and communication costs and other such practical overheads. On the receiving side, an important issue is to have some assurance of the correctness and characteristics of the code received and also of the kind of load the particular task is going to pose, which can be specified by means of certificates. In this paper we present in a tutorial way a number of general solutions to these problems, and illustrate them through their implementation in the Ciao multi-paradigm language and program development environment. This system includes facilities for parallel and distributed execution, an assertion language for specifying complex programs properties (including safety and resource-related properties), and compile-time and run-time tools for performing automated parallelization and resource control, as well as certification of programs with resource consumption assurances and efñcient checking of such certificates.

Resource bounds analysis.

We present a generic analysis that infers both upper and lower bounds on the usage that a program makes of a set of user-definable resources. The inferred bounds will in general be functions of input data sizes. A resource in our approach is a quite general, user-defined notion which associates a basic cost function with elementary operations. The analysis then derives the related (upper- and lower- bound) cost functions for all procedures in the program. We also present an assertion language which is used to define both such resources and resource-related properties that the system can then check based on the results of the analysis. We have performed some experiments with some concrete resource-related properties such as execution steps, bits sent or received by an application, number of arithmetic operations performed, number of calls to a procedure, number of transactions, etc. presenting the resource usage functions inferred and the times taken to perform the analysis. Applications of our analysis include resource consumption verification and debugging (including for mobile code), resource control in parallel/distributed computing, and resource-oriented specialization.

A multi-resource load balancing algorithm for cloud cache systems

With the advent of cloud computing model, distributed caches have become the cornerstone for building scalable applications. Popular systems like Facebook [1] or Twitter use Memcached [5], a highly scalable distributed object cache, to speed up applications by avoiding database accesses. Distributed object caches assign objects to cache instances based on a hashing function, and objects are not moved from a cache instance to another unless more instances are added to the cache and objects are redistributed. This may lead to situations where some cache instances are overloaded when some of the objects they store are frequently accessed, while other cache instances are less frequently used. In this paper we propose a multi-resource load balancing algorithm for distributed cache systems. The algorithm aims at balancing both CPU and Memory resources among cache instances by redistributing stored data. Considering the possible conflict of balancing multiple resources at the same time, we give CPU and Memory resources weighted priorities based on the runtime load distributions. A scarcer resource is given a higher weight than a less scarce resource when load balancing. The system imbalance degree is evaluated based on monitoring information, and the utility load of a node, a unit for resource consumption. Besides, since continuous rebalance of the system may affect the QoS of applications utilizing the cache system, our data selection policy ensures that each data migration minimizes the system imbalance degree and hence, the total reconfiguration cost can be minimized. An extensive simulation is conducted to compare our policy with other policies. Our policy shows a significant improvement in time efficiency and decrease in reconfiguration cost.

An Incremental EM-based Learning Approach for On-Line Prediction of Hospital Resource Utilization

Objective: Inpatient length of stay (LOS) is an important measure of hospital activity, health care resource consumption, and patient acuity. This research work aims at developing an incremental expectation maximization (EM) based learning approach on mixture of experts (ME) system for on-line prediction of LOS. The use of a batchmode learning process in most existing artificial neural networks to predict LOS is unrealistic, as the data become available over time and their pattern change dynamically. In contrast, an on-line process is capable of providing an output whenever a new datum becomes available. This on-the-spot information is therefore more useful and practical for making decisions, especially when one deals with a tremendous amount of data. Methods and material: The proposed approach is illustrated using a real example of gastroenteritis LOS data. The data set was extracted from a retrospective cohort study on all infants born in 1995-1997 and their subsequent admissions for gastroenteritis. The total number of admissions in this data set was n = 692. Linked hospitalization records of the cohort were retrieved retrospectively to derive the outcome measure, patient demographics, and associated co-morbidities information. A comparative study of the incremental learning and the batch-mode learning algorithms is considered. The performances of the learning algorithms are compared based on the mean absolute difference (MAD) between the predictions and the actual LOS, and the proportion of predictions with MAD < 1 day (Prop(MAD < 1)). The significance of the comparison is assessed through a regression analysis. Results: The incremental learning algorithm provides better on-line prediction of LOS when the system has gained sufficient training from more examples (MAD = 1.77 days and Prop(MAD < 1) = 54.3%), compared to that using the batch-mode learning. The regression analysis indicates a significant decrease of MAD (p-value = 0.063) and a significant (p-value = 0.044) increase of Prop(MAD

Positive development

net sustainability. At best they reduce relative resource consumption. They still consume vast quantities of materials, energy, water and ecosystems during construction. Moreover, green buildings replace land and ecosystems with structures that, at the very best, only 'mimic' ecosystems<'). Mimicking nature is little compensation when we have lost a third of species that are integral parts of our life support system. Already, development has exceeded the Earth's ecological carrying capacity, so even 'restorative' design is not enough. Urban areas must be retrofitted to increase net bioregional carrying capacity - just to support existing or reduced population levels in cities. The eco-retrofitting of our built environment is therefore an essential precondition of achieving a sustainable society. But we need to eco-retrofit cities in ways that increase net sustainability, not just relative efficiency.

Challenging 'best practice' subtropical design

Genuine sustainability would require that urban development provide net positive social and ecological gains to compensate for previous lost natural capital and carrying capacity. Thus far, green buildings do not contribute to net sustainability. While they reduce relative resource consumption, they consume vast quantities of materials, energy and water.i Moreover, they replace land and ecosystems with structures that, at best, ‘mimic’ ecosystems. Elsewhere, the author has proposed a‘sustainability standard’, where development would leave the ecology, as well as society, better off after construction than before.ii To meet this standard, a development would need to add natural and social capital beyond what existed prior to development. Positive DesignTM or Positive DevelopmentTM is that which expands both the ecological base (life support system) and the public estate (equitable access to means of survival). How to achieve this is discussed in Positive Development (Birkeland 2008). This paper examines how net positive gains can be achieved in a ubtropical as well as temperate environment.

"Well, now I'm upset": Moral and social orders in the playground

There is much still to learn about how young children’s membership with peers shapes their constructions of moral and social obligations within everyday activities in the school playground. This paper investigates how a small group of girls, aged four to six years, account for their everyday social interactions in the playground. They were video-recorded as they participated in a pretend game of school. Several days later, a video-recorded excerpt of the interaction was shown to them and invited to comment on what was happening in the video. This conversation was audio-recorded. Drawing on a conversation analysis approach, this chapter shows that, despite their discontent and complaining about playing the game of school, the girls’ actions showed their continued orientation to the particular codes of the game, of ‘no going away’ and ‘no telling’. By making relevant these codes, jointly constructed by the girls during the interview, they managed each other’s continued participation within two arenas of action: the pretend, as a player in a pretend game of school; and the real, as a classroom member of a peer group. Through inferences to explicit and implicit codes of conduct, moral obligations were invoked as the girls attempted to socially exclude or build alliances with others, and enforce their own social position. As well, a shared history that the girls re-constructed has moral implications for present and future relationships. The girls oriented to the history as an interactional resource for accounting for their actions in the pretend game. This paper uncovers how children both participate in, and shape, their everyday social worlds through talk and interaction and the consequences a taken-for-granted activity such as playing school has for their moral and social positions in the peer group.

Sustainable urban development : a quadruple bottom line assessment framework

Sustainable development has long been promoted as the best answer to the world's environmental problems. This term has generated mass appeal as it implies that the development of the built environment and its associated resource consumption can both be achieved without jeopardising the natural environment. In the urban context, sustainability issues have been reflected in the pomotion of sustainable urbanisation in a manner that allows future generations to repeat this process. This paper attempts to highlight an increasing urgency in formulating a suitable model for assessing sustainability at urban level, because this is where the bulk of a nation's population reside, and where sustainability problems mostly occur. It will also point out to the increasing importance of governance in facilitating urban sustainability research. This assessment involves the use of physical, social, environmental and goverance aspects in assessing the extent to which development of an urban settlement is sustainable. Specifically, this assessment model is carried out to determine whether or not sustainable urban development pratice is implemented in the provision of residential development, and in particular whether the development of master-planned residential communities have more desireable outcomes compared to traditional residential subdivision.

Curbing paper wastage using flavoured feedback

In November 2009 the researcher embarked on a project aimed at reducing the amount of paper used by Queensland University of Technology (QUT) staff in their daily workplace activities. The key goal was to communicate to staff that excessive printing has a tangible and negative effect on their workplace and local environment. The research objective was to better understand what motivates staff towards more ecologically sustainable printing practises, whilst meeting their job’s demands. The current study is built on previous research that found that one interface does not address the needs of all users when creating persuasive Human Computer Interaction (HCI) interventions targeting resource consumption. In response, the current study created and trialled software that communicates individual paper consumption in precise metrics. Based on preliminary research data different metric sets have been defined to address the different motivations and beliefs of user archetypes using descriptive and injunctive normative information.

Sustainable urban development : an integrated framework for urban planning and development

Sustainable development has long been promoted as the best answer to the world’s environmental problems. This term has generated mass appeal as it implies that both the development of the built environment and its associated resource consumption can be achieved without jeopardising the natural environment. In the urban context, sustainability issues have been reflected in the promotion of sustainable urban development, which emphasises the sensible exploitation of scarce natural resources for urbanisation in a manner that allows future generations to repeat the process. This chapter highlights attempts to promote sustainable urban development through an integration of three important considerations: planning, development and the ecosystem. It highlights the fact that spatial planning processes were traditionally driven by economic and social objectives, and rarely involved promoting the sustainability agenda to achieve a sustainable urban future. As a result, rapid urbanisation has created a variety of pressures on the ecosystem upon which we rely. It is believed that the integration of the urban planning and development processes within the limitations of the ecosystem, monitored by a sustainability assessment mechanism, would offer a better approach to maintaining sustainable resource use without compromising urban development.

Evaluation of accessibility for knowledge-based cities

Purpose: The purpose of the paper is to develop a framework for evaluation of accessibility for knowledge based cities. ----- ----- Design/methodology/approach: This approach notifies common mistakes and problems in accessibility assessment for knowledge cities. ----- ----- Originality/value: Accessibility plays a key role in transport sustainability and recognizes the crucial links between transport and sustainable goals like air quality, environmental resource consumption & social equity. In knowledge cities, accessibility has significant effects on quality of life and social equity by improving the mobility of people and goods. Accessibility also influences patterns of growth and economic health by providing access to land. Accessibility is not only one of the components of knowledge cities but also affects other elements of knowledge cities directly or indirectly. ----- ----- Practical implications: The outcomes of the application will be helpful for developing particular methodologies for evaluating knowledge cities. On other words, this methodology attempts to develop an assessment procedure for examining accessibility of knowledge-based cities.

Design for eco-services. Part A - Environmental Services

Without the virtually free services of nature like clean air and water, humans would not last long. Natural systems can be incorporated in existing urban structures or spaces to add public amenity, mitigate the heat island effect, reduce pollution, add oxygen, and ensure water, electricity and food security in urban areas. Th ere are many eco-solutions that could radically reduce resource consumption and pollution and even provide surplus ecosystem services in the built environment at little or no operational cost, if adequately supported by design. Th is paper is the fi rst of a two part paper that explains what eco-services are, then provides examples of how design can generate natural as well as social capital. Using examples of actual and notional solutions, both papers set out to challenge designers to ‘think again’, and invent ways of creating net positive environmental gains through built environment design.

Design for eco-services. Part B - Building Services

Without the virtually free services of nature like clean air and water, humans would not last long. Natural systems can be incorporated in existing urban structures or spaces to add public amenity, mitigate the heat island eff ect, reduce pollution, add oxygen, and ensure water, electricity and food security in urban areas. Th ere are many eco-solutions that could radically reduce resource consumption and pollution and even provide surplus ecosystem services in the built environment at little or no operational cost, if adequately supported by design. Th is is the second part of a two part paper that explains what eco-services are, then provides examples of how design can generate natural as well as social capital. Using examples of actual and notional solutions, both papers set out to challenge designers to ‘think again’, and invent ways of creating net positive environmental gains through built environment design.