Practice-Level Variation in Outpatient Cardiac Care and Association With Outcomes.

BACKGROUND: Utilization of cardiac services varies across regions and hospitals, yet little is known regarding variation in the intensity of outpatient cardiac care across cardiology physician practices or the association with clinical endpoints, an area of potential importance to promote efficient care. METHODS AND RESULTS: We included 7 160 732 Medicare beneficiaries who received services from 5635 cardiology practices in 2012. Beneficiaries were assigned to practices providing the plurality of office visits, and practices were ranked and assigned to quartiles using the ratio of observed to predicted annual payments per beneficiary for common cardiac services (outpatient intensity index). The median (interquartile range) outpatient intensity index was 1.00 (0.81-1.24). Mean payments for beneficiaries attributed to practices in the highest (Q4) and lowest (Q1) quartile of outpatient intensity were: all cardiac payments (Q4 $1272 vs Q1 $581; ratio, 2.2); cardiac catheterization (Q4 $215 vs Q1 $64; ratio, 3.4); myocardial perfusion imaging (Q4 $253 vs Q1 $83; ratio, 3.0); and electrophysiology device procedures (Q4 $353 vs Q1 $142; ratio, 2.5). The adjusted odds ratios (95% CI) for 1 incremental quartile of outpatient intensity for each outcome was: cardiac surgical/procedural hospitalization (1.09 [1.09, 1.10]); cardiac medical hospitalization (1.00 [0.99, 1.00]); noncardiac hospitalization (0.99 [0.99, 0.99]); and death at 1 year (1.00 [0.99, 1.00]). CONCLUSION: Substantial variation in the intensity of outpatient care exists at the cardiology practice level, and higher intensity is not associated with reduced mortality or hospitalizations. Outpatient cardiac care is a potentially important target for efforts to improve efficiency in the Medicare population.

Flexible and robust run-time configuration for self-managing systems

This paper describes a methodology for deploying flexible dynamic configuration into embedded systems whilst preserving the reliability advantages of static systems. The methodology is based on the concept of decision points (DP) which are strategically placed to achieve fine-grained distribution of self-management logic to meet application-specific requirements. DP logic can be changed easily, and independently of the host component, enabling self-management behavior to be deferred beyond the point of system deployment. A transparent Dynamic Wrapper mechanism (DW) automatically detects and handles problems arising from the evaluation of self-management logic within each DP and ensures that the dynamic aspects of the system collapse down to statically defined default behavior to ensure safety and correctness despite failures. Dynamic context management contributes to flexibility, and removes the need for design-time binding of context providers and consumers, thus facilitating run-time composition and incremental component upgrade.

Effects of exercise intensity on salivary antimicrobial proteins and markers of stress in active men

In the present study, we assessed the effects of exercise intensity on salivary immunoglobulin A (s-IgA) and salivary lysozyme (s-Lys) and examined how these responses were associated with salivary markers of adrenal activation. Using a randomized design, 10 healthy active men participated in three experimental cycling trials: 50% maximal oxygen uptake (VO2max), 75%VO2max, and an incremental test to exhaustion. The durations of the trials were the same as for a preliminary incremental test to exhaustion (22.3 min, sx = 0.8). Timed, unstimulated saliva samples were collected before exercise, immediately after exercise, and 1 h after exercise. In the incremental exhaustion trial, the secretion rates of both s-IgA and s-Lys were increased. An increase in s-Lys secretion rate was also observed at 75%VO2max. No significant changes in saliva flow rate were observed in any trial. Cycling at 75%VOmax and to exhaustion increased the secretion of alpha-amylase and chromogranin A immediately after exercise; higher cortisol values at 75%VO2max and in the incremental exhaustion trial compared with 50%VO2max were observed 1 h immediately after exercise only. These findings suggest that short-duration, high-intensity exercise increases the secretion rate of s-IgA and s-Lys despite no change in the saliva flow rate. These effects appear to be associated with changes in sympathetic activity and not the hypothalamic - pituitary - adrenal axis.

EU Environmental Policy under Pressure: Chemicals Policy Change between Antagonistic Goals?

Until now, chemicals policy was unable to find a method to establish a sound balance between the benefits and risks of chemical substances. Policy learning within the European Union (EU) resulted in the formulation of an alternative approach to future chemicals policy in some quarters. The Commission's proposal for new chemicals legislation - presented as 'paradigmatic' policy change - led to a highly controversial lobbying debate. This paper deals in particular with the influence of structures, policy networks, multi-level governance and the influence of new modes of governance on chemicals policy-making. It argues that future policy will not represent the paradigmatic change announced by the Commission but only one incremental, cost-effective step towards such a reform. The final proposal is criticised as a neo-liberal interpretation of the Lisbon strategy which includes a dangerous shift in environmental policy making.

Place and Special Places: Innovations in Conservation Practice in Northern Ireland

The sense of place that relates human beings to their environment is under threat from the rising tide of placelessness which can result from potentially positive forces such as urban regeneration as well as negative ones such as incremental degradation. The concept of sense of place, and the need to protect and enhance special places, has underpinned UK conservation legislation and policy in the post-war era. In Northern Ireland, due to its distinctive settlement tradition, its troubled political circumstances and its centralised administrative system, a unique hierarchy of special places has evolved, involving areas of townscape and village character as well as conventional conservation areas. For the first time a comprehensive comparative survey of the townscape quality of most of these areas has been carried out in order to test the hypothesis that too many conservation area designations may devalue the conservation coinage. It also assesses the contribution that areas of townscape character can make in this situation, as potential conservation areas or as second-level local amenity designations. Its findings support the initial hypothesis: assessment of townscape quality on the basis of consistent criteria demonstrates a decline in the quality of more recent conservation area designations, and hence some devaluation of the coinage. However, the need for local discretion in the protection of local amenity supports the concept of areas of townscape and village character as an additional and distinct designation. This contradicts recent policy recommendations from the Northern Ireland Planning Commission and contains valuable lessons for conservation policy and practice in other parts of the UK.

Software Release Planning: An Evolutionary and Iterative Approach

Abstract To achieve higher flexibility and to better satisfy actual customer requirements, there is an increasing tendency to develop and deliver software in an incremental fashion. In adopting this process, requirements are delivered in releases and so a decision has to be made on which requirements should be delivered in which release. Three main considerations that need to be taken account of are the technical precedences inherent in the requirements, the typically conflicting priorities as determined by the representative stakeholders, as well as the balance between required and available effort. The technical precedence constraints relate to situations where one requirement cannot be implemented until another is completed or where one requirement is implemented in the same increment as another one. Stakeholder preferences may be based on the perceived value or urgency of delivered requirements to the different stakeholders involved. The technical priorities and individual stakeholder priorities may be in conflict and difficult to reconcile. This paper provides (i) a method for optimally allocating requirements to increments; (ii) a means of assessing and optimizing the degree to which the ordering conflicts with stakeholder priorities within technical precedence constraints; (iii) a means of balancing required and available resources for all increments; and (iv) an overall method called EVOLVE aimed at the continuous planning of incremental software development. The optimization method used is iterative and essentially based on a genetic algorithm. A set of the most promising candidate solutions is generated to support the final decision. The paper evaluates the proposed approach using a sample project.

A critical evaluation of Raman spectroscopy for the analysis of lipids: fatty acid methyl esters.

The work presented here is aimed at determining the potential and limitations of Raman spectroscopy for fat analysis by carrying out a systematic investigation of C-4-C-24 FAME. These provide a simple, well-characterized set of compounds in which the effect of making incremental changes can be studied over a wide range of chain lengths and degrees of unsaturation. The effect of temperature on the spectra was investigated over much larger ranges than would normally be encountered in real analytical measurements. It was found that for liquid FAME the best internal standard band was the carbonyl stretching vibration nu(C = O), whose position is affected by changes in sample chain length and physical state; in the samples studied here, it was found to lie between 1729 and 1748 cm(-1). Further, molar unsaturation could be correlated with the ratio of the nu(C = O) to either nu(C = C) or delta(H-C = ) with R-2 > 0.995. Chain length was correlated with the delta(CH2)(tw)/nu(C = O) ratio, (where "tw" indicates twisting) but separate plots for odd- and even-numbered carbon chains were necessary to obtain R-2 > 0.99 for liquid samples. Combining the odd- ani even-numbered carbon chain data in a single plot reduced the correlation to R-2 = 0.94-0.96, depending on the band ratios used. For molal unsaturation the band ratio that correlated linearly with unsaturation (R-2 > 0.99) was nu(C = C)/delta(CH2)(SC) (where "sc" indicates scissoring). Other band ratios show much more complex behavior with changes in chemical and physical structure. This complex behavior results from the fact that the bands do not arise from simple vibrations of small, discrete regions of the molecules but are due to complex motions of large sections of the FAME so that making incremental changes in structure does not necessarily lead to simple incremental changes in spectra.

A geotechnical description of fresh cement grout - filtration and consolidation behaviour

The removal of water from three Portland cement grouts by pressure filtration is examined, and the consolidation behaviour of the filtered material clarified. The filtration takes place by the laying down of a very stiff filter cake through the removal of excess water. The behaviour due to further loading resembles that of a re-constituted silt. For stress levels above the filtration pressure the calculated permeability values are similar to those from the filtration phase only if the data sampling rate was sufficiently rapid to discriminate the first portion of the observed primary consolidation curve. The change in void ratio for incremental loading is roughly linear with the change in the logarithm of the vertical effective stress. The characterisation of fresh cement paste using standard soil mechanics models is both appropriate and useful, at least during the first few hours after mixing.

Software project initiation and planning – an empirical study

This study describes a study of 14 software companies, on how they initiate and pre-plan software projects. The aim was to obtain an indication of the range of planning activities carried out. The study, using a convenience sample, was carried out using structured interviews, with questions about early software project planning activities. The study offers evidence that an iterative and incremental development process presents extra difficulties in the case of fixed-contract projects. The authors also found evidence that feasibility studies were common, but generally informal in nature. Documentation of the planning process, especially for project scoping, was variable. For incremental and iterative development projects, an upfront decision on software architecture was shown to be preferred over allowing the architecture to just ‘emerge’. There is also evidence that risk management is recognised but often performed incompletely. Finally appropriate future research arising from the study is described.

What the Papers Say: Trends in Sustainability

This paper presents an overview of the results of a longitudinal analysis of the coverage of sustainability-related concepts in 115 leading national newspapers worldwide between January 1990 and July 2008, covering approximately 20,500,000 articles in 340,000 newspaper issues in 39 countries. On a global level, sustainable development and corporate social responsibility seem to have reached the mainstream public arena, whereas the coverage of corporate citizenship and corporate sustainability remains marginal. The increase in sustainability related media coverage since 1990 largely seems to be of an incremental nature, rather than clearly associated with specific events. Only very few truly global events can be identified that triggered a substantial amount of media coverage globally. Furthermore, marked regional and national differences in the coverage of sustainability related concepts can be identified.

International order flows: Explaining equity and exchange rate returns

Macroeconomic models of equity and exchange rate returns perform poorly at high frequencies. The proportion of daily returns that these models explain is essentially zero. Instead of relying on macroeconomic determinants, we model equity price and exchange rate behavior based on a concept from microstructure – order flow. The international order flows are derived from belief changes of different investor groups in a two-country setting. We obtain a structural relationship between equity returns, exchange rate returns and their relationship to home and foreign equity market order flow. To test the model we construct daily aggregate order flow data from 800 million equity trades in the U.S. and France from 1999 to 2003. Almost 60% of the daily returns in the S&P100 index are explained jointly by exchange rate returns and aggregate order flows in both markets. As predicted by the model, daily exchange rate returns and order flow into the French market have significant incremental explanatory power for the daily S&P returns. The model implications are also validated for intraday returns.

Role of creatine supplementation on exercise-induced cardiovascular function and oxidative stress

Many degenerative diseases are associated with increased oxidative stress. Creatine has the potential to act as an indirect and direct antioxidant; however, limited data exist to evaluate the antioxidant capabdities of creatine supplementation within in vivo human systems. This study aimed to investigate the effects of oral creatine supplementation on markers of oxidative stress and antioxidant defenses following exhaustive cycling exercise. Following preliminary testing and two additional familiarization sessions, 18 active males repeated two exhaustive incremental cycling trials (T1 and T2) separated by exactly 7 days. The subjects were assigned, in a double-blind manner, to receive either 20 g of creatine (Cr) or a placebo (P) for the 5 days preceding T2. Breath-by-breath respiratory data and heart rate were continually recorded throughout the exercise protocol and blood samples were obtained at rest (preexercise), at the end of exercise (postexercise), and the day following exercise (post24 h). Serum hypdroperoxide concentrations were elevated at postexercise by 17 +/- 5% above preexercise values (p = 0.030). However, supplementation did not influence lipid peroxidation (serum hypdroperoxide concentrations), resistance of low density lipoprotein to oxidative stress (t(1/2max) LDL oxidation) and plasma concentrations of non-enzymatic antioxidants (retinol, alpha-carotene, beta-carotene, alpha-tocopherol, gamma-tocopherol, lycopene and vitamin Q. Heart rate and oxygen uptake responses to exercise were not affected by supplementation. These findings suggest that short-term creatine supplementation does not enhance non-enzymatic antioxidant defence or protect against lipid peroxidation induced by exhaustive cycling in healthy males.

Validity and reliability of cardiorespiratory measurements recorded by the LifeShirt during exercise tests

The LifeShirt is a novel ambulatory monitoring system that records cardio respiratory measurements outside the laboratory. Validity and reliability of cardiorespiratory measurements recorded by the LifeShirt were assessed and two methods of calibrating the LifeShirt were compared. Participants performed an incremental treadmill test and a constant work rate test (65% peak oxygen uptake) on four occasions (>48 In apart) and wore the LifeShirt, COSMED system and Polar Sport Tester simultaneously. The LifeShirt was calibrated using two methods: comparison to a spirometer; and 800 ml fixed-volume bag. Ventilation, respiratory rate, expiratory time and heart rate recorded by the LifeShirt were compared to measurements recorded by laboratory equipment. Sixteen adults participated (6M: 10F); mean (SD) age 23.1 (2.9) years. Agreement between the LifeShirt and laboratory equipment was acceptable. Agreement for ventilation was improved by calibrating the LifeShirt using a spirometer. Reliability was similar for the LifeShirt and the laboratory equipment. This study suggests that the LifeShirt provides a valid and reliable method of ambulatory monitoring. (C) 2009 Elsevier B.V. All rights reserved.

The cost-effectiveness of the SPHERE intervention for the secondary prevention of coronary heart disease

Objectives: The Secondary Prevention of Heart disEase in geneRal practicE (SPHERE) trial has recently reported. This study examines the cost-effectiveness of the SPHERE intervention in both healthcare systems on the island of Ireland. Methods: Incremental cost-effectiveness analysis. A probabilistic model was developed to combine within-trial and beyond-trial impacts of treatment to estimate the lifetime costs and benefits of two secondary prevention strategies: Intervention - tailored practice and patient care plans; and Control - standardized usual care. Results: The intervention strategy resulted in mean cost savings per patient of 512.77 (95 percent confidence interval [CI], 1086.46-91.98) and an increase in mean quality-adjusted life-years (QALYs) per patient of 0.0051 (95 percent CI, 0.0101-0.0200), when compared with the control strategy. The probability of the intervention being cost-effective was 94 percent if decision makers are willing to pay €45,000 per additional QALY. Conclusions: Decision makers in both settings must determine whether the level of evidence presented is sufficient to justify the adoption of the SPHERE intervention in clinical practice. Copyright © Cambridge University Press 2010.

Output Additionality of Public Support for Innovation: Evidence for Irish Manufacturing Plants

Public support for private R&D and innovation is part of most national and regional innovation support regimes. In this article, we estimate the effect of public innovation support on innovation outputs in Ireland and Northern Ireland. Three dimensions of output additionality are considered: extensive additionality, in which public support encourages a larger proportion of the population of firms to innovate; improved product additionality, in which there is an increase in the average importance of incremental innovation; new product additionality, in which there is an increase in the average importance of more radical innovation. Using an instrumental variable approach, our results are generally positive, with public support for innovation having positive, and generally significant, extensive, improved and new product additionality effects. These results hold both for all plants and indigenously owned plants, a specific target of policy in both jurisdictions. The suggestion is that grant aid to firms can be effective in both encouraging firms to initiate new innovation and improve the quality and sophistication of their innovation activity. Our results also emphasize the importance for innovation of in-house R&D, supply-chain linkages, skill levels and capital investment, all of which may be the focus of complementary policy initiatives.