Validation of the potentially avoidable hospital readmission rate as a routine indicator of the quality of hospital care

BACKGROUND: The hospital readmission rate has been proposed as an important outcome indicator computable from routine statistics. However, most commonly used measures raise conceptual issues. OBJECTIVES: We sought to evaluate the usefulness of the computerized algorithm for identifying avoidable readmissions on the basis of minimum bias, criterion validity, and measurement precision. RESEARCH DESIGN AND SUBJECTS: A total of 131,809 hospitalizations of patients discharged alive from 49 hospitals were used to compare the predictive performance of risk adjustment methods. A subset of a random sample of 570 medical records of discharge/readmission pairs in 12 hospitals were reviewed to estimate the predictive value of the screening of potentially avoidable readmissions. MEASURES: Potentially avoidable readmissions, defined as readmissions related to a condition of the previous hospitalization and not expected as part of a program of care and occurring within 30 days after the previous discharge, were identified by a computerized algorithm. Unavoidable readmissions were considered as censored events. RESULTS: A total of 5.2% of hospitalizations were followed by a potentially avoidable readmission, 17% of them in a different hospital. The predictive value of the screen was 78%; 27% of screened readmissions were judged clearly avoidable. The correlation between the hospital rate of clearly avoidable readmission and all readmissions rate, potentially avoidable readmissions rate or the ratio of observed to expected readmissions were respectively 0.42, 0.56 and 0.66. Adjustment models using clinical information performed better. CONCLUSION: Adjusted rates of potentially avoidable readmissions are scientifically sound enough to warrant their inclusion in hospital quality surveillance.

Correlation between depressive symptoms and quality of life in users of psychoactive substances

Objectives: To evaluate the correlation between the presence of depressive symptoms and quality of life in users of psychoactive substances from Psychosocial Attention Centers in Mato Grosso. Method: A cross-sectional analytical study, conducted in Psychosocial Attention Centers, with 109 users. The instruments used were: Medical Outcomes Study 36, Beck Depression Inventory, socio-demographic variables and the use of psychoactive substances. A Tukey analysis and a Spearman correlation were conducted with a significance level of α<0,05. Results: The most affected domains of quality of life were emotional, social and mental health aspects, besides the strong correlation between depressive symptoms and quality of life. Conclusion: The use of psychoactive substances and the presence of symptoms significantly interfere in the life of users, which can compromise the motivation to the treatment, negatively affecting the quality of life in this population.



Causes for the underreporting of adverse drug events by health professionals: a systematic review

Objective: Identifying the main causes for underreporting of Adverse Drug Reaction (ADR) by health professionals. Method: A systematic review carried out in the following databases: LILACS, PAHO, SciELO, EMBASE and PubMed in the period between 1992 and 2012. Descriptors were used in the search for articles, and the identified causes of underreporting were analyzed according to the classification of Inman. Results: In total, were identified 149 articles, among which 29 were selected. Most studies were carried out in hospitals (24/29) for physicians (22/29), and pharmacists (10/29). The main causes related to underreporting were ignorance (24/29), insecurity (24/29) and indifference (23/29). Conclusion: The data show the eighth sin in underreporting, which is the lack of training in pharmacovigilance. Therefore, continuing education can increase adherence of professionals to the service and improve knowledge and communication of risks due to drug use.


Myocardial flow reserve by Rb-82 cardiac PET improves the selection of patients eligible for invasive coronary angiography

Aim: We asked whether myocardial flow reserve (MFR) by Rb-82 cardiac PET improve the selection of patients eligible for invasive coronary angiography (ICA). Material and Methods: We enrolled 26 consecutive patients with suspected or known coronary artery disease who performed dynamic Rb-82 PET/CT and (ICA) within 60 days; 4 patients who underwent revascularization or had any cardiovascular events between PET and ICA were excluded. Myocardial blood flow at rest (rMBF), at stress with adenosine (sMBF) and myocardial flow reserve (MFR=sMBF/rMBF) were estimated using the 1-compartment Lortie model (FlowQuant) for each coronary arteries territories. Stenosis severity was assessed using computer-based automated edge detection (QCA). MFR was divided in 3 groups: G1:MFR<1.5, G2:1.5≤MFR<2 and G3:2≤MFR. Stenosis severity was graded as non-significant (<50% or FFR ≥0.8), intermediate (50%≤stenosis<70%) and severe (≥70%). Correlation between MFR and percentage of stenosis were assessed using a non-parametric Spearman test. Results: In G1 (44 vessels), 17 vessels (39%) had a severe stenosis, 11 (25%) an intermediate one, and 16 (36%) no significant stenosis. In G2 (13 vessels), 2 (15%) vessels presented a severe stenosis, 7 (54%) an intermediate one, and 4 (31%) no significant stenosis. In G3 (9 vessels), 0 vessel presented a severe stenosis, 1 (11%) an intermediate one, and 8 (89%) no significant stenosis. Of note, among 11 patients with 3-vessel low MFR<1.5 (G1), 9/11 (82%) had at least one severe stenosis and 2/11 (18%) had at least one intermediate stenosis. There was a significant inverse correlation between stenosis severity and MFR among all 66 territories analyzed (rho= -0.38, p=0.002). Conclusion: Patients with MFR>2 could avoid ICA. Low MFR (G1, G2) on a vessel-based analysis seems to be a poor predictor of severe stenosis severity. Patients with 3-vessel low MFR would benefit from ICA as they are likely to present a significant stenosis in at least one vessel.

Geology and correlation of the Mersin mélanges, southern Turkey

Our paper aims to give a thorough description of the infra-ophiolitic melanges associated with the Mersin ophiolite. We propose new regional correlations of the Mersin melanges with other melange-like units or similar series, located both in southern Turkey and adjacent regions. The palaeotectonic implications of the correlations are also discussed. The main results may be summarized as follows: the infra-ophiolitic melange is subdivided into two units, the Upper Cretaceous Sorgun ophiolitic melange and the Ladinian-Carnian Hacialani melange. The Mersin melanges, together with the Antalya and Mamonia domains, are represented by a series of exotic units now found south of the main Taurus range, and are characteristic of the South-Taurides Exotic Units. These melanges clearly show the mixed origin of the different blocks and broken formations. Some components have a Palaeotethyan origin and are characterized by Pennsylvanian and Lower to Middle Permian pelagic and slope deposits. These Palaeotethyan remnants, found exclusively in the Hacialani melange, were reworked as major olistostromes in the Neotethys basin during the Eo-Cimmerian orogenic event. Neotethyan elements are represented by Middle Triassic seamounts and by broken formations containing typical Neotethyan conodont faunas such as Metapolygnathus mersinensis Kozur & Moix and M. primitius s. s., both present in the latest Carnian interval, as well as the occurrence of the middle Norian Epigondolella praeslovakensis Kozur, Masset & Moix. Other elements are clearly derived from the former north Anatolian passive margin and are represented by Huglu-type series including the Upper Triassic syn-rift volcanic event. These sequences attributed to the Huglu-Pindos back-arc ocean were displaced southward during the Late Cretaceous obduction event. The Tauric elements are represented by Eo-Cimmerian flysch-like and molasse sequences intercalated in Neotethyan series. Additionally, some shallow-water blocks might be derived from the Bolkardag para-autochthonous and the Taurus-Beydaglari marginal sequences.

Iowa Department of Commerce - Credit Union Division, Agency Performance Plan, 2007

Annual Report, Agency Performance Plan

Equilibrium asset prices and savings of heterogeneous agents in the presence of incomplete markets and portfolio constraints

We study the quantitative properties of a dynamic general equilibrium model in which agents face both idiosyncratic and aggregate income risk, state-dependent borrowing constraints that bind in some but not all periods and markets are incomplete. Optimal individual consumption-savings plans and equilibrium asset prices are computed under various assumptions about income uncertainty. Then we investigate whether our general equilibrium model with incomplete markets replicates two empirical observations: the high correlation between individual consumption and individual income, and the equity premium puzzle. We find that, when the driving processes are calibrated according to the data from wage income in different sectors of the US economy, the results move in the direction of explaining these observations, but the model falls short of explaining the observed correlations quantitatively. If the incomes of agents are assumed independent of each other, the observations can be explained quantitatively.

Credit card debt puzzles

Most US credit card holders revolve high-interest debt, often combined with substantial (i) asset accumulation by retirement, and (ii) low-rate liquid assets. Hyperbolic discounting can resolve only the former puzzle (Laibson et al., 2003). Bertaut and Haliassos (2002) proposed an 'accountant-shopper'framework for the latter. The current paper builds, solves, and simulates a fully-specified accountant-shopper model, to show that this framework canactually generate both types of co-existence, as well as target credit card utilization rates consistent with Gross and Souleles (2002). The benchmark model is compared to setups without self-control problems, with alternative mechanisms, and with impatient but fully rational shoppers.

The credit ratings game

The spectacular failure of top-rated structured finance products has broughtrenewed attention to the conflicts of interest of Credit Rating Agencies (CRAs). We modelboth the CRA conflict of understating credit risk to attract more business, and the issuerconflict of purchasing only the most favorable ratings (issuer shopping), and examine theeffectiveness of a number of proposed regulatory solutions of CRAs. We find that CRAs aremore prone to inflate ratings when there is a larger fraction of naive investors in the marketwho take ratings at face value, or when CRA expected reputation costs are lower. To theextent that in booms the fraction of naive investors is higher, and the reputation risk forCRAs of getting caught understating credit risk is lower, our model predicts that CRAs aremore likely to understate credit risk in booms than in recessions. We also show that, due toissuer shopping, competition among CRAs in a duopoly is less efficient (conditional on thesame equilibrium CRA rating policy) than having a monopoly CRA, in terms of both totalex-ante surplus and investor surplus. Allowing tranching decreases total surplus further.We argue that regulatory intervention requiring upfront payments for rating services (beforeCRAs propose a rating to the issuer) combined with mandatory disclosure of any ratingproduced by CRAs can substantially mitigate the con.icts of interest of both CRAs andissuers.

Macroprudential policy, countercyclical bank capital buffers and credit supply: Evidence from the Spanish dynamic provisioning experiments

We analyze the impact of countercyclical capital buffers held by banks on the supplyof credit to firms and their subsequent performance. Spain introduced dynamicprovisioning unrelated to specific bank loan losses in 2000 and modified its formulaparameters in 2005 and 2008. In each case, individual banks were impacteddifferently. The resultant bank-specific shocks to capital buffers, coupled withcomprehensive bank-, firm-, loan-, and loan application-level data, allow us toidentify its impact on the supply of credit and on real activity. Our estimates showthat countercyclical dynamic provisioning smooths cycles in the supply of credit andin bad times upholds firm financing and performance.

Snapshot Events, 2005

This monthly report from the Iowa Department of Transportation is about the water quality management of Iowa's rivers, streams and lakes.

Correlation between the infestation level of Sitophilus zeamais Motschulsky, 1855 (Coleoptera, Curculionidae) and the quality factors of stored corn, Zea mays L. (Poaceae)

This experiment was carried out in order to evaluate the effect of Sitophilus zeamais on physical, physiological and sanitary quality of stored corn. Samples of 500 g of the hybrid OC-705, in three replicates, were conditioned in glasses covered with a screened lid, and kept in chamber at 25±2ºC, 70±5% RH and 12 h of photophase, for 150 days. The infestation levels were 0, 5, 15 and 50 adults/replicate, for the storage periods of 30, 60, 90, 120 and 150 days. The moisture content, classification, weight loss, germination and internal infestation were evaluated monthly. Significant inverse correlations were verified between the number of insects and both the germination and the weight loss; also between the internal infestation and the germination and the standard type. The presence of S. zeamais showed a positive correlation with the weight loss, what means that the internal and external infestations contribute to the reduction of physiological and physical quality of corn seeds. The mean dry matter loss was 0,36%/day, corresponding to a consumption of 0,0001%/insect/month. As the result of those damages, the product suffered reduction of the commercial grade in 30 days, with significant loss in all quality factors.

Credit lines: The other side of corporate liquidity

In this paper we offer the first large sample evidence on the availability and usage ofcredit lines in U.S. public corporations and use it to re-examine the existing findings oncorporate liquidity. We show that the availability of credit lines is widespread and thataverage undrawn credit is of the same order of magnitude as cash holdings. We test thetrade-off theory of liquidity according to which firms target an optimum level of liquidity,computed as the sum of cash and undrawn credit lines. We provide support for the existenceof a liquidity target, but also show that the reasons why firms hold cash and credit linesare very different. While the precautionary motive explains well cash holdings, the optimumlevel of credit lines appears to be driven by the restrictions imposed by the credit line itself,in terms of stated purpose and covenants. In support to these findings, credit line drawdownsare associated with capital expenditures, acquisitions, and working capital.

Endogenous credit cycles

I develop an overlapping-generations framework in which changes in lending standards generateendogenous cycles. In my economy, entrepreneurs who are privately informed about thequality of their projects need to borrow funds. Intermediaries screen entrepreneurs both throughthe amount of investment undertaken and through the level of entrepreneurial net worth.I show that endogenous regime switches in financial contracts from pooling to separatingand vice-versa may generate fluctuations even in the absence of exogenous shocks. Whenthe economy is in the pooling (separating) regime, lending standards seem lax ( tight ) andinvestment is high (low). Differently from the existing literature, my model does not requireentrepreneurial net worth to be counter cyclycal or inconsequential for determining aggregateinvestment.