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.

Development of a Safety protocol for Management Thirst in the Immediate Postoperative Period

Objective To develop a safety protocol for the management of thirst in the immediate postoperative period. Method Quantitative, methodological, and applied study conducted in April-August 2012. An extensive literature search and expert consultation was carried out to develop the protocol and its operating manual. Theoretical and semantic analyzes were carried out by experts. Results Assessment of level of consciousness, reflexes of protection of the airways (cough and swallowing), and absence of nausea and vomiting were selected as safety criteria. These criteria were grouped and formatted in a graph algorithm, which indicates the need to interrupt the procedure if a security criterion does not reach the expected standard. Conclusion The protocol was elaborated to fill in the gap in the literature of a specific model concerning nursing actions in the safe management of thirst in the immediate postoperative period.

Professional competencies in primary health care for attending to older adults

Objective To identify and analyze the necessary competencies in primary health care for attending to older adults. Method An exploratory, descriptive, and quali-quantitative study was developed. Three rounds of the Delphi Technique were conducted with participants from primary health care services and a multidisciplinary committee. The first questionnaire asked participants to indicate the competencies needed for attending to older adults in primary health care. They were compiled into a list and added to a Likert Scale (from 1 to 5) for the second and third questionnaires. A consensus criterion of 70% was adopted. Results Twenty eight competencies were reached by consensus and were classified into twelve domains. Conclusion The competencies reflect Brazilian health care policy and constitute a reference for professional health practice and education when caring for the older adult in primary health care.

Exotic taxa less related to native species are more invasive.

Some species introduced into new geographical areas from their native ranges wreak ecological and economic havoc in their new environment. Although many studies have searched for either species or habitat characteristics that predict invasiveness of exotic species, the match between characteristics of the invader and those of members of the existing native community may be essential to understanding invasiveness. Here, we find that one metric, the phylogenetic relatedness of an invader to the native community, provides a predictive tool for invasiveness. Using a phylogenetic supertree of all grass species in California, we show that highly invasive grass species are, on average, significantly less related to native grasses than are introduced but noninvasive grasses. The match between the invader and the existing native community may explain why exotic pest species are not uniformly noxious in all novel habitats. Relatedness of invaders to the native biota may be one useful criterion for prioritizing management efforts of exotic species.

Living Snow Fences, 2006

Blowing snow can cause significant problems for mobility and safety during winter weather in three distinct ways. It may drift onto the road, thus requiring almost continuous plowing while the wind is blowing (which may occur when a given winter storm is over). Snow may drift onto wet pavement (perhaps caused by ice control chemicals) and dilute out the chemicals on the road, creating ice on the road. And sufficient blowing snow can cause a major deterioration in visibility on the road, a factor which has been shown to be significant in winter crashes. The problem of blowing snow can be very effectively addressed by creating a snow storage device upwind of the road that requires protection from snow drifting. Typically, these storage devices are fences. Extensive design guidance exists for the required height and placement of such fences for a given annual snowfall and given local topography. However, the design information on the placement of living snow fences is less complete. The purpose of this report is to present the results of three seasons of study on using standing corn as snow fences. In addition, the experience of using switch grass as a snow storage medium is also presented. On the basis of these experimental data, a design guide has been developed that makes use of the somewhat unique snow storage characteristics of standing corn snow fences. The results of the field tests on using standing corn showed that multiple rows of standing corn store snow rather differently than a traditional wooden snow fence. Specifically, while a traditional fence stores most of the snow downwind from the fence (and thus must be placed a significant distance upwind of the road to be protected, specifically at least 35 times the snow fence height) rows of standing corn store the majority of the snow within the rows. Results from the three winters of testing show that the standing corn snow fences can store as much snow within the rows of standing corn as a traditional fence of typical height for operation in Iowa (4 to 6 feet) can store. This finding is significant because it means that the snow fences can be placed at the edge of the farmer’s field closest to the road, and still be effective. This is typically much more convenient for the farmer and thus may mean that more farmers would be willing to participate in a program that uses standing corn than in traditional programs. ii On the basis of the experimental data, design guidance for the use of standing corn as a snow storage device in Iowa is given in the report. Specifically, it is recommended that if the fetch in a location to be protected is less than 5,000 feet, then 16 rows of standing corn should be used, at the edge of the field adjacent to the right of way. If the fetch is greater than 5,000 feet, then 24 rows of standing corn should be used. This is based on a row spacing of 22 inches. Further, it should be noted that these design recommendations are ONLY for the State of Iowa. Other states of course have different winter weather and without extensive further study, it cannot be said that these guidelines would be effective in other locations with other winter conditions.

Experimental design on the simplex

Optimum experimental designs depend on the design criterion, the model andthe design region. The talk will consider the design of experiments for regressionmodels in which there is a single response with the explanatory variables lying ina simplex. One example is experiments on various compositions of glass such asthose considered by Martin, Bursnall, and Stillman (2001).Because of the highly symmetric nature of the simplex, the class of models thatare of interest, typically Scheff´e polynomials (Scheff´e 1958) are rather differentfrom those of standard regression analysis. The optimum designs are also ratherdifferent, inheriting a high degree of symmetry from the models.In the talk I will hope to discuss a variety of modes for such experiments. ThenI will discuss constrained mixture experiments, when not all the simplex is availablefor experimentation. Other important aspects include mixture experimentswith extra non-mixture factors and the blocking of mixture experiments.Much of the material is in Chapter 16 of Atkinson, Donev, and Tobias (2007).If time and my research allows, I would hope to finish with a few comments ondesign when the responses, rather than the explanatory variables, lie in a simplex.ReferencesAtkinson, A. C., A. N. Donev, and R. D. Tobias (2007). Optimum ExperimentalDesigns, with SAS. Oxford: Oxford University Press.Martin, R. J., M. C. Bursnall, and E. C. Stillman (2001). Further results onoptimal and efficient designs for constrained mixture experiments. In A. C.Atkinson, B. Bogacka, and A. Zhigljavsky (Eds.), Optimal Design 2000,pp. 225–239. Dordrecht: Kluwer.Scheff´e, H. (1958). Experiments with mixtures. Journal of the Royal StatisticalSociety, Ser. B 20, 344–360.1

Compensation for environmental damages under international law

ABSTRACT The purpose of this research is to clarify the contribution of international dispute adjudication mechanisms in regard to environmental protection. Most specifically, the study aims to identify and develop the criterion adopted by the international judge in relation to the compensation for environmental damages. In this perspective, the study identifies some gaps between international responsibility and environmental protection interests. The premise sustained all along the study is that compensation is determinant to conciliate environmental prerogatives with mechanisms of international adjudication, in particular the system of international responsibility. Supported by the analysis of treaties, international decisions and secondary sources, the thesis defends the idea that some elements of international law allow the adjudicator to adapt the compensation to attend certain environmental interests, creating a new approach which was entitled 'fair compensation'. The antithesis of this approach is the idea that compensation in international law is limited exclusively to the strict reparation of the material losses incurred by the victim. As a synthesis, the study defends the specificity of environmental damages in relation to other kind of damages that are subject to compensation under international law. The measure upon which compensation for environmental damages could be classified as a specific type of damage under international law remains to be determined. The main conclusion of the study is that the existing standard of compensation defined by the theory and practice of international law is impossible to be strictly respected in cases involving environmental damages. This limitation is mainly due to the complexity of the notion of environment, which is constantly conflicting with the anthropologic view of legal theory. The study supports the idea that the establishment of a 'fair compensation' which takes into account the political, legal and technical context of the environmental damage, is the best possible approach to conciliate internationally responsibility and environmental interests. This could be implemented by the observance of certain elements by the international judge/arbitrator through a case-by-case analysis.

Prevalence of normal weight obesity in the general population

Background and Aims: normal weight obesity (NWO) has been defined as an excessive body fat (BF) associated with a normal body mass index (BMI). Little is known regarding its prevalence in the general population or which cut-offs for BF should be used. Methods: convenience sample of 1,523 Portuguese adults. BF was measured by validated hand-held bioimpedance. NWO was defined as a BMI<25 kg/m2 and a %BF mass>30%, along other published criteria. Results: prevalence of NWO was 10.1% in women and 3.2% in men. In women, prevalence of NWO increased considerably with age, and virtually all women aged over 55 with a BMI<25 kg/m2 were actually considered as NWO. Using gender specific cut-offs for BF (29.1% in men and 37.2% in women) led to moderately lower of NWO in women. Using gender- and age-specific cut-points for %BF considerably decreased the prevalence of NWO in women (0.5 to 2.5% depending on the criterion) but not in men (1.9 to 3.4%). Conclusions: gender- and age- specific or at least gender-specific, instead of single cut-offs for %BF, should be used to characterize and study NWO.

Efficient interval scoring rules

Scoring rules that elicit an entire belief distribution through the elicitation of point beliefsare time-consuming and demand considerable cognitive e¤ort. Moreover, the results are validonly when agents are risk-neutral or when one uses probabilistic rules. We investigate a classof rules in which the agent has to choose an interval and is rewarded (deterministically) onthe basis of the chosen interval and the realization of the random variable. We formulatean e¢ ciency criterion for such rules and present a speci.c interval scoring rule. For single-peaked beliefs, our rule gives information about both the location and the dispersion of thebelief distribution. These results hold for all concave utility functions.

Iterated local search

Iterated Local Search has many of the desirable features of a metaheuristic: it is simple, easy to implement, robust, and highly effective. The essential idea of Iterated Local Search lies in focusing the search not on the full space of solutions but on a smaller subspace defined by the solutions that are locally optimal for a given optimization engine. The success of Iterated Local Search lies in the biased sampling of this set of local optima. How effective this approach turns out to be depends mainly on the choice of the local search, the perturbations, and the acceptance criterion. So far, in spite of its conceptual simplicity, it has lead to a number of state-of-the-art results without the use of too much problem-specific knowledge. But with further work so that the different modules are well adapted to the problem at hand, Iterated Local Search can often become a competitive or even state of the artalgorithm. The purpose of this review is both to give a detailed description of this metaheuristic and to show where it stands in terms of performance.

Regions of rationality: Maps for bounded agents

An important problem in descriptive and prescriptive research in decision making is to identify regions of rationality, i.e., the areas for which heuristics are and are not effective. To map the contours of such regions, we derive probabilities that heuristics identify the best of m alternatives (m > 2) characterized by k attributes or cues (k > 1). The heuristics include a single variable (lexicographic), variations of elimination-by-aspects, equal weighting, hybrids of the preceding, and models exploiting dominance. We use twenty simulated and four empirical datasets for illustration. We further provide an overview by regressing heuristic performance on factors characterizing environments. Overall, sensible heuristics generally yield similar choices in many environments. However, selection of the appropriate heuristic can be important in some regions (e.g., if there is low inter-correlation among attributes/cues). Since our work assumes a hit or miss decision criterion, we conclude by outlining extensions for exploring the effects of different loss functions.

Elytra colour polymorphism and randomness of matings in Chauliognathus fallax Germar 1824 from southern Brazil (Coleoptera, Cantharidae)

Beetles of the species Chauliognathus fallax Germar 1824 are polymorphic for elytron colouration with six morphs distinguished on the basis of black pigmentation on a yellow background. We investigated samples of C. fallax taken in eight consecutive weeks aiming to determine the frequency of the morphs which were grouped, for statistical analysis, into three classes according to elytra pigmentation as well as the possible occurrence of assortative mating. Our results showed a variation in the frequency of the classes throughout the season, both in males and females, with the maximum frequency of each class at the fourth and fifth week. The three classes (A, B, C) showed the same pattern of variation, and class B was always the more frequent. To test randomness of matings two approaches were taken: in the first, we compared the frequency of each class in copulating and non-copulating insects. In the second, the frequency of each class in the whole sample was taken as the probability of occurrence of the respective class; then, using the criterion of the probability of independent events we calculated the expected proportion of copulating insects for each pair of events. Both methods gave non-significant differences, suggesting that the matings were random.

Armazenagem de pequenos insetos secos em bandeja-manta adaptada de "cd box"

The display tray holds the specimens over a thin cotton layer glued to a thick paper attached to the cd holder tray. Althought only a temporary storing method, it is a good alternative when compared to other layer models. It has the advantages of low cost, protection of specimens, minimal or no damage, as well as good visibility through its cover.

Forced diuresis improves the diagnostic accuracy of 18F-FDG PET in abdominopelvic malignancies.

Our aim was to evaluate the role of forced diuresis in improving the diagnostic accuracy of abdominopelvic (18)F-FDG PET. METHODS: Thirty-two patients were enrolled. Besides the presence of known intravesical tumors or undefined renal lesions on the initial PET scan, the inclusion criterion was the appearance of indeterminate or equivocal (18)F-FDG foci that extended along the course of the urinary tract and could not confidently be separated from urinary activity. For each patient, a second abdominopelvic PET study was performed after intravenous injection of 0.5 mg of furosemide per kilogram of body weight (maximum, 40 mg) coupled with parenteral infusion of physiologic saline. RESULTS: Forced diuresis coupled with parenteral hydration eliminated any significant (18)F-FDG activity from the lower urinary tract in 31 (97%) of 32 patients after the bladder had been voided 3 successive times. Twelve intravesical lesions were visualized with outstanding clarity, whereas radiologic suspicion of locally recurrent bladder tumors was ruled out in 3 patients. Among 14 indeterminate or equivocal extravesical foci, 7 were deemed of no clinical value because they disappeared after furosemide challenge, whereas 7 persisting foci were proven to be true-positive PET findings. The performance of (18)F-FDG PET in characterizing 3 renal-space-occupying lesions could not be improved by our protocol. CONCLUSION: Furosemide challenge has the potential to noninvasively resolve the inherent (18)F-FDG contrast handicap in the lower urinary tract.

Robust response transformations based on optimal prediction

Nonlinear regression problems can often be reduced to linearity by transforming the response variable (e.g., using the Box-Cox family of transformations). The classic estimates of the parameter defining the transformation as well as of the regression coefficients are based on the maximum likelihood criterion, assuming homoscedastic normal errors for the transformed response. These estimates are nonrobust in the presence of outliers and can be inconsistent when the errors are nonnormal or heteroscedastic. This article proposes new robust estimates that are consistent and asymptotically normal for any unimodal and homoscedastic error distribution. For this purpose, a robust version of conditional expectation is introduced for which the prediction mean squared error is replaced with an M scale. This concept is then used to develop a nonparametric criterion to estimate the transformation parameter as well as the regression coefficients. A finite sample estimate of this criterion based on a robust version of smearing is also proposed. Monte Carlo experiments show that the new estimates compare favorably with respect to the available competitors.