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.

The view of teachers on bullying and implications for nursing

Objective: To understand school bullying from the perspective of teachers and reflect about the possible actions of the health area when coping with it. The guidelines of the School Health Program of the Ministries of Health and Education were used to reach that purpose. Method: A qualitative study carried out with teachers of a public school in Minas Gerais. Focus groups were used to collect data and the empirical material was decoded from thematic analysis of content, resulting in an analytical category: conceptions and experiences of teachers on bullying. Results: Specific perceptions about the phenomenon and the use of ineffective intervention resources were identified. In the interpretive plan were problematized the health and nursing contributions with resizing the interventions and the continuing training process of teachers. Conclusion: The results point to the construction of intersectoral practices for coping with bullying.


The decision of an obese woman to have bariatric surgery: the social phenomenology

Objective To understand the process by which an obese woman decides to have bariatric surgery. Method A qualitative survey with a social phenomenology approach, carried out in 2012, with 12 women, using the phenomenological interview. Results A woman bases the decision to have the surgery on: the inappropriateness of her eating habits; a physical appearance that is incompatible with an appearance that is standardized by society; the social prejudice that she has to live with; the limitations imposed by obesity; and her lack of success with previous attempts to lose weight. Outcomes that she hopes for from the decision to have the surgery include: restoring her health; achieving social inclusion; and entering the labor market. Conclusion This study allows one to reflect that prescriptive actions do not give a satisfactory response to a complexity of the subjective questions involved in the decision to have surgery for obesity. For this, what is called for is a program of work based on an interdisciplinary approach, and training that gives value to the bio-psycho-social aspects involved in a decision in favor of surgical treatment.

Assessment of primary health care: health professionals’ perspective

Objective To assess primary health care attributes of access to a first contact, comprehensiveness, coordination, continuity, family guidance and community orientation. Method An evaluative, quantitative and cross-sectional study with 35 professional teams in the Family Health Program of the Alfenas region, Minas Gerais, Brazil. Data collection was done with the Primary Care Assessment Tool - Brazil, professional version. Results Results revealed a low percentage of medical experts among the participants who evaluated the attributes with high scores, with the exception of access to a first contact. Data analysis revealed needs for improvement: hours of service; forms of communication between clients and healthcare services and between clients and professionals; the mechanism of counter-referral. Conclusion It was concluded that there is a mismatch between the provision of services and the needs of the population, which compromises the quality of primary health care.




Lessons learned from developing a national NCD programme in low- and middle-income countries (Seychelles)

This paper identifies selected issues and lessons learned from the implementation of a national program of prevention and control of non-communicable diseases (NCD) during the past 20 years in the Seychelles, a small island state in the African region. As early as in 1989, population-based surveys demonstrated high levels of several cardiovascular risk factors, which prompted an organized response by the government. The early creation of a NCD unit within the Ministry of Health, coupled with cooperation with international partners, enabled incremental capacity building and coherent development of NCD programs and policy. Information campaigns and screening for hypertension and diabetes in work/public places raised awareness and rallied increasingly broad awareness and support to NCD prevention and control. A variety of interventions were organized for tobacco control and comprehensive tobacco control legislation was enacted in 2009 (including total bans on tobacco advertising and on smoking in all enclosed public and work places). A recent School Nutrition Policy prohibits the sale of soft drinks in schools. At primary health care level, guidelines were developed for the management of hypertension and diabetes (these conditions are managed in all health centers within a national health system); regular interactive education sessions were organized for groups of high risk patients ("heart health club"); and specialized "NCD nurses" were trained. Decreasing prevalence of smoking is evidence of success, but the raising "diabesity epidemic" calls for strengthened health care to high-risk patients and broader multisectoral policy to mould an environment conducive to healthy behaviors. Key components of NCD prevention and control in Seychelles include effective surveillance mechanisms supplemented by focused research; generating broad interest and consensus on the need for prevention and control of NCD; mobilizing leadership and commitment at all levels; involving local and international expertise; building on existing efforts; and seeking integrated, multi-disciplinary and multisectoral approaches.

The quality and characteristics of sleep of hypertensive patients

OBJECTIVEAnalyzing the quality of sleep of hypertensive patients registered in the national registration system and monitoring of hypertensive patients.METHODSA cross-sectional study of quantitative and descriptive analyses with 280 hypertensive patients registered in the National Program of Hypertension and Diabetes of the Federal Government in the months from August to October 2011. Questionnaires were used which allowed for tracking sociodemographic data on hypertension and Pittsburgh Sleep Quality Index (PSQI).RESULTSThe prevalence of poor sleep quality among respondents (156 hypertensive patients) and high rates of using medication for sleeping (106 hypertensive patients) was observed. Other relevant data refers to the quality of sleep among hypertensive patients using sleep medication compared to those who do not use it (p≤0.01).CONCLUSIONIndividuals with high blood pressure have a negative association with sleep quality.

The INTERNORM project : bridging two worlds of expert- and layknowledge in standardization

This paper presents a pilot project to reinforce participatory practices in standardization. The INTERNORM project is funded by the University of Lausanne, Switzerland. It aims to create an interactive knowledge center based on the sharing of academic skills and the experiences accumulated by the civil society, especially consumer associations, environmental associations and trade unions to strengthen the participatory process of standardization. The first objective of the project is action-oriented: INTERNORM provides a common knowledge pool supporting the participation of civil society actors to international standard-setting activities by bringing them together with academic experts in working groups and by providing logistic and financial support to their participation to meetings of national and international technical committees. The second objective of the project is analytical: the standardization action initiated through INTERNORM provides a research field for a better understanding of the participatory dynamics underpinning international standardization. The paper presents three incentives that explain civil society (non-)involvement in standardization that try to overcome conventional resource-based hypotheses: an operational incentive, related to the use of standards in the selective goods provided by associations to their membership; a thematic incentive, provided by the setting of priorities by strategic committees created in some standardization organization; a rhetorical incentive, related to the discursive resource that civil society concerns offers to the different stakeholders.

A portrait of the Spanish accounting community

This study presents a portrait of the Spanish academic accountingcommunity in 1995, based upon a questionnaire circulated to Spanishaccounting academics in 1995 and upon an analysis of authorship andcitations in the main Spanish accounting journals. The approach tothese analyses is grounded in similar studies which have been carriedout in the United States, Spain and elsewhere. but the combination oftechniques used in this study is particularly broad in range.The results of the study are used to describe a range ofcharacteristics of Spanish accounting academics, for example,publications records and length of academic experience. The analysisof publications produces a ranking by institutional affiliation ofthe most significant contributors to current debates on accounting.Citation analysis is used to identify the range and extent ofinternational influences upon the Spanish academic accountingcommunity, and to provide an additional ranking by institutionalaffiliation of the most frequently cited sources A significantfinding was that the nature and extent of international influence hadchanged very little over the ten year period since Spain entered theEuropean Union and started to implement European Directives.Perceptions of journal quality were elicited by questionnaire. Fortyfive journals, Spanish and international are included in a listranked for perceived importance as outlets for publication. and assources of support for teaching and research. The results of thisexercise show that Spanish journals were ranked low relative tojournals published in the United Kingdom and United States.Finally the study examines the extent of purpose upon Spanishaccounting academies to publish, by presenting results of a questionabout criteria for promotion, and also by examining and increasingtendency to publish co-authored work.

Annual Report of Iowa Highway Research Board Research and Development Activities FY 08

RESEARCH AND DEVELOPMENT The Highway Division of the Iowa Department of Transportation (Iowa DOT) engages in research and development for two reasons: first, to find workable solutions to the many problems that require more than ordinary, routine investigation; second, to identify and implement improved engineering and management practices. This report, entitled "Iowa Highway Research Board Research and Development Activities FY2008" is submitted in compliance with Sections 310.36 and 3 I2.3A, Code of Iowa, which direct the submission of a report of the Secondary Road Research Fund and the Street Research Fund respectively. It is a report of the status of research and development projects in progress on June 30, 2008; it is also a report on projects completed during the fiscal year beginning July 1, 2007, and ending June 30, 2008. Detailed information on each of the research and development projects mentioned in this report is available in the Research and Technology Bureau in the Highway Division of the Iowa Department of Transportation. IOWA HIGHWAY RESEARCH BOARD In developing a progressive, continuing and coordinated program of research and development, the Highway Division is assisted by the Iowa Highway Research Board. This advisory group was established in 1949 by the Iowa State Highway Commission to respond to the research denoted in Section 310.36 of the Code of Iowa and now is denoted by 312.3A. The Research Board consists of 15 regular members: seven Iowa county engineers, four Iowa DOT engineers, one representative from Iowa State University, one from The University of Iowa, and two engineers employed by Iowa municipalities. Each regular member may have an alternate who will serve at the request of the regular member. The regular members and their alternates are appointed for a three-year term. The membership of the Research Board as of June 30, 2008, is listed in Table I. The Research Board held nine regular meetings during the period ofJuly 1, 2007, to June 30, 2008. Suggestions for research and development were reviewed at these meetings and recommendations were made by the Board.

Annual Report of Iowa Highway Research Board Research and Development Activities 2007

RESEARCH AND DEVELOPMENT The Highway Division of the Iowa Department of Transportation (Iowa DOT) engages in research and development for two reasons: first, to find workable solutions to the many problems that require more than ordinary, routine investigation; second, to identify and implement improved engineering and management practices. This report, entitled "Iowa Highway Research Board Research and Development Activities FY2008" is submitted in compliance with Sections 310.36 and 3 I2.3A, Code of Iowa, which direct the submission of a report of the Secondary Road Research Fund and the Street Research Fund respectively. It is a report of the status of research and development projects in progress on June 30, 2008; it is also a report on projects completed during the fiscal year beginning July 1, 2007, and ending June 30, 2008. Detailed information on each of the research and development projects mentioned in this report is available in the Research and Technology Bureau in the Highway Division of the Iowa Department of Transportation. IOWA HIGHWAY RESEARCH BOARD In developing a progressive, continuing and coordinated program of research and development, the Highway Division is assisted by the Iowa Highway Research Board. This advisory group was established in 1949 by the Iowa State Highway Commission to respond to the research denoted in Section 310.36 of the Code of Iowa and now is denoted by 312.3A. The Research Board consists of 15 regular members: seven Iowa county engineers, four Iowa DOT engineers, one representative from Iowa State University, one from The University of Iowa, and two engineers employed by Iowa municipalities. Each regular member may have an alternate who will serve at the request of the regular member. The regular members and their alternates are appointed for a three-year term. The membership of the Research Board as of June 30, 2008, is listed in Table I. The Research Board held nine regular meetings during the period ofJuly 1, 2007, to June 30, 2008. Suggestions for research and development were reviewed at these meetings and recommendations were made by the Board.

Multifactorial ERβ and NOTCH1 control of squamous differentiation and cancer.

Downmodulation or loss-of-function mutations of the gene encoding NOTCH1 are associated with dysfunctional squamous cell differentiation and development of squamous cell carcinoma (SCC) in skin and internal organs. While NOTCH1 receptor activation has been well characterized, little is known about how NOTCH1 gene transcription is regulated. Using bioinformatics and functional screening approaches, we identified several regulators of the NOTCH1 gene in keratinocytes, with the transcription factors DLX5 and EGR3 and estrogen receptor β (ERβ) directly controlling its expression in differentiation. DLX5 and ERG3 are required for RNA polymerase II (PolII) recruitment to the NOTCH1 locus, while ERβ controls NOTCH1 transcription through RNA PolII pause release. Expression of several identified NOTCH1 regulators, including ERβ, is frequently compromised in skin, head and neck, and lung SCCs and SCC-derived cell lines. Furthermore, a keratinocyte ERβ-dependent program of gene expression is subverted in SCCs from various body sites, and there are consistent differences in mutation and gene-expression signatures of head and neck and lung SCCs in female versus male patients. Experimentally increased ERβ expression or treatment with ERβ agonists inhibited proliferation of SCC cells and promoted NOTCH1 expression and squamous differentiation both in vitro and in mouse xenotransplants. Our data identify a link between transcriptional control of NOTCH1 expression and the estrogen response in keratinocytes, with implications for differentiation therapy of squamous cancer.

Regulation of glucose transporter expression in cardiac myocytes: p38 MAPK is a strong inducer of GLUT4.

OBJECTIVE: In vivo differentiation of cardiac myocytes is associated with downregulation of the glucose transporter isoform GLUT1 and upregulation of the isoform GLUT4. Adult rat cardiomyocytes in primary culture undergo spontaneous dedifferentiation, followed by spreading and partial redifferentiation, which can be influenced by growth factors. We used this model to study the signaling mechanisms modifying the expression of GLUT4 in cardiac myocytes. RESULTS: Adult rat cardiomyocytes in primary culture exhibited spontaneous upregulation of GLUT1 and downregulation of GLUT4, suggesting resumption of a fetal program of GLUT gene expression. Treatment with IGF-1 and, to a minor extent, FGF-2 resulted in restored expression of GLUT4 protein and mRNA. Activation of p38 MAPK mediated the increased expression of GLUT4 in response to IGF-1. Transient transfection experiments in neonatal cardiac myocytes confirmed that p38 MAPK could activate the glut4 promoter. Electrophoretic mobility shift assay in adult rat cardiomyocytes and transient transfection experiments in neonatal cardiac myocytes indicated that MEF2 was the main transcription factor transducing the effect of p38 MAPK activation on the glut4 promoter. CONCLUSION: Spontaneous dedifferentiation of adult rat cardiomyocytes in vitro is associated with downregulation of GLUT4, which can be reversed by treatment with IGF-1. The effect of IGF-1 is mediated by the p38 MAPK/MEF2 axis, which is a strong inducer of GLUT4 expression.

Rapid antagonistic coevolution between strains of the social amoeba Dictyostelium discoideum.

Social groups face a fundamental problem of overcoming selfish individuals capable of destroying cooperation. In the social amoeba Dictyostelium discoideum, there is evidence that some clones ('cheaters') contribute disproportionately to the viable spores in a fruiting body while avoiding the dead stalk cell fate. It remains unclear, however, whether this cheating is actually the product of selection. Here, I report the results of an experimental evolution study designed to test whether clones of D. discoideum will evolve resistance to cheating in the laboratory with genetic variation created only through spontaneous mutation. Two strains, one green fluorescent protein (GFP)-labelled and one wild-type, were allowed to grow and develop together before the wild-type strain was removed and replaced with a naïve strain evolving in parallel. Over the course of 10 social generations, the GFP-labelled strain reliably increased its representation in the spores relative to control populations that had never experienced the competitor. This competitive advantage extended to the non-social, vegetative growth portion of the life cycle, but not to pairwise competition with two other strains. These results indicate strong antagonism between strains, mediated by ample mutational variation for cheating and also suggest that arms races between strains in the wild may be common.

Tricky and terrible T-cell tumors: these are thrilling times for testing: molecular pathology of peripheral T-cell lymphomas.

Peripheral T-cell lymphomas (PTCLs) encompass a group of rare and usually clinically aggressive diseases. The classification and diagnosis of these diseases are compounded by their marked pathological heterogeneity and complex clinical features. With the exception of ALK-positive anaplastic large cell lymphoma (ALCL), which is defined on the basis of ALK rearrangements, genetic features play little role in the definition of other disease entities. In recent years, hitherto unrecognized chromosomal translocations have been reported in small subsets of PTCLs, and genome-wide array-based profiling investigations have provided novel insights into their molecular characteristics. This article summarizes the current knowledge on the best-characterized genetic and molecular alterations underlying the pathogenesis of PTCLs, with a focus on recent discoveries, their relevance to disease classification, and their management implications from a diagnostical and therapeutical perspective.

FOXC2 and NFATc1 control formation and maturation of collecting lymphatic vessels

The mechanisms of blood vessel maturation into distinct parts of the blood vasculature such as arteries, veins, and capillaries have been the subject of intense investigation over recent years. In contrast, our knowledge of lymphatic vessel maturation is still fragmentary. In this study, we provide a molecular and morphological characterization of the major steps in the maturation of the primary lymphatic capillary plexus into collecting lymphatic vessels during development and show that forkhead transcription factor Foxc2 controls this process. We further identify transcription factor NFATc1 as a novel regulator of lymphatic development and describe a previously unsuspected link between NFATc1 and Foxc2 in the regulation of lymphatic maturation. We also provide a genome-wide map of FOXC2-binding sites in lymphatic endothelial cells, identify a novel consensus FOXC2 sequence, and show that NFATc1 physically interacts with FOXC2-binding enhancers. These data provide novel insights into the molecular program of lymphatic vascular specification and suggest that FOXC2 and NFATc1 are potential targets for therapeutic intervention.