Procedure for the identification of population characteristics for targeting intervention services on the basis of outcome-goal priorities: Case management services for the chronic mentally ill

Although the processes involved in rational patient targeting may be obvious for certain services, for others, both the appropriate sub-populations to receive services and the procedures to be used for their identification may be unclear. This project was designed to address several research questions which arise in the attempt to deliver appropriate services to specific populations. The related difficulties are particularly evident for those interventions about which findings regarding effectiveness are conflicting. When an intervention clearly is not beneficial (or is dangerous) to a large, diverse population, consensus regarding withholding the intervention from dissemination can easily be reached. When findings are ambiguous, however, conclusions may be impossible.^ When characteristics of patients likely to benefit from an intervention are not obvious, and when the intervention is not significantly invasive or dangerous, the strategy proposed herein may be used to identify specific characteristics of sub-populations which may benefit from the intervention. The identification of these populations may be used both in further informing decisions regarding distribution of the intervention and for purposes of planning implementation of the intervention by identifying specific target populations for service delivery.^ This project explores a method for identifying such sub-populations through the use of related datasets generated from clinical trials conducted to test the effectiveness of an intervention. The method is specified in detail and tested using the example intervention of case management for outpatient treatment of populations with chronic mental illness. These analyses were applied in order to identify any characteristics which distinguish specific sub-populations who are more likely to benefit from case management service, despite conflicting findings regarding its effectiveness for the aggregate population, as reported in the body of related research. However, in addition to a limited set of characteristics associated with benefit, the findings generated, a larger set of characteristics of patients likely to experience greater improvement without intervention. ^

INTAKE VARIABLES AS PREDICTORS OF ASSESSMENT AND REFERRAL PROCEDURE OUTCOMES IN EMPLOYEE ASSISTANCE PROGRAMS

While reported prevalence rates of troubled employees vary considerably, even conservative estimates indicate a major public health problem. For example, alcohol and drug related problems alone cost U.S. industry more than 45 billion dollars annually.^ Of the alternatives available to deal with these problems, e.g., dismissal or disciplinary actions, the most viable and cost effective are employee assistance programs (EAP), designed to provide professional assistance to employees experiencing alcohol, drug, emotional or personal crisis.^ The principal component of an EAP is that of assessment and referral, and this study was developed to determine which EAP client intake variables are the most efficacious predictors of assessment and referral procedures.^ Although, specific client intake variables were statistically significant the discriminant classification analysis was demonstrably inadequate. Nevertheless, the identification of A/R procedure phases which were not efficacious, as well as EAP client populations for whom services were not effective, were extremely valuable discernments. Identifying the less efficacious components of the A/R process provided an opportunity to recommend alternatives to current program procedures and practices, which may ameliorate program effectiveness. ^

Development of a standard sign-out procedure for clinicians in a pediatric intensive care unit

Background: Poor communication among health care providers is cited as the most common cause of sentinel events involving patients. Sign-out of patient data at the change of clinician shifts is a component of communication that is especially vulnerable to errors. Sign-outs are particularly extensive and complex in intensive care units (ICUs). There is a paucity of validated tools to assess ICU sign-outs. ^ Objective: To design a valid and reliable survey tool to assess the perceptions of Pediatric ICU (PICU) clinicians about sign-out. ^ Design: Cross-sectional, web-based survey ^ Setting: Academic hospital, 31-bed PICU ^ Subjects: Attending faculty, fellows, nurse practitioners and physician assistants. ^ Interventions: A survey was designed with input from a focus group and administered to PICU clinicians. Test-retest reliability, internal consistency and validity of the survey tool were assessed. ^ Measurements and Main Results: Forty-eight PICU clinicians agreed to participate. We had 42(88%) and 40(83%) responses in the test and retest phases. The mean scores for the ten survey items ranged from 2.79 to 3.67 on a five point Likert scale with no significant test-retest difference and a Pearson correlation between pre and post answers of 0.65. The survey item scores showed internal consistency with a Cronbach's Alpha of 0.85. Exploratory factor analysis revealed three constructs: efficacy of sign-out process, recipient satisfaction and content applicability. Seventy eight % clinicians affirmed the need for improvement of the sign-out process and 83% confirmed the need for face- to-face verbal sign-out. A system-based sign-out format was favored by fellows and advanced level practitioners while attendings preferred a problem-based format (p=0.003). ^ Conclusions: We developed a valid and reliable survey to assess clinician perceptions about the ICU sign-out process. These results can be used to design a verbal template to improve and standardize the sign-out process.^

Policy analysis of shifting to the state-run Texas women's health program

During the 82nd Texas legislature, state leaders passed a provision stating that healthcare providers, who perform, promote, or affiliate with providers who perform or promote elective abortion services may not be eligible to participate in the Texas Medicaid Women's Health Program (WHP). The federal government reacted to this new provision by vowing to eliminate its 90% share of program support on the grounds that the provision violated a patient's freedom to choose a provider; a right protected by the Social Security Act. Texas leaders stated that the Women's Health Program would continue without federal support, financed exclusively with state funds.^ The following policy analysis compares the projected impact of the current Medicaid Women's Health Program to the proposed state-run program using the criteria-alternative matrix framework. The criteria used to evaluate the program alternatives include population affected, unintended pregnancy and abortion impact, impact on cervical cancer rate, and state-level government expenditures. Each criterion was defined by selected measures. The population affected was measured by the number of women served in the programs. Government expenditures were measured in terms of payments for program costs, Medicaid delivery costs, and cervical cancer diagnostic costs. Unintended pregnancy impact was measured by the number of projected unplanned pregnancies and abortions under each alternative. The impact on cervical cancer was projected in terms of the number of new cervical cancer cases under each alternative. Differences in the projections with respect to each criterion were compared to assess the impact of shifting to the state-only policy.^ After examining program alternatives, it is highly recommended that Texas retain the Medicaid WHP. If the state does decide to move forward with the state-run WHP, it is recommended that the program run at its previous capacity. Furthermore, for the purpose of addressing the relatively high cervical cancer incidence rate in Texas, incorporating HPV vaccination coverage for women ages 18-26 as part of the Women's Health Program is recommended.^

Shifting the focus: Addressing breast cancer disparities at the health care organization level

The purpose of this study was to understand the scope of breast cancer disparities within the Texas Medical Center. The goal was to increase the awareness of breast cancer disparities at the health care organization level, and to foster the development of organizational interventions to reduce breast cancer disparities. The study seeks to answer the following questions: 1. Are hospitals in the Texas Medical Center implementing interventions to reduce breast cancer disparities? 2. What are their interventions for reducing the effects of non clinical factors on breast cancer treatment disparities? 3. What are their measures for monitoring, continuously improving, and evaluating the success of their interventions? ^ This research project was designed as a mixed methods case study. Quantitative breast cancer data for the years 2000-2009 was obtained from the Texas Cancer Registry (TCR). Qualitative data collection and analysis was done by conducting a total of 20 semi-structured interviews of administrators, physicians and nurses at five hospitals (A, B, C, D and E) in the Texas Medical Center (TMC). For quantitative analysis, the study was limited to early stage breast cancer patients: local and regional. The dependent variable was receipt of standard treatment: Surgery (Yes/No), BCS vs Mastectomy, Chemotherapy (Yes/No) and Radiation after BCS (Yes/No). The main independent variable was race: non-Hispanic White (NHW) , non-Hispanic Black (NHB), and Hispanic. Other covariates included age at diagnosis, diagnosis date, percent poverty, grade, stage, and regional nodes. Multivariate logistic regression was used to test the adjusted association between receipt of standard care and race. Qualitative data was analyzed with the Atlas.ti7 software (ATLAS.ti GmbH, Berlin). ^ Though there were significant differences by race for all dependent variables when the data was analyzed as a single group of all hospitals; at the level of the individual hospitals the results were not consistent by race/ethnicity across all dependent variables for hospitals A, B, and E. There were no racial differences in adjusted analysis for receipt of chemotherapy for the individual hospitals of interest in this study. For hospitals C and D, no racial disparities in treatment was observed in adjusted multivariable analysis. All organizations in this study were aware of the body of research which shows that there are disparities in breast cancer outcomes for patient population groups. However, qualitative data analysis found that there were differences in interest among hospitals in addressing breast cancer disparities in their patient population groups. Some organizations were actively implementing directed measures to reduce the breast cancer disparity gap in outcomes for patients, and others were not. Despite the differences in levels of interest, quantitative data analysis showed that organizations in the Texas Medical Center were making progress in reducing the burden of breast cancer disparities in the patient populations being served.^

The dynamic evaluation of the learning potential: a procedure

Fil: Malbrán, María del Carmen. Universidad Nacional de La Plata. Facultad de Humanidades y Ciencias de la Educación; Argentina.

The dynamic evaluation of the learning potential: a procedure

Fil: Malbrán, María del Carmen. Universidad Nacional de La Plata. Facultad de Humanidades y Ciencias de la Educación; Argentina.

Simulated changes in ocean physics and carbon cycle for LGM experiments with shifting positions of the Southern Hemisphere westerly winds using the MITgcm, links to model results in NetCDF format

We explore the impact of a latitudinal shift in the westerly wind belt over the Southern Ocean on the Atlantic meridional overturning circulation (AMOC) and on the carbon cycle for Last Glacial Maximum background conditions using a state-of-the-art ocean general circulation model. We find that a southward (northward) shift in the westerly winds leads to an intensification (weakening) of no more than 10% of the AMOC. This response of the ocean physics to shifting winds agrees with other studies starting from preindustrial background climate, but the responsible processes are different. In our setup changes in AMOC seemed to be more pulled by upwelling in the south than pushed by downwelling in the north, opposite to what previous studies with different background climate are suggesting. The net effects of the changes in ocean circulation lead to a rise in atmospheric pCO2 of less than 10 atm for both northward and southward shift in the winds. For northward shifted winds the zone of upwelling of carbon- and nutrient-rich waters in the Southern Ocean is expanded, leading to more CO2 outgassing to the atmosphere but also to an enhanced biological pump in the subpolar region. For southward shifted winds the upwelling region contracts around Antarctica, leading to less nutrient export northward and thus a weakening of the biological pump. These model results do not support the idea that shifts in the westerly wind belt play a dominant role in coupling atmospheric CO2 rise and Antarctic temperature during deglaciation suggested by the ice core data.

Analysis of the Fracture of Reinforced Concrete Flat Elements Subjected to Explosions. Experimental Procedure and Numerical Validation

Many of the material models most frequently used for the numerical simulation of the behavior of concrete when subjected to high strain rates have been originally developed for the simulation of ballistic impact. Therefore, they are plasticity-based models in which the compressive behavior is modeled in a complex way, while their tensile failure criterion is of a rather simpler nature. As concrete elements usually fail in tensión when subjected to blast loading, available concrete material models for high strain rates may not represent accurately their real behavior. In this research work an experimental program of reinforced concrete fíat elements subjected to blast load is presented. Altogether four detonation tests are conducted, in which 12 slabs of two different concrete types are subjected to the same blast load. The results of the experimental program are then used for the development and adjustment of numerical tools needed in the modeling of concrete elements subjected to blast.

Blind reconiliation

Information reconciliation is a crucial procedure in the classical post-processing of quantum key distribution (QKD). Poor reconciliation e?ciency, revealing more information than strictly needed, may compromise the maximum attainable distance, while poor performance of the algorithm limits the practical throughput in a QKD device. Historically, reconciliation has been mainly done using close to minimal information disclosure but heavily interactive procedures, like Cascade, or using less e?cient but also less interactive ?just one message is exchanged? procedures, like the ones based in low-density parity-check (LDPC) codes. The price to pay in the LDPC case is that good e?ciency is only attained for very long codes and in a very narrow range centered around the quantum bit error rate (QBER) that the code was designed to reconcile, thus forcing to have several codes if a broad range of QBER needs to be catered for. Real world implementations of these methods are thus very demanding, either on computational or communication resources or both, to the extent that the last generation of GHz clocked QKD systems are ?nding a bottleneck in the classical part. In order to produce compact, high performance and reliable QKD systems it would be highly desirable to remove these problems. Here we analyse the use of short-length LDPC codes in the information reconciliation context using a low interactivity, blind, protocol that avoids an a priori error rate estimation. We demonstrate that 2×103 bits length LDPC codes are suitable for blind reconciliation. Such codes are of high interest in practice, since they can be used for hardware implementations with very high throughput.

Criterios para el dimensionamiento de redes de riego robustas frente a cambios en la alternativa de cultivos

En los años 50 y 60 del siglo XX se produjo en Europa un cambio en la concepción de los sistemas de riego, en los cuales se pasó del regadío por superficie al presurizado y con ello del riego por turnos al riego a la demanda. Las ventajas de este nuevo sistema de riego dieron lugar a una gran expansión de las redes colectivas de riego a presión, especialmente en los países del arco mediterráneo y del Sur de Europa (Francia, España, Italia, Portugal y Grecia). Desde entonces el riego presurizado a la demanda ha tenido una evolución permanente, en la que han mejorado los equipos y las técnicas de aplicación del riego, siempre con una clara orientación hacía el incremento de la productividad. Esta evolución unida a los vaivenes de los mercados, al abaratamiento de los transportes y la globalización, y a las subvenciones agrícolas, ha propiciado que las alternativas de cultivos previstas hayan sufrido cambios. El cambio de la alternativa de cultivos hacia otros más exigentes desde el punto de vista de las necesidades hídricas tiene como consecuencia el aumento de los consumos, circunstancia para cual debe estar capacitada la red. Otros fenómenos como el cambio climático, de amplio interés a día de hoy, presentan algunos escenarios en lo que se prevé un incremento de las temperaturas que unido a una reducción en las precipitaciones, supondría también que se elevarían las necesidades de riego de los cultivos. Todas estas circunstancias deben ser contempladas en la redacción de los proyectos de transformación de nuevas zonas regables y en los de modernización de las existentes. Las redes de riego deben estar dimensionadas para poder atender dichos incrementos de consumo. La fortaleza de la red para atender variaciones en las demandas de agua se convierte por tanto en una premisa del proyecto. Dicha fortaleza se puede conseguir de formas diferentes y a costos distintos, puesto que en el proceso de dimensionamiento estadístico de los caudales circulantes en punta de campaña intervienen muchas variables y parámetros de riego. En la presente tesis doctoral se analiza en detalle el estado del arte en la materia, se efectúa un análisis de la función específica y la influencia en el cálculo de cada uno de los parámetros, se establece un procedimiento de actuación que optimice el dimensionamiento de la red colectiva para que ésta disponga de la robustez necesaria para hacer frente a incrementos potenciales de consumo de agua sobre la previsiones de base del proyecto y se establecen los criterios, rangos y combinaciones de parámetros que permiten dotar a la red de la fortaleza necesaria de la manera más eficiente posible. During the 1950s and 1960s the design of irrigation systems in Europe underwent change. Traditional surface irrigation was replaced by pressure irrigation, with the delivery method shifting from a scheduled type to an on-demand one. The advantages obtained with this new system led to a significant development of on-demand pressurised irrigation districts, especially in the Southern countries (France, Greece, Italy, Portugal and Spain). On-demand pressurised irrigation has since evolved in a continuous manner in which, with the purpose of gaining productivity, on-farm equipment and automation instruments have seen improvements. Such developments, along with market fluctuations, reductions in transport costs, globalisation and the influence of agricultural subsidies, have resulted in changes in the crop pattern. The farming of new crops may require more water and the consumption may become greater. In addition to this, other phenomena, such as the frequently-debated effects of climate change, reveal scenarios in which an increase in temperatures and the accompanying reductions in rainfall are expected. One consequence of this would be an increase in irrigation requirements and subsequent impact on irrigation networks. All such circumstances should be taken into account in both the design of new irrigation districts and the upgrading of the existing ones. Irrigation networks should be of a size that allows them to meet increases in consumption. The robustness of the network, defined as its capacity to absorb increments in water requirements, becomes a key point to be taken into account in the design phase. Given that there are several parameters that influence the calculus of design flows, such robustness may be obtained in different ways and at varying costs. In the context of this, the thesis reviews the state of the art, analyses the role and influence of each parameter, establishes a procedure for checking the design and robustness of on-demand irrigation networks, and sets design criteria for selecting the most effective range and combination of parameters that provide the network with such robustness.

Simplified Procedure for the Nonlinear Seismic Analysis of Bridges

The severe accidents suffered by bridges during recent earthquake show that more careful analysis are needed to guarantee their behaviour. In particular simplified non-linear analysis could be useful to bridge the gap between theoretical research and practical applications. This paper presents one of those simplified methods that can be applied for first designs or to retrofitting of groups of bridges.

A robust procedure for damage detection from strain measurements based on principal component analysis

FBGs are excellent strain sensors, because of its low size and multiplexing capability. Tens to hundred of sensors may be embedded into a structure, as it has already been demonstrated. Nevertheless, they only afford strain measurements at local points, so unless the damage affects the strain readings in a distinguishable manner, damage will go undetected. This paper show the experimental results obtained on the wing of a UAV, instrumented with 32 FBGs, before and after small damages were introduced. The PCA algorithm was able to distinguish the damage cases, even for small cracks. Principal Component Analysis (PCA) is a technique of multivariable analysis to reduce a complex data set to a lower dimension and reveal some hidden patterns that underlie.