Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): a multicentre, open-label randomised controlled trial.

PubMed

Koopmans, Corine M; Bijlenga, Denise; Groen, Henk; Vijgen, Sylvia M C; Aarnoudse, Jan G; Bekedam, Dick J; van den Berg, Paul P; de Boer, Karin; Burggraaff, Jan M; Bloemenkamp, Kitty W M; Drogtrop, Addy P; Franx, Arie; de Groot, Christianne J M; Huisjes, Anjoke J M; Kwee, Anneke; van Loon, Aren J; Lub, Annemiek; Papatsonis, Dimitri N M; van der Post, Joris A M; Roumen, Frans J M E; Scheepers, Hubertina C J; Willekes, Christine; Mol, Ben W J; van Pampus, Maria G

2009-09-19

Robust evidence to direct management of pregnant women with mild hypertensive disease at term is scarce. We investigated whether induction of labour in women with a singleton pregnancy complicated by gestational hypertension or mild pre-eclampsia reduces severe maternal morbidity. We undertook a multicentre, parallel, open-label randomised controlled trial in six academic and 32 non-academic hospitals in the Netherlands between October, 2005, and March, 2008. We enrolled patients with a singleton pregnancy at 36-41 weeks' gestation, and who had gestational hypertension or mild pre-eclampsia. Participants were randomly allocated in a 1:1 ratio by block randomisation with a web-based application system to receive either induction of labour or expectant monitoring. Masking of intervention allocation was not possible. The primary outcome was a composite measure of poor maternal outcome--maternal mortality, maternal morbidity (eclampsia, HELLP syndrome, pulmonary oedema, thromboembolic disease, and placental abruption), progression to severe hypertension or proteinuria, and major post-partum haemorrhage (>1000 mL blood loss). Analysis was by intention to treat and treatment effect is presented as relative risk. This study is registered, number ISRCTN08132825. 756 patients were allocated to receive induction of labour (n=377 patients) or expectant monitoring (n=379). 397 patients refused randomisation but authorised use of their medical records. Of women who were randomised, 117 (31%) allocated to induction of labour developed poor maternal outcome compared with 166 (44%) allocated to expectant monitoring (relative risk 0.71, 95% CI 0.59-0.86, p<0.0001). No cases of maternal or neonatal death or eclampsia were recorded. Induction of labour is associated with improved maternal outcome and should be advised for women with mild hypertensive disease beyond 37 weeks' gestation. ZonMw.

Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations

PubMed Central

Arndt, Brian G.; Beasley, John W.; Watkinson, Michelle D.; Temte, Jonathan L.; Tuan, Wen-Jan; Sinsky, Christine A.; Gilchrist, Valerie J.

2017-01-01

PURPOSE Primary care physicians spend nearly 2 hours on electronic health record (EHR) tasks per hour of direct patient care. Demand for non–face-to-face care, such as communication through a patient portal and administrative tasks, is increasing and contributing to burnout. The goal of this study was to assess time allocated by primary care physicians within the EHR as indicated by EHR user-event log data, both during clinic hours (defined as 8:00 am to 6:00 pm Monday through Friday) and outside clinic hours. METHODS We conducted a retrospective cohort study of 142 family medicine physicians in a single system in southern Wisconsin. All Epic (Epic Systems Corporation) EHR interactions were captured from “event logging” records over a 3-year period for both direct patient care and non–face-to-face activities, and were validated by direct observation. EHR events were assigned to 1 of 15 EHR task categories and allocated to either during or after clinic hours. RESULTS Clinicians spent 355 minutes (5.9 hours) of an 11.4-hour workday in the EHR per weekday per 1.0 clinical full-time equivalent: 269 minutes (4.5 hours) during clinic hours and 86 minutes (1.4 hours) after clinic hours. Clerical and administrative tasks including documentation, order entry, billing and coding, and system security accounted for nearly one-half of the total EHR time (157 minutes, 44.2%). Inbox management accounted for another 85 minutes (23.7%). CONCLUSIONS Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. EHR event logs can identify areas of EHR-related work that could be delegated, thus reducing workload, improving professional satisfaction, and decreasing burnout. Direct time-motion observations validated EHR-event log data as a reliable source of information regarding clinician time allocation. PMID:28893811

Tethered to the EHR: Primary Care Physician Workload Assessment Using EHR Event Log Data and Time-Motion Observations.

PubMed

Arndt, Brian G; Beasley, John W; Watkinson, Michelle D; Temte, Jonathan L; Tuan, Wen-Jan; Sinsky, Christine A; Gilchrist, Valerie J

2017-09-01

Primary care physicians spend nearly 2 hours on electronic health record (EHR) tasks per hour of direct patient care. Demand for non-face-to-face care, such as communication through a patient portal and administrative tasks, is increasing and contributing to burnout. The goal of this study was to assess time allocated by primary care physicians within the EHR as indicated by EHR user-event log data, both during clinic hours (defined as 8:00 am to 6:00 pm Monday through Friday) and outside clinic hours. We conducted a retrospective cohort study of 142 family medicine physicians in a single system in southern Wisconsin. All Epic (Epic Systems Corporation) EHR interactions were captured from "event logging" records over a 3-year period for both direct patient care and non-face-to-face activities, and were validated by direct observation. EHR events were assigned to 1 of 15 EHR task categories and allocated to either during or after clinic hours. Clinicians spent 355 minutes (5.9 hours) of an 11.4-hour workday in the EHR per weekday per 1.0 clinical full-time equivalent: 269 minutes (4.5 hours) during clinic hours and 86 minutes (1.4 hours) after clinic hours. Clerical and administrative tasks including documentation, order entry, billing and coding, and system security accounted for nearly one-half of the total EHR time (157 minutes, 44.2%). Inbox management accounted for another 85 minutes (23.7%). Primary care physicians spend more than one-half of their workday, nearly 6 hours, interacting with the EHR during and after clinic hours. EHR event logs can identify areas of EHR-related work that could be delegated, thus reducing workload, improving professional satisfaction, and decreasing burnout. Direct time-motion observations validated EHR-event log data as a reliable source of information regarding clinician time allocation. © 2017 Annals of Family Medicine, Inc.

Research on allocation efficiency of the daisy chain allocation algorithm

NASA Astrophysics Data System (ADS)

Shi, Jingping; Zhang, Weiguo

2013-03-01

With the improvement of the aircraft performance in reliability, maneuverability and survivability, the number of the control effectors increases a lot. How to distribute the three-axis moments into the control surfaces reasonably becomes an important problem. Daisy chain method is simple and easy to be carried out in the design of the allocation system. But it can not solve the allocation problem for entire attainable moment subset. For the lateral-directional allocation problem, the allocation efficiency of the daisy chain can be directly measured by the area of its subset of attainable moments. Because of the non-linear allocation characteristic, the subset of attainable moments of daisy-chain method is a complex non-convex polygon, and it is difficult to solve directly. By analyzing the two-dimensional allocation problems with a "micro-element" idea, a numerical calculation algorithm is proposed to compute the area of the non-convex polygon. In order to improve the allocation efficiency of the algorithm, a genetic algorithm with the allocation efficiency chosen as the fitness function is proposed to find the best pseudo-inverse matrix.

Allocation of Internal Medicine Resident Time in a Swiss Hospital: A Time and Motion Study of Day and Evening Shifts.

PubMed

Wenger, Nathalie; Méan, Marie; Castioni, Julien; Marques-Vidal, Pedro; Waeber, Gérard; Garnier, Antoine

2017-04-18

Little current evidence documents how internal medicine residents spend their time at work, particularly with regard to the proportions of time spent in direct patient care versus using computers. To describe how residents allocate their time during day and evening hospital shifts. Time and motion study. Internal medicine residency at a university hospital in Switzerland, May to July 2015. 36 internal medicine residents with an average of 29 months of postgraduate training. Trained observers recorded the residents' activities using a tablet-based application. Twenty-two activities were categorized as directly related to patients, indirectly related to patients, communication, academic, nonmedical tasks, and transition. In addition, the presence of a patient or colleague and use of a computer or telephone during each activity was recorded. Residents were observed for a total of 696.7 hours. Day shifts lasted 11.6 hours (1.6 hours more than scheduled). During these shifts, activities indirectly related to patients accounted for 52.4% of the time, and activities directly related to patients accounted for 28.0%. Residents spent an average of 1.7 hours with patients, 5.2 hours using computers, and 13 minutes doing both. Time spent using a computer was scattered throughout the day, with the heaviest use after 6:00 p.m. The study involved a small sample from 1 institution. At this Swiss teaching hospital, internal medicine residents spent more time at work than scheduled. Activities indirectly related to patients predominated, and about half the workday was spent using a computer. Information Technology Department and Department of Internal Medicine of Lausanne University Hospital.

Comparison of direct and indirect methods of estimating health state utilities for resource allocation: review and empirical analysis.

PubMed

Arnold, David; Girling, Alan; Stevens, Andrew; Lilford, Richard

2009-07-22

Utilities (values representing preferences) for healthcare priority setting are typically obtained indirectly by asking patients to fill in a quality of life questionnaire and then converting the results to a utility using population values. We compared such utilities with those obtained directly from patients or the public. Review of studies providing both a direct and indirect utility estimate. Papers reporting comparisons of utilities obtained directly (standard gamble or time tradeoff) or indirectly (European quality of life 5D [EQ-5D], short form 6D [SF-6D], or health utilities index [HUI]) from the same patient. PubMed and Tufts database of utilities. Sign test for paired comparisons between direct and indirect utilities; least squares regression to describe average relations between the different methods. Mean utility scores (or median if means unavailable) for each method, and differences in mean (median) scores between direct and indirect methods. We found 32 studies yielding 83 instances where direct and indirect methods could be compared for health states experienced by adults. The direct methods used were standard gamble in 57 cases and time trade off in 60(34 used both); the indirect methods were EQ-5D (67 cases), SF-6D (13), HUI-2 (5), and HUI-3 (37). Mean utility values were 0.81 (standard gamble) and 0.77 (time tradeoff) for the direct methods; for the indirect methods: 0.59(EQ-5D), 0.63 (SF-6D), 0.75 (HUI-2) and 0.68 (HUI-3). Direct methods of estimating utilities tend to result in higher health ratings than the more widely used indirect methods, and the difference can be substantial.Use of indirect methods could have important implications for decisions about resource allocation: for example, non-lifesaving treatments are relatively more favoured in comparison with lifesaving interventions than when using direct methods.

Effect of physician perspective on allocation of Medicare resources for patients with advanced cancer.

PubMed

Rocke, Daniel J; Beumer, Halton W; Thomas, Steven; Lee, Walter T

2014-05-01

To assess how physician perspective (perspective of patient vs perspective of physician) affects Medicare resource allocation for patients with advanced cancer and compare physician allocations with actual cancer patient and caregiver allocations. Cross-sectional assessment. National assessment. Otolaryngologists. Physicians used a validated tool to create a Medicare plan for patients with advanced cancer. Participants took the perspective of an advanced cancer patient and made resource allocations between 15 benefit categories (assessment 2, November/December 2012). Results were compared with data from a prior assessment made from a physician's perspective (assessment 1, February/March 2012) and with data from a separate study with patients with cancer and caregivers. In total, 767 physicians completed assessment 1 and 237 completed assessment 2. Results were compared with 146 cancer patient and 114 caregiver assessments. Assessment 1 physician responses differed significantly from patients/caregivers in 14 categories (P < .05), while assessment 2 differed in 11. When comparing physician data, assessment 2 allocations differed significantly from assessment 1 in 7 categories. When these 7 categories were compared with patient/caregiver data, assessment 2 allocations in emotional care, drug coverage, and nursing facility categories were not significantly different. Assessment 1 allocations in cosmetic care, dental, home care, and primary care categories were more similar to patient/caregiver preferences, although all but home care were still significantly different. Otolaryngology-head and neck surgery physician perspectives on end-of-life care differ significantly from cancer patient/caregiver perspectives, even when physicians take a patient's perspective when allocating resources. This demonstrates the challenges inherent in end-of-life discussions.

The ethical complexities of online organ solicitation via donor-patient websites: avoiding the "beauty contest".

PubMed

Neidich, E M; Neidich, A B; Cooper, J T; Bramstedt, K A

2012-01-01

The proliferation of the Internet has spurred the creation of websites dedicated to facilitating living directed organ donations. We argue that such sites potentially devolve into "beauty contests" where patients in need are evaluated on the basis of their personal appearance and biography-variables which should have no relevance to organ allocation. Altruism should be the guiding motivation for all donations, and when it does, there is no place for a beauty contest. The power of the Internet is optimally used when it facilitates Good Samaritan donations-donations to any stranger, rather than handpicked ones. Social networking sites which aim to match potential donors and patients should mask personal identifying information, allowing the ethical principles of altruism and justice to guide organ allocation. ©Copyright 2011 The American Society of Transplantation and the American Society of Transplant Surgeons.

Time utilization and perceived psychosocial work environment among staff in Swedish primary care settings.

PubMed

Anskär, Eva; Lindberg, Malou; Falk, Magnus; Andersson, Agneta

2018-03-07

Over the past decades, reorganizations and structural changes in Swedish primary care have affected time utilization among health care professionals. Consequently, increases in administrative tasks have substantially reduced the time available for face-to-face consultations. This study examined how work-time was utilized and the association between work time utilization and the perceived psychosocial work environment in Swedish primary care settings. This descriptive, multicentre, cross-sectional study was performed in 2014-2015. Data collection began with questionnaire. In the first section, respondents were asked to estimate how their workload was distributed between patients (direct and indirect patient work) and other work tasks. The questionnaire also comprised the Copenhagen Psychosocial Questionnaire, which assessed the psychosocial work environment. Next a time study was conducted where the participants reported their work-time based on three main categories: direct patient-related work, indirect patient-related work, and other work tasks. Each main category had a number of subcategories. The participants recorded the time spent (minutes) on each work task per hour, every day, for two separate weeks. Eleven primary care centres located in southeast Sweden participated. All professionals were asked to participate (n = 441), including registered nurses, primary care physicians, care administrators, nurse assistants, and allied professionals. Response rates were 75% and 79% for the questionnaires and the time study, respectively. All health professionals allocated between 30.9% - 37.2% of their work-time to each main category: direct patient work, indirect patient work, and other work. All professionals estimated a higher proportion of time spent in direct patient work than they reported in the time study. Physicians scored highest on the psychosocial scales of quantitative demands, stress, and role conflicts. Among allied professionals, the proportion of work-time spent on administrative tasks was associated with more role conflicts. Younger staff perceived more adverse working conditions than older staff. This study indicated that Swedish primary care staff spent a limited proportion of their work time directly with patients. PCPs seemed to perceive their work environment in negative terms to a greater extent than other staff members. This study showed that work task allocations influenced the perceived psychosocial work environment.

28 CFR 100.14 - Directly allocable costs.

Code of Federal Regulations, 2010 CFR

2010-07-01

... incurred for the same purpose in like circumstances have been included as a direct cost of that, or any... personnel administration within the engineering group). (2) Such allocation necessitates selecting a... selected so as to permit allocation of the grouping on the basis of the benefits accruing to the multiple...

Physicians as gatekeepers: illness certification as a rationing device.

PubMed

Stone, D A

1979-01-01

Illness or disability is often used as an eligibility criterion by public programs that distribute money, services, privileges, and exemptions. Physicians then play a central role in the allocation process. But physicians are caught between a large pool of applicants who want some benefit, on the one hand, and an organization with limited resources to distribute, on the other hand. Three conflicts are engendered in this gatekeeping role: the tension between trusting and mistrusting information provided by the patient, the tension between erring on the false positive side and the false negative side in diagnostic decision-making, and the tension between doing everything possible for each patient and allocating limited resources among several needy clients. Several non-medical factors influence the ultimate outcome of this allocation process, which, in theory, rests on clinical decision-making: the specificity and restrictiveness of the formal definitions of illness and disability used by a program; the structure of the determination process; the overall policy of the organization on distribution of benefits; and the ability of the organization to use administrative review, direct incentives, and written standards to control the certifying behavior of physicians.

Are Indirect Benefits Relevant to Health Care Allocation Decisions?

PubMed Central

Du Toit, Jessica; Millum, Joseph

2016-01-01

Abstract When allocating scarce healthcare resources, the expected benefits of alternative allocations matter. But, there are different kinds of benefits. Some are direct benefits to the recipient of the resource such as the health improvements of receiving treatment. Others are indirect benefits to third parties such as the economic gains from having a healthier workforce. This article considers whether only the direct benefits of alternative healthcare resource allocations are relevant to allocation decisions, or whether indirect benefits are relevant too. First, we distinguish different conceptions of direct and indirect benefits and argue that only a recipient conception could be morally relevant. We analyze four arguments for thinking that indirect benefits should not count and argue that none is successful in showing that the indirectness of a benefit is a good reason not to count it. We conclude that direct and indirect benefits should be evaluated in the same way. PMID:27465773

Does routine psychosocial screening improve referral to psychosocial care providers and patient-radiotherapist communication? A cluster randomized controlled trial.

PubMed

Braeken, Anna P B M; Lechner, Lilian; Eekers, Daniëlle B P; Houben, Ruud M A; van Gils, Francis C J M; Ambergen, Ton; Kempen, Gertrudis I J M

2013-11-01

This study tests whether using a screening instrument improves referral to psychosocial care providers (e.g. psychologist) and facilitates patient-radiotherapist communication. A cluster randomized controlled trial was used. Fourteen radiotherapists were randomly allocated to the experimental or control group and 568 of their patients received care in accordance with the group to which their radiotherapist was allocated. Patients in the experimental group were asked to complete a screening instrument before and at the end of the radiation treatment period. All patients were requested to complete questionnaires concerning patient-physician communication after the first consultation and concerning psychosocial care 3 and 12 months post-intervention. Patients who completed the screening instrument were referred to social workers at an earlier stage than patients who did not (P<0.01). No effects were observed for numbers of referred patients, or for improved patient-radiotherapist communication. Our results suggest that a simple screening procedure can be valuable for the timely treatment of psychosocial problems in patients. Future efforts should be directed at appropriate timing of screening and enhancing physicians' awareness regarding the importance of identifying, discussing and treating psychosocial problems in cancer patients. Psychosocial screening can be enhanced by effective radiotherapist-patient communication. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties.

PubMed

Sinsky, Christine; Colligan, Lacey; Li, Ling; Prgomet, Mirela; Reynolds, Sam; Goeders, Lindsey; Westbrook, Johanna; Tutty, Michael; Blike, George

2016-12-06

Little is known about how physician time is allocated in ambulatory care. To describe how physician time is spent in ambulatory practice. Quantitative direct observational time and motion study (during office hours) and self-reported diary (after hours). U.S. ambulatory care in 4 specialties in 4 states (Illinois, New Hampshire, Virginia, and Washington). 57 U.S. physicians in family medicine, internal medicine, cardiology, and orthopedics who were observed for 430 hours, 21 of whom also completed after-hours diaries. Proportions of time spent on 4 activities (direct clinical face time, electronic health record [EHR] and desk work, administrative tasks, and other tasks) and self-reported after-hours work. During the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on EHR and desk work. The 21 physicians who completed after-hours diaries reported 1 to 2 hours of after-hours work each night, devoted mostly to EHR tasks. Data were gathered in self-selected, high-performing practices and may not be generalizable to other settings. The descriptive study design did not support formal statistical comparisons by physician and practice characteristics. For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work. American Medical Association.

A prospective cohort study assessing clinical referral management & workforce allocation within a UK regional medical genetics service.

PubMed

Benjamin, Caroline; Houghton, Catherine; Foo, Claire; Edgar, Chris; Mannion, Gail; Birch, Jan; Ellis, Ian; Weber, Astrid

2015-08-01

Ensuring patient access to genomic information in the face of increasing demand requires clinicians to develop innovative ways of working. This paper presents the first empirical prospective observational cohort study of UK multi-disciplinary genetic service delivery. It describes and explores collaborative working practices including the utilisation and role of clinical geneticists and non-medical genetic counsellors. Six hundred and fifty new patients referred to a regional genetics service were tracked through 850 clinical contacts until discharge. Referral decisions regarding allocation of lead health professional assigned to the case were monitored, including the use of initial clinical contact guidelines. Significant differences were found in the cases led by genetic counsellors and those led by clinical geneticists. Around a sixth, 16.8% (109/650) of referrals were dealt with by a letter back to the referrer or re-directed to another service provider and 14.8% (80/541) of the remaining patients chose not to schedule an appointment. Of the remaining 461 patients, genetic counsellors were allocated as lead health professional for 46.2% (213/461). A further 61 patients did not attend. Of those who did, 86.3% (345/400) were discharged after one or two appointments. Genetic counsellors contributed to 95% (784/825) of total patient contacts. They provided 93.7% (395/432) of initial contacts and 26.8% (106/395) of patients were discharged at that point. The information from this study informed a planned service re-design. More research is needed to assess the effectiveness and efficiency of different models of collaborative multi-disciplinary working within genetics services.

Transcranial Direct Current Stimulation Potentiates Improvements in Functional Ability in Patients With Chronic Stroke Receiving Constraint-Induced Movement Therapy.

PubMed

Figlewski, Krystian; Blicher, Jakob Udby; Mortensen, Jesper; Severinsen, Kåre Eg; Nielsen, Jørgen Feldbæk; Andersen, Henning

2017-01-01

Transcranial direct current stimulation may enhance effect of rehabilitation in patients with chronic stroke. The objective was to evaluate the efficacy of anodal transcranial direct current stimulation combined with constraint-induced movement therapy of the paretic upper limb. A total of 44 patients with stroke were randomly allocated to receive 2 weeks of constraint-induced movement therapy with either anodal or sham transcranial direct current stimulation. The primary outcome measure, Wolf Motor Function Test, was assessed at baseline and after the intervention by blinded investigators. Both groups improved significantly on all Wolf Motor Function Test scores. Group comparison showed improvement on Wolf Motor Function Test in the anodal group compared with the sham group. Anodal transcranial direct current stimulation combined with constraint-induced movement therapy resulted in improvement of functional ability of the paretic upper limb compared with constraint-induced movement therapy alone. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01983319. © 2016 American Heart Association, Inc.

Are Indirect Benefits Relevant to Health Care Allocation Decisions?

PubMed

Du Toit, Jessica; Millum, Joseph

2016-10-01

When allocating scarce healthcare resources, the expected benefits of alternative allocations matter. But, there are different kinds of benefits. Some are direct benefits to the recipient of the resource such as the health improvements of receiving treatment. Others are indirect benefits to third parties such as the economic gains from having a healthier workforce. This article considers whether only the direct benefits of alternative healthcare resource allocations are relevant to allocation decisions, or whether indirect benefits are relevant too. First, we distinguish different conceptions of direct and indirect benefits and argue that only a recipient conception could be morally relevant. We analyze four arguments for thinking that indirect benefits should not count and argue that none is successful in showing that the indirectness of a benefit is a good reason not to count it. We conclude that direct and indirect benefits should be evaluated in the same way. Published by Oxford University Press on behalf of the Journal of Medicine and Philosophy, Inc. 2016.

Allocation of substance use disorder patients to appropriate levels of care: feasibility of matching guidelines in routine practice in Dutch treatment centres.

PubMed

Merkx, Maarten J M; Schippers, Gerard M; Koeter, Maarten J W; Vuijk, Pieter Jelle; Oudejans, Suzan; de Vries, Carlijn C Q; van den Brink, Wim

2007-03-01

To examine the feasibility of implementing evidence-based guidelines for patient-treatment-matching to levels of care in two Dutch substance abuse treatment centres. Multi-centre observational follow-up study. Two large substance abuse treatment centres (SATCs). All 4394 referrals to the two SATCs in 2003. Baseline patient characteristics needed for treatment allocation according to protocol, treatment allocation according to matching protocol, treatment allocation according to actual level of care (LOC) entered. Comparison of recommended and actual LOC entered. Evaluation of reasons for observed differences between recommended and actual LOC entered. Data needed for treatment allocation according to protocol were available for 2269 (51.6%) patients. Data needed for evaluation of actual LOC entered were available for 1765 (40.2%) patients. Of these patients, 1089 (60.8%) were allocated according to protocol: 48.4% based on the guideline algorithm and 12.4% based on clinically justified deviations from this algorithm. The main reason for deviation was a different appraisal of addiction severity, made by the intake counsellor compared to the protocol. The feasibility of guideline-based treatment allocation is seriously limited due to inadequate data collection of patient characteristics and suboptimal guideline-based treatment allocation. As a consequence, only 24.4% of the patients could be evaluated as being matched properly to the treatment planned. The results indicate several barriers which limit the adequate implementation of patient-treatment-matching guidelines: problems in the infrastructure of data collection and storage and the inertia of intake staff who did not adhere to the guidelines for assessment and matching.

Advances in liver transplantation allocation systems.

PubMed

Schilsky, Michael L; Moini, Maryam

2016-03-14

With the growing number of patients in need of liver transplantation, there is a need for adopting new and modifying existing allocation policies that prioritize patients for liver transplantation. Policy should ensure fair allocation that is reproducible and strongly predictive of best pre and post transplant outcomes while taking into account the natural history of the potential recipients liver disease and its complications. There is wide acceptance for allocation policies based on urgency in which the sickest patients on the waiting list with the highest risk of mortality receive priority. Model for end-stage liver disease and Child-Turcotte-Pugh scoring system, the two most universally applicable systems are used in urgency-based prioritization. However, other factors must be considered to achieve optimal allocation. Factors affecting pre-transplant patient survival and the quality of the donor organ also affect outcome. The optimal system should have allocation prioritization that accounts for both urgency and transplant outcome. We reviewed past and current liver allocation systems with the aim of generating further discussion about improvement of current policies.

Why does primary angioplasty not work in registries? Quantifying the susceptibility of real-world comparative effectiveness data to allocation bias.

PubMed

Sen, Sayan; Davies, Justin E; Malik, Iqbal S; Foale, Rodney A; Mikhail, Ghada W; Hadjiloizou, Nearchos; Hughes, Alun; Mayet, Jamil; Francis, Darrel P

2012-11-01

Meta-analysis of registries (comparative effectiveness research) shows that primary angioplasty and fibrinolysis have equivalent real-world survival. Yet, randomized, controlled trials consistently find primary angioplasty superior. Can unequal allocation of higher-risk patients in registries have masked primary angioplasty benefit? First, we constructed a model to demonstrate the potential effect of allocation bias. We then analyzed published registries (55022 patients) for allocation of higher-risk patients (Killip class ≥1) to determine whether the choice of reperfusion therapy was affected by the risk level of the patient. Meta-regression was used to examine the relationship between differences in allocation of high-risk patient to primary angioplasty or fibrinolysis and mortality. Initial modeling suggested that registry outcomes are sensitive to allocation bias of high-risk patients. Across the registries, the therapy receiving excess high-risk patients had worse mortality. Unequal distribution of high-risk status accounted for most of the between-registry variance (adjusted R(2)(meta)=83.1%). Accounting for differential allocation of higher-risk patients, primary angioplasty gave 22% lower mortality (odds ratio, 0.78; 95% confidence interval, 0.64-0.97; P=0.029). We derive a formula, called the number needed to abolish, highlighting situations in which comparative effectiveness studies are particularly vulnerable to this bias. In ST-segment elevation myocardial infarction, clinicians' preference for management of a few high-risk patients can shift mortality substantially. Comparative effectiveness research in any disease is vulnerable to this, especially diseases with an immediately identifiable high-risk subgroup that clinicians prefer to allocate to 1 therapy. For this reason, preliminary indications from registry-based comparative effectiveness research should be definitively tested by randomized, controlled trials.

Impact of regulatory assessment on clinical studies in Brazil.

PubMed

Russo, Luis Augusto Tavares; Eliaschewitz, Freddy Goldberg; Harada, Vitor; Trefiglio, Roberta Pereira; Picciotti, Raffaella; Machado, Paula Goulart Pinheiro; Kesselring, Gustavo Luiz Ferreira

2016-01-01

Despite the recent expansion of clinical studies allocated to Brazil, the delay of local regulatory deadlines directly impacts their completion. This article examines the allocation process of clinical studies to Brazil in comparison with other countries, as well as the financial impact of studies not completed due to interruption caused by the delay in the regulatory process. The allocation processes of studies were compared in nine countries with similar stages of economic development and countries in Latin America using the websites http://data.worldbank.org/data-catalog/GDP-rankings-table and http://worldpopulationreview.com and clinicaltrials.gov, comprising 185 countries. The 46 studies sponsored by the pharmaceutical industry underwent an analysis of the regulatory review process. 46 studies sponsored by the industry and submitted in the country between June 2007 and June 2013 were analyzed; 18 (39%) were discontinued due to the delay in obtaining the necessary approvals. For the approved studies, patient recruitment began an average of 11 months after the other countries. It is estimated that 530 Brazilians patients did not have the opportunity to participate in these studies. Financial losses were to the order of 14.6 million dollars for the country, including patient, medication and supplies costs, and expenses. Brazil has enormous potential for the realization of clinical studies. Researchers, associations of disabled people and patients with chronic diseases, sponsors and the authorities must work together to develop an approval process that is efficient, predictable and, most of all, transparent. The current regulatory environment must and can be improved and optimized in order to result in tangible benefits for patients, society and the country's scientific development.

A decision-theoretic approach to identifying future high-cost patients.

PubMed

Pietz, Kenneth; Byrne, Margaret M; Petersen, Laura A

2006-09-01

The objective of this study was to develop and evaluate a method of allocating funding for very-high-cost (VHC) patients among hospitals. Diagnostic cost groups (DCGs) were used for risk adjustment. The patient population consisted of 253,013 veterans who used Department of Veterans Affairs (VA) medical care services in fiscal year (FY) 2003 (October 1, 2002-September 30, 2003) in a network of 8 VA hospitals. We defined VHC as greater than 75,000 dollars (0.81%). The upper fifth percentile was also used for comparison. A Bayesian decision rule for classifying patients as VHC/not VHC using DCGs was developed and evaluated. The method uses FY 2003 DCGs to allocate VHC funds for FY 2004. We also used FY 2002 DCGs to allocate VHC funds for FY 2003 for comparison. The resulting allocation was compared with using the allocation of VHC patients among the hospitals in the previous year. The decision rule identified DCG 17 as the optimal cutoff for identifying VHC patients for the next year. The previous year's allocation came closest to the actual distribution of VHC patients. The decision-theoretic approach may provide insight into the economic consequences of classifying a patient as VHC or not VHC. More research is needed into methods of identifying future VHC patients so that capitation plans can fairly reimburse healthcare systems for appropriately treating these patients.

29 CFR 4211.35 - Direct attribution method for withdrawals after the initial plan year.

Code of Federal Regulations, 2010 CFR

2010-07-01

... WITHDRAWING EMPLOYERS Allocation Methods for Merged Multiemployer Plans § 4211.35 Direct attribution method for withdrawals after the initial plan year. The allocation method under this section is the... 29 Labor 9 2010-07-01 2010-07-01 false Direct attribution method for withdrawals after the initial...

[Inadequate ICU-admissions : A 12-month prospective cohort study at a German University Hospital].

PubMed

Bangert, K; Borch, J; Ferahli, S; Braune, S A; de Heer, G; Kluge, S

2016-05-01

Intensive care medicine (ICM) is increasingly utilized by a growing number of critically ill patients worldwide. The reasons for this are an increasingly ageing and multimorbid population and technological improvements in ICM. Inappropriate patient admissions to the intensive care unit (ICU) can be a threat to rational resource allocation and to patient autonomy. In this study, the incidence, characteristics, and resource utilization of patients inappropriately admitted to ICUs are studied. This prospective study included all consecutive patients admitted from 01 September 2012 to 31 August 2013 to the Department of Intensive Care Medicine of a German university hospital comprised of 10 ICUs and 120 beds. Inappropriate admission was defined according to category 4B of the recommendations of the Society of Critical Care Medicine (SCCM; "futility of ICU treatment" or "ICU declined by patient") and was determined in each suspected case by structured group discussions between the study team and all involved care givers including the referring team. In all, 66 of 6452 ICU admissions (1 %) were suspected to have been inappropriate on retrospective evaluation the day after admission. In 50 patients (0.8 %), an interdisciplinary consensus was reached on the inappropriateness of the ICU admission. Of these 50 patients, 41 (82 %) had previously declined ICU treatment in principle. This information was based on the patient's presumed wish as expressed by next of kin (56 %) or in a written advanced directive (26 %). In 9 patients (18 %), ICU treatment was considered futile. In all cases, a lack of information regarding a patient's wishes or clinical prognosis was the reason for inappropriate ICU admission. In this study, patients were regularly admitted to the ICU despite their contrary wish/directive or an unfavorable clinical condition. Although this was registered in only 1 % of all admissions, optimizing preICU admission information flow with regard to relevant exclusion criteria not only helps respect patient autonomy but also allows for more adequate resource allocation.

Current Subcounty Allocation Practices: Volume I of the Title I, ESEA, Subcounty Allocation Study.

ERIC Educational Resources Information Center

Paller, Alan T.; Gutmann, Babette

In this report, subcounty allocation of Title I of the Elementary and Secondary Education Act (ESEA) funds is described in terms of direct allocation, use of the statutory formula emphasizing census data, United States Office of Education (USOE) regulations, participating states, geographic and administrative overlaps, hold harmless adjustments…

Tactical resource allocation and elective patient admission planning in care processes.

PubMed

Hulshof, Peter J H; Boucherie, Richard J; Hans, Erwin W; Hurink, Johann L

2013-06-01

Tactical planning of resources in hospitals concerns elective patient admission planning and the intermediate term allocation of resource capacities. Its main objectives are to achieve equitable access for patients, to meet production targets/to serve the strategically agreed number of patients, and to use resources efficiently. This paper proposes a method to develop a tactical resource allocation and elective patient admission plan. These tactical plans allocate available resources to various care processes and determine the selection of patients to be served that are at a particular stage of their care process. Our method is developed in a Mixed Integer Linear Programming (MILP) framework and copes with multiple resources, multiple time periods and multiple patient groups with various uncertain treatment paths through the hospital, thereby integrating decision making for a chain of hospital resources. Computational results indicate that our method leads to a more equitable distribution of resources and provides control of patient access times, the number of patients served and the fraction of allocated resource capacity. Our approach is generic, as the base MILP and the solution approach allow for including various extensions to both the objective criteria and the constraints. Consequently, the proposed method is applicable in various settings of tactical hospital management.

Cost accounting and public reimbursement schemes in Spanish hospitals.

PubMed

Sánchez-Martínez, Fernando; Abellán-Perpiñán, José-María; Martínez-Pérez, Jorge-Eduardo; Puig-Junoy, Jaume

2006-08-01

The objective of this paper is to provide a description and analysis of the main costing and pricing (reimbursement) systems employed by hospitals in the Spanish National Health System (NHS). Hospitals cost calculations are mostly based on a full costing approach as opposite to other systems like direct costing or activity based costing. Regional and hospital differences arise on the method used to allocate indirect costs to cost centres and also on the approach used to measure resource consumption. Costs are typically calculated by disaggregating expenditure and allocating it to cost centres, and then to patients and DRGs. Regarding public reimbursement systems, the impression is that unit costs are ignored, except for certain type of high technology processes and treatments.

Children's self-allocation and use of classroom curricular time.

PubMed

Ingram, J; Worrall, N

1992-02-01

A class of 9-10 year-olds (N = 12) in a British primary school were observed as it moved over a one-year period through three types of classroom environment, traditional directive, transitional negotiative and established negotiative. Each environment offered the children a differing relationship with curricular time, its control and allocation, moving from teacher-allocated time to child allocation. Pupil self-report and classroom observation indicated differences in the balance of curricular spread and allocated time on curricular subject in relation to the type of classroom organisation and who controlled classroom time. These differences were at both class and individual child level. The established negotiative environment recorded the most equitable curricular balance, traditional directive the least. While individual children responded differently within and across the three classroom environments, the established negotiative where time was under child control recorded preference for longer activity periods compared to where the teacher controlled time allocations.

Fiscal scarcity and the inevitability of bedside budget balancing.

PubMed

Morreim, E H

1989-05-01

Until recently, generous third-party reimbursements enabled physicians to pursue each patient's interests with little regard to costs. Conscious rationing was required only episodically as some particular commodity, eg, transplant organs, was too scarce to meet demand, or as some patients lacked basic access to the health care system. Cost containment and the economic reorganization of medicine introduce a new sort of scarcity, requiring a different sort of rationing. "Fiscal scarcity," the general contraction of health care dollars, means that because every medical decision has its cost, every decision is now subject to scrutiny for its economic as well as its medical wisdom. Therefore, every detail of medicine is an allocation problem. Many observers argue that physicians can nevertheless avoid directly trading patients' interests against economic considerations: through "efficiency protocols" that eliminate marginal benefits, through turning economic rationing decisions over to outside parties, through avoiding cost constraints until society has established a just health care allocation system. This article shows that none of these proposals permits the physician to escape cost-cutting at the bedside.

Patient preferences, knowledge and beliefs about kidney allocation: qualitative findings from the UK-wide ATTOM programme.

PubMed

Gibbons, Andrea; Cinnirella, Marco; Bayfield, Janet; Wu, Diana; Draper, Heather; Johnson, Rachel J; Tomson, Charles R V; Forsythe, John L R; Metcalfe, Wendy; Fogarty, Damian; Roderick, Paul; Ravanan, Rommel; Oniscu, Gabriel C; Watson, Christopher J E; Bradley, J Andrew; Bradley, Clare

2017-01-27

To explore how patients who are wait-listed for or who have received a kidney transplant understand the current UK kidney allocation system, and their views on ways to allocate kidneys in the future. Qualitative study using semistructured interviews and thematic analysis based on a pragmatic approach. 10 deceased-donor kidney transplant recipients, 10 live-donor kidney transplant recipients, 12 participants currently wait-listed for a kidney transplant and 4 participants whose kidney transplant failed. Semistructured telephone interviews conducted with participants in their own homes across the UK. Three main themes were identified: uncertainty of knowledge of the allocation scheme; evaluation of the system and participant suggestions for future allocation schemes. Most participants identified human leucocyte anitgen matching as a factor in determining kidney allocation, but were often uncertain of the accuracy of their knowledge. In the absence of information that would allow a full assessment, the majority of participants consider that the current system is effective. A minority of participants were concerned about the perceived lack of transparency of the general decision-making processes within the scheme. Most participants felt that people who are younger and those better matched to the donor kidney should be prioritised for kidney allocation, but in contrast to the current scheme, less priority was considered appropriate for longer waiting patients. Some non-medical themes were also discussed, such as whether parents of dependent children should be prioritised for allocation, and whether patients with substance abuse problems be deprioritised. Our participants held differing views about the most important factors for kidney allocation, some of which were in contrast to the current scheme. Patient participation in reviewing future allocation policies will provide insight as to what is considered acceptable to patients and inform healthcare staff of the kinds of information patients would find most useful. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Relationship between patient characteristics and treatment allocation for patients with personality disorders.

PubMed

van Manen, Janine G; Andrea, Helene; van den Eijnden, Ellen; Meerman, Anke M M A; Thunnissen, Moniek M; Hamers, Elisabeth F M; Huson, Nelleke; Ziegler, Uli; Stijnen, Theo; Busschbach, Jan J V; Timman, Reinier; Verheul, Roel

2011-10-01

Within a large multi-center study in patients with personality disorders, we investigated the relationship between patient characteristics and treatment allocation. Personality pathology, symptom distress, treatment history, motivational factors, and sociodemographics were measured at intake in 923 patients, who subsequently enrolled in short-term or long-term outpatient, day hospital, or inpatient psychotherapy for personality pathology. Logistic regressions were used to examine the predictors of allocation decisions. We found a moderate relationship (R(2) = 0.36) between patient characteristics and treatment setting, and a weak relationship (R(2) = 0.18) between patient characteristics and treatment duration. The most prominent predictors for setting were: symptom distress, cluster C personality pathology, level of identity integration, treatment history, motivation, and parental responsibility. For duration the most prominent predictor was age. We conclude from this study that, in addition to pathology and motivation factors, sociodemographics and treatment history are related to treatment allocation in clinical practice.

29 CFR 4207.7 - Liability for subsequent complete withdrawals and related adjustments for allocating unfunded...

Code of Federal Regulations, 2010 CFR

2010-07-01

... uses either the “presumptive” or the “direct attribution” method (section 4211(b) or (c)(4), respectively) for allocating unfunded vested benefits, the plan shall modify those allocation methods as... using “presumptive” method. In a plan using the “presumptive” allocation method under section 4211(b) of...

When time is more than money: the allocation of time between work and leisure in HIV-infected patients.

PubMed

Sendi, Pedram; Brouwer, Werner B F; Bucher, Heiner C; Weber, Rainer; Battegay, Manuel

2007-06-01

Time is a limited resource and individuals have to decide how many hours they should allocate to work and to leisure activities. Differences in wage rate or availability of non-labour income (financial support from families and savings) may influence how individuals allocate their time between work and leisure. An increase in wage rate may induce income effects (leisure time demanded increases) and substitution effects (leisure time demanded decreases) whereas an increase in non-labour income only induces income effects. We explored the effects of differences in wage rate and non-labour income on the allocation of time in HIV-infected patients. Patients enrolled in the Swiss HIV Cohort Study (SHCS) provided information on their time allocation, i.e. number of hours worked in 1998. A multinomial logistic regression model was used to test for income and substitution effects. Our results indicate that (i) the allocation of time in HIV-infected patients does not differ with level of education (i.e., wage rate), and that (ii) availability of non-labour income induces income effects, i.e. individuals demand more leisure time.

Direct Allocation Costing: Informed Management Decisions in a Changing Environment.

ERIC Educational Resources Information Center

Mancini, Cesidio G.; Goeres, Ernest R.

1995-01-01

It is argued that colleges and universities can use direct allocation costing to provide quantitative information needed for decision making. This method of analysis requires institutions to modify traditional ideas of costing, looking to the private sector for examples of accurate costing techniques. (MSE)

Theories of the price and quantity of physician services. A synthesis and critique.

PubMed

Farley, P J

1986-12-01

In the traditional neoclassical model of supply and demand, prices determine the allocation of economic resources. The difficulty in applying this model to physician services is the rationing of resources directly by physicians themselves, eliminating the allocative function of prices. Welfare consequences are appropriately judged in terms of efficiency and equity, not departures from the structural relationships implied by supply and demand. As interpreted here, both competitive theories and target-income theories of this market imply that physicians consider both their own welfare and the welfare of their patients in their decision-making. All consumer benefits and all producer costs are internalized by physicians. They consequently have an incentive to obtain the maximum possible social benefit from the resources at their disposal, to the extent that they are (implicitly) allowed to share in the resulting social gains. The distribution of gains between patients and physicians is determined by professional ethics within bounds imposed by competitive forces.

Surgical Versus Nonsurgical Management of Rotator Cuff Tears: Predictors of Treatment Allocation.

PubMed

Kweon, Christopher; Gagnier, Joel J; Robbins, Christopher B; Bedi, Asheesh; Carpenter, James E; Miller, Bruce S

2015-10-01

Rotator cuff tears are a common shoulder disorder resulting in significant disability to patients and financial burden on the health care system. While both surgical and nonsurgical management are accepted treatment options, there is a paucity of data to support a treatment algorithm for care providers. Defining variables to guide treatment allocation may be important for patient education and counseling, as well as to deliver the most efficient care plan at the time of presentation. To identify independent variables at the time of initial clinical presentation that are associated with preferred allocation to surgical versus nonsurgical management for patients with known full-thickness rotator cuff tears. Case control study; Level of evidence, 3. A total of 196 consecutive adult patients with known full-thickness rotator cuff tears were enrolled into a prospective cohort study. Robust data were collected for each subject at baseline, including age, sex, body mass index (BMI), shoulder activity score, smoking status, size of cuff tear, duration of symptoms, functional comorbidity index, the American Shoulder and Elbow Surgeons (ASES) score, the Western Ontario Rotator Cuff index (WORC), and the Veterans Rand 12-Item Health Survey (VR-12). Logistic regression was performed to identify variables associated with treatment allocation, and the corresponding odds ratios were calculated. Of the 196 patients enrolled, 112 underwent surgical intervention and 84 nonoperative management. With covariates controlled for, significant baseline patient characteristics predictive of eventual allocation to surgical treatment included younger age, lower BMI, and durations of symptoms less than 1 year. Increasing age, higher BMI, and duration of symptoms longer than 1 year were predictive of nonsurgical treatment. Factors that were not associated with treatment allocation included sex, tear size, functional comorbidity score, or any of the patient-derived outcome scores at presentation (ASES, WORC, VR-12, shoulder activity score). Patient demographics at the time of initial presentation for a symptomatic rotator cuff tear are more predictive of treatment allocation to a surgical or nonoperative approach than the patient-derived outcome scores for activity level and shoulder disability. Further study is warranted to help define appropriate indications for treatment allocation in patients with rotator cuff tears. © 2015 The Author(s).

Ethical assessment of hepatitis C virus treatment: The lesson from first generation protease inhibitors.

PubMed

Sacchini, Dario; Craxì, Lucia; Refolo, Pietro; Minacori, Roberta; Cicchetti, Americo; Gasbarrini, Antonio; Cammà, Calogero; Spagnolo, Antonio G

2015-05-01

Since chronic hepatitis C has mostly become curable, issues concerning choice and allocation of treatment are of major concern. We assessed the foremost ethical issues in hepatitis C virus therapy with 1st generation protease inhibitors using the personalist ethical framework within the health technology assessment methodology. Our aim was to identify values at stake/in conflict and to support both the physicians' choices in hepatitis C therapy and social (macro-) allocation decision-making. The ethical assessment indicates that: (1) safety/effectiveness profile of treatment is guaranteed if its use is restricted to the patients subgroups who may benefit from it; (2) patients should be carefully informed, particularly on treatment deferral, and widespread information on these therapies should be implemented; (3) since treatment was proven to be cost-effective, its use is acceptable respecting resource macro-allocation. Concerning individual (micro-) location criteria: (a) criteria for eligibility to treatment should be clearly identified and updated periodically; (b) information on criteria for eligibility/deferral to treatment for specific patients' subgroups should be made widely known. Interferon-based regimens will disappear from use within the next year, with the introduction of highly effective/tolerable combination regimens of direct-acting antivirals, thus profoundly changing social choices. Nonetheless, our model could support future ethical assessment since the evaluation pertaining ethical domains remains generally applicable. Copyright © 2014 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Advances and Future Directions in the Treatment of Hepatocellular Carcinoma

PubMed Central

Gosalia, Ashil J.; Martin, Paul

2017-01-01

Hepatocellular carcinoma (HCC) is the second leading cause of cancer-related deaths worldwide. Liver transplant is considered the gold standard for curative therapy for HCC when patients are not candidates for surgical resection or ablation. Because a subset of patients with HCC have a survival rate with liver transplantation that is comparable to that of cirrhotic patients without tumors, the organ allocation system allows for increased priority for transplant in potential recipients within the Milan criteria. With the recent change in the Model for End-Stage Liver Disease exception point allocation, patients with HCC will now need to wait at least 6 months before being awarded extra points. This extension leads to increased time on the transplant waiting list and underscores the importance of locoregional therapy to contain the tumor burden. Fortunately, there has been significant progress in therapy for HCC in the past few decades, namely due to advances in interventional radiology, radiotherapy, and expanded surgical and transplant criteria. Recent advances in immunotherapy also provide promising options for patients who are not candidates for other therapies. This article highlights the major therapeutic options for HCC, including surgical resection, liver transplant, thermal and nonthermal ablation, chemoembolization, radiotherapy, and systemic chemotherapy, as well as discusses the evidence supporting these approaches. PMID:28867968

50 CFR 648.293 - Tilefish trip limits.

Code of Federal Regulations, 2011 CFR

2011-10-01

... forth as follows: § 648.293 Tilefish accountability measures. (a) If the ACL is exceeded, the amount of the ACL overage that cannot be directly attributed to IFQ allocation holders having exceeded their IFQ allocation will be deducted from the ACL in the following fishing year. All overages directly attributable to...

Understanding the New A-21 Allocation and Documentation Standard.

ERIC Educational Resources Information Center

Sellers, William

1994-01-01

New federal regulations concerning direct cost accounting for college and university research projects are explained. It is concluded that the new standard allows institutions to reduce the signatures required on cost transfers and use reasonable cost allocation methods to simplify distribution of direct costs when research is supported by…

48 CFR 1631.203-70 - Allocation techniques.

Code of Federal Regulations, 2010 CFR

2010-10-01

... shall consistently apply the methods and techniques established to classify direct and indirect costs... meant to be exhaustive, but rather are examples of allocation methods that may be acceptable under... 48 Federal Acquisition Regulations System 6 2010-10-01 2010-10-01 true Allocation techniques. 1631...

Patient agency and contested notions of disability in social assistance applications in South Africa.

PubMed

Kelly, Gabrielle

2017-02-01

Problems in fairly allocating welfare and health resources are very often located in the spaces where citizens interact directly with state workers. This study draws on observations of doctor-patient encounters in disability assessments for the South African disability grant (DG) to examine how doctor-patient interactions and patient agency shape social welfare allocation in a context of high poverty and inequality. Data were gathered via interviews with healthcare workers and observations of doctor-patient interactions in twelve clinics and three hospitals in the Western Cape province between October 2013 and August 2014. Twenty-four doctors were interviewed, of whom seventeen were observed conducting a total of 216 consultations with patients. Two training sessions of DG assessors were also observed. Findings show that interactions between doctors and patients are sites of negotiation and contestation over rights to social assistance. Claimants' understanding of disability differed from biomedical and bureaucratic definitions. Patients attempted to influence doctors' decisions through narratives of suffering and performances of disability. Others used verbal or physical abuse as a form of protest against perceived unfair treatment. To defend themselves from these pressures and maintain authority in these interactions, doctors employed coping strategies that distanced and objectified claimants. This resulted in strained doctor-patient relationships and made the DG system confusing to the public. This demonstrates the importance of considering trust, power dynamics and the exercise of agency by both patients and providers in understanding policy implementation. Copyright © 2017 Elsevier Ltd. All rights reserved.

Cost-effectiveness of the 21-gene breast cancer assay in Mexico.

PubMed

Bargalló-Rocha, Juan Enrique; Lara-Medina, Fernando; Pérez-Sánchez, Victor; Vázquez-Romo, Rafael; Villarreal-Garza, Cynthia; Martínez-Said, Hector; Shaw-Dulin, Robin J; Mohar-Betancourt, Alejandro; Hunt, Barnaby; Plun-Favreau, Juliette; Valentine, William J

2015-03-01

The 21-gene breast cancer assay (Oncotype DX(®); Genomic Health, Inc.) is a validated diagnostic test that predicts the likelihood of adjuvant chemotherapy benefit and 10-year risk of distant recurrence in patients with hormone-receptor-positive, human epidermal growth receptor 2-negative, early-stage breast cancer. The aim of this analysis was to evaluate the cost-effectiveness of using the assay to inform adjuvant chemotherapy decisions in Mexico. A Markov model was developed to make long-term projections of distant recurrence, survival, and direct costs in scenarios using conventional diagnostic procedures or the 21-gene assay to inform adjuvant chemotherapy recommendations. Transition probabilities and risk adjustment were taken from published landmark trials. Costs [2011 Mexican Pesos (MXN)] were estimated from an Instituto Mexicano del Seguro Social perspective. Costs and clinical benefits were discounted at 5% annually. Following assay testing, approximately 66% of patients previously receiving chemotherapy were recommended to receive hormone therapy only after consideration of assay results. Furthermore, approximately 10% of those previously allocated hormone therapy alone had their recommendation changed to add chemotherapy. This optimized therapy allocation led to improved mean life expectancy by 0.068 years per patient and increased direct costs by MXN 1707 [2011 United States Dollars (USD) 129] per patient versus usual care. This is equated to an incremental cost-effectiveness ratio (ICER) of MXN 25,244 (USD 1914) per life-year gained. In early-stage breast cancer patients in Mexico, guiding decision making on adjuvant therapy using the 21-gene assay was projected to improve life expectancy in comparison with the current standard of care, with an ICER of MXN 25,244 (USD 1914) per life-year gained, which is within the range generally considered cost-effective.

Comparing methodologies for the allocation of overhead and capital costs to hospital services.

PubMed

Tan, Siok Swan; van Ineveld, Bastianus Martinus; Redekop, William Ken; Hakkaart-van Roijen, Leona

2009-06-01

Typically, little consideration is given to the allocation of indirect costs (overheads and capital) to hospital services, compared to the allocation of direct costs. Weighted service allocation is believed to provide the most accurate indirect cost estimation, but the method is time consuming. To determine whether hourly rate, inpatient day, and marginal mark-up allocation are reliable alternatives for weighted service allocation. The cost approaches were compared independently for appendectomy, hip replacement, cataract, and stroke in representative general hospitals in The Netherlands for 2005. Hourly rate allocation and inpatient day allocation produce estimates that are not significantly different from weighted service allocation. Hourly rate allocation may be a strong alternative to weighted service allocation for hospital services with a relatively short inpatient stay. The use of inpatient day allocation would likely most closely reflect the indirect cost estimates obtained by the weighted service method.

The Wire-Grasping Method as a New Technique for Forceps Biopsy of Biliary Strictures: A Prospective Randomized Controlled Study of Effectiveness.

PubMed

Yamashita, Yasunobu; Ueda, Kazuki; Kawaji, Yuki; Tamura, Takashi; Itonaga, Masahiro; Yoshida, Takeichi; Maeda, Hiroki; Magari, Hirohito; Maekita, Takao; Iguchi, Mikitaka; Tamai, Hideyuki; Ichinose, Masao; Kato, Jun

2016-07-15

Transpapillary forceps biopsy is an effective diagnostic technique in patients with biliary stricture. This prospective study aimed to determine the usefulness of the wire-grasping method as a new technique for forceps biopsy. Consecutive patients with biliary stricture or irregularities of the bile duct wall were randomly allocated to either the direct or wire-grasping method group. In the wiregrasping method, forceps in the duodenum grasps a guidewire placed into the bile duct beforehand, and then, the forceps are pushed through the papilla without endoscopic sphincterotomy. In the direct method, forceps are directly pushed into the bile duct alongside a guide-wire. The primary endpoint was the success rate of obtaining specimens suitable for adequate pathological examination. In total, 32 patients were enrolled, and 28 (14 in each group) were eligible for analysis. The success rate was significantly higher using the wire-grasping method than the direct method (100% vs 50%, p=0.016). Sensitivity and accuracy for the diagnosis of cancer were comparable in patients with the successful procurement of biopsy specimens between the two methods (91% vs 83% and 93% vs 86%, respectively). The wire-grasping method is useful for diagnosing patients with biliary stricture or irregularities of the bile duct wall.

A review of organizations influencing radio frequency allocations to deep space research

NASA Technical Reports Server (NTRS)

1976-01-01

The charters and functions of various national and international scientific organizations were examined to identify those which have a direct or indirect influence on the allocation of radio frequencies for use in deep space research. Those organizations identified as having the ability to influence frequency allocations are described. A brief description of each organization is provided, and the members who are influential specifically in frequency allocations are listed. The interrelations between the organizations and how they influence allocations are explained.

Indirect vs direct bonding of mandibular fixed retainers in orthodontic patients: a single-center randomized controlled trial comparing placement time and failure over a 6-month period.

PubMed

Bovali, Efstathia; Kiliaridis, Stavros; Cornelis, Marie A

2014-12-01

The objective of this 2-arm parallel single-center trial was to compare placement time and numbers of failures of mandibular lingual retainers bonded with an indirect procedure vs a direct bonding procedure. Sixty-four consecutive patients at the postgraduate orthodontic clinic of the University of Geneva in Switzerland scheduled for debonding and mandibular fixed retainer placement were randomly allocated to either an indirect bonding procedure or a traditional direct bonding procedure. Eligibility criteria were the presence of the 4 mandibular incisors and the 2 mandibular canines, and no active caries, restorations, fractures, or periodontal disease of these teeth. The patients were randomized in blocks of 4; the randomization sequence was generated using an online randomization service (www.randomization.com). Allocation concealment was secured by contacting the sequence generator for treatment assignment; blinding was possible for outcome assessment only. Bonding time was measured for each procedure. Unpaired t tests were used to assess differences in time. Patients were recalled at 1, 2, 4, and 6 months after bonding. Mandibular fixed retainers having at least 1 composite pad debonded were considered as failures. The log-rank test was used to compare the Kaplan-Meier survival curves of both procedures. A test of proportion was applied to compare the failures at 6 months between the treatment groups. Sixty-four patients were randomized in a 1:1 ratio. One patient dropped out at baseline after the bonding procedure, and 3 patients did not attend the recalls at 4 and 6 months. Bonding time was significantly shorter for the indirect procedure (321 ± 31 seconds, mean ± SD) than for the direct procedure (401 ± 40 seconds) (per protocol analysis of 63 patients: mean difference = 80 seconds; 95% CI = 62.4-98.1; P <0.001). The 6-month numbers of failures were 10 of 31 (32%) with the indirect technique and 7 of 29 (24%) with the direct technique (log rank: P = 0.35; test of proportions: risk difference = 0.08; 95% CI = -0.15 to 0.31; P = 0.49). No serious harm was observed except for plaque accumulation. Indirect bonding was statistically significantly faster than direct bonding, with both techniques showing similar risks of failure. This trial was not registered. The protocol was not published before trial commencement. No funding or conflict of interest to be declared. Copyright © 2014 American Association of Orthodontists. Published by Elsevier Inc. All rights reserved.

The patient-physician relationship and the allocation of scarce resources: a law and economics approach.

PubMed

Mehlman, M J; Massey, S R

1994-12-01

Patients with insufficient financial resources place physicians in a conflict of interest between the patients' needs and the financial interests of the physician, other patients, and society. Not only must physicians act ethically, but they must avoid liability for violating their legal duties to their patients. The traditional rules of contract and malpractice law that govern the patient-physician relationship do not provide satisfactory guidelines. Better answers are found in the rules of fiduciary law, but only with regard to direct conflicts between patients and physicians and only at the risk of reducing patient access to care. Certain types of legislative action can resolve these conflicts by altering the traditional legal rules, but care must be taken to preserve patient-physician trust, which the legal rules were designed to enhance.

78 FR 12294 - Proposed Information Collection; Comment Request; Defense Priorities and Allocations System

Federal Register 2010, 2011, 2012, 2013, 2014

2013-02-22

... Request; Defense Priorities and Allocations System AGENCY: Bureau of Industry and Security, Commerce...: Direct all written comments to Jennifer Jessup, Departmental Paperwork Clearance Officer, Department of... Priorities and Allocations System regulation (15 CFR part 700) must retain the records for at least 3 years...

75 FR 12173 - Proposed Information Collection; Comment Request; Defense Priorities and Allocations System

Federal Register 2010, 2011, 2012, 2013, 2014

2010-03-15

... Allocations System regulation (15 CFR part 700) must retain the records for at least 3 years. II. Method of... Request; Defense Priorities and Allocations System AGENCY: Bureau of Industry and Security, Commerce...: Direct all written comments to Diana Hynek, Departmental Paperwork Clearance Officer, Department of...

Indirect vs direct bonding of mandibular fixed retainers in orthodontic patients: Comparison of retainer failures and posttreatment stability. A 2-year follow-up of a single-center randomized controlled trial.

PubMed

Egli, Fabienne; Bovali, Efstathia; Kiliaridis, Stavros; Cornelis, Marie A

2017-01-01

The objectives of this 2-arm parallel trial were to compare the numbers of failures of mandibular fixed retainers bonded with indirect and direct methods and to investigate the posttreatment changes 2 years after placement. Sixty-four consecutive patients from the postgraduate orthodontic clinic of the University of Geneva in Switzerland were randomly allocated to either an indirect or a traditional direct bonding procedure of a mandibular fixed retainer at the end of their orthodontic treatment (T0). Eligibility criteria were the presence of the 4 mandibular incisors and the 2 mandibular canines, and no active caries, restorations, fractures, or periodontal disease of these teeth. The patients were randomized in blocks of 4 (using an online randomization service) with allocation concealment secured by contacting the sequence generator for assignment. The patients were recalled 12 months and 24 months (T3) after retainer bonding. The main outcome was any first-time failure of retainers (ie, at least 1 composite pad debonded or fractured); unexpected posttreatment changes of the mandibular incisors and canines were a secondary outcome. Impressions and lateral cephalograms were taken at T0 and T3: changes in mandibular intercanine and interpremolar distances and mandibular incisor inclination were assessed. Blinding was applicable for outcome assessment only. The chi-square test and Cox regression were used to compare the survival rates of the retainers bonded with direct and indirect methods. Paired t tests were used to assess differences in intercanine and interpremolar distances and mandibular incisor inclination at T0 and T3. Significance was set at P <0.05. Sixty-four patients were randomized in a 1:1 ratio. One patient dropped out at baseline, and 3 patients did not reach the T3 recall. In 24 of 60 (40%) patients, the fixed retainer failed within 2 years: 13 of 30 (43%) in the indirect bonding group and 11 of 30 (37%) in the direct bonding group (log-rank test, P = 0.64). The hazard ratio was 1.26 (95% confidence interval, 0.56-2.81; P = 0.58). Bond failures occurred mainly during the first year. There were no clinically significant changes in mandibular intercanine distance, interpremolar distance, and incisor inclination between T0 and T3, or between groups. In 5 patients (17%), all in the direct bonding group, unexpected posttreatment changes, systematically consisting in a lingual inclination of the mandibular left canine, were observed. In 1 patient (3%), the change was considered clinically severe. No other serious harm was observed. There was no difference in the risks of failure between mandibular retainers bonded with direct and indirect methods. Bonded retainers are effective in maintaining intercanine and interpremolar distances. There seem to be fewer unexpected posttreatment changes with retainers bonded with the indirect compared with the direct method. The trial was not registered. The protocol was not published before trial commencement. No funding or conflict of interest to be declared. Copyright © 2017 American Association of Orthodontists. Published by Elsevier Inc. All rights reserved.

Associations between national tuberculosis program budgets and tuberculosis outcomes: an ecological study.

PubMed

Chapple, Will; Katz, Alan Roy; Li, Dongmei

2012-01-01

The objective of this study is to explore the associations between national tuberculosis program (NTP) budget allocation and tuberculosis related outcomes in the World Health Organization's 22 high burden countries from 2007-2009. This ecological study used mixed effects and generalized estimating equation models to identify independent associations between NTP budget allocations and various tuberculosis related outcomes. Models were adjusted for a number of independent variables previously noted to be associated with tuberculosis incidence. Increasing the percent of the NTP budget for advocacy, communication and social mobilization was associated with an increase in the case detection rate. Increasing TB-HIV funding was associated with an increase in HIV testing among TB patients. Increasing the percent of the population covered by the Directly Observed Therapy (DOT) program was associated with an increase in drug susceptibility testing. Laboratory funding was positively associated with tuberculosis notification. Increasing the budgets for first line drugs, management and multi-drug resistant tuberculosis (MDR-TB) was associated with a decrease in smear positive deaths. Effective TB control is a complex and multifaceted challenge. This study revealed a number of budget allocation related factors associated with improved TB outcome parameters. If confirmed with future longitudinal studies, these findings could help guide NTP managers with allocation decisions.

Associations between national tuberculosis program budgets and tuberculosis outcomes: an ecological study

PubMed Central

Chapple, Will; Katz, Alan Roy; Li, Dongmei

2012-01-01

Introduction The objective of this study is to explore the associations between national tuberculosis program (NTP) budget allocation and tuberculosis related outcomes in the World Health Organization's 22 high burden countries from 2007–2009. Methods This ecological study used mixed effects and generalized estimating equation models to identify independent associations between NTP budget allocations and various tuberculosis related outcomes. Models were adjusted for a number of independent variables previously noted to be associated with tuberculosis incidence. Results Increasing the percent of the NTP budget for advocacy, communication and social mobilization was associated with an increase in the case detection rate. Increasing TB-HIV funding was associated with an increase in HIV testing among TB patients. Increasing the percent of the population covered by the Directly Observed Therapy (DOT) program was associated with an increase in drug susceptibility testing. Laboratory funding was positively associated with tuberculosis notification. Increasing the budgets for first line drugs, management and multi-drug resistant tuberculosis (MDR-TB) was associated with a decrease in smear positive deaths. Conclusion Effective TB control is a complex and multifaceted challenge. This study revealed a number of budget allocation related factors associated with improved TB outcome parameters. If confirmed with future longitudinal studies, these findings could help guide NTP managers with allocation decisions. PMID:23024825

Allocating scarce medical resources to the overweight.

PubMed

Furnham, Adrian; Loganathan, Niroosha; McClelland, Alastair

2010-01-01

A programmatic research effort investigated how lay people weigh information on hypothetical patients when making decisions regarding the allocation of scarce medical resources. This study is partly replicative and partly innovative, and looks particularly at whether overweight patients would be discriminated against in allocating resources. This study aims to determine the importance given to specific patient characteristics when lay participants are asked to allocate scarce medical resources. In all, 156 British adults (82 males, 73 females), aged 19 to 84 years, took part. There were few students. Participants completed a questionnaire requiring them to rank 16 hypothetical patients for access to a kidney dialysis machine.The demographic information presented regarding each hypothetical patient differed on four dimensions: gender, weight, mental health, and religiousness. There were significant main effects for gender, weight, and mental health; females, patients of normal weight, and the mentally well were ranked the highest priority for access to a kidney dialysis machine. Participants discriminated most regarding the weight of hypothetical patients. Different patient characteristics, unrelated to medical prognoses, particularly being overweight, may have an impact on decisions regarding the use of scarce medical resources.

The positive financial impact of using an Intensive Care Information System in a tertiary Intensive Care Unit.

PubMed

Levesque, Eric; Hoti, Emir; de La Serna, Sofia; Habouchi, Houssam; Ichai, Philippe; Saliba, Faouzi; Samuel, Didier; Azoulay, Daniel

2013-03-01

In the French healthcare system, the intensive care budget allocated is directly dependent on the activity level of the center. To evaluate this activity level, it is necessary to code the medical diagnoses and procedures performed on Intensive Care Unit (ICU) patients. The aim of this study was to evaluate the effects of using an Intensive Care Information System (ICIS) on the incidence of coding errors and its impact on the ICU budget allocated. Since 2005, the documentation on and monitoring of every patient admitted to our ICU has been carried out using an ICIS. However, the coding process was performed manually until 2008. This study focused on two periods: the period of manual coding (year 2007) and the period of computerized coding (year 2008) which covered a total of 1403 ICU patients. The time spent on the coding process, the rate of coding errors (defined as patients missed/not coded or wrongly identified as undergoing major procedure/s) and the financial impact were evaluated for these two periods. With computerized coding, the time per admission decreased significantly (from 6.8 ± 2.8 min in 2007 to 3.6 ± 1.9 min in 2008, p<0.001). Similarly, a reduction in coding errors was observed (7.9% vs. 2.2%, p<0.001). This decrease in coding errors resulted in a reduced difference between the potential and real ICU financial supplements obtained in the respective years (€194,139 loss in 2007 vs. a €1628 loss in 2008). Using specific computer programs improves the intensive process of manual coding by shortening the time required as well as reducing errors, which in turn positively impacts the ICU budget allocation. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who have had a stroke (CLOTS 3): a multicentre randomised controlled trial.

PubMed

Dennis, M; Sandercock, P; Reid, J; Graham, C; Forbes, J; Murray, G

2013-08-10

Venous thromboembolism is a common, potentially avoidable cause of death and morbidity in patients in hospital, including those with stroke. In surgical patients, intermittent pneumatic compression (IPC) reduces the risk of deep vein thrombosis (DVT), but no reliable evidence exists about its effectiveness in patients who have had a stroke. We assessed the effectiveness of IPC to reduce the risk of DVT in patients who have had a stroke. The CLOTS 3 trial is a multicentre parallel group randomised trial assessing IPC in immobile patients (ie, who cannot walk to the toilet without the help of another person) with acute stroke. We enrolled patients from day 0 to day 3 of admission and allocated them via a central randomisation system (ratio 1:1) to receive either IPC or no IPC. A technician who was masked to treatment allocation did a compression duplex ultrasound (CDU) of both legs at 7-10 days and, wherever practical, at 25-30 days after enrolment. Caregivers and patients were not masked to treatment assignment. Patients were followed up for 6 months to determine survival and later symptomatic venous thromboembolism. The primary outcome was a DVT in the proximal veins detected on a screening CDU or any symptomatic DVT in the proximal veins, confirmed on imaging, within 30 days of randomisation. Patients were analysed according to their treatment allocation. ISRCTN93529999. Between Dec 8, 2008, and Sept 6, 2012, 2876 patients were enrolled in 94 centres in the UK. The included patients were broadly representative of immobile stroke patients admitted to hospital and had a median age of 76 years (IQR 67-84). The primary outcome occurred in 122 (8·5%) of 1438 patients allocated IPC and 174 (12·1%) of 1438 patients allocated no IPC; an absolute reduction in risk of 3·6% (95% CI 1·4-5·8). Excluding the 323 patients who died before any primary outcome and 41 without any screening CDU, the adjusted OR for the comparison of 122 of 1267 patients vs 174 of 1245 patients was 0·65 (95% CI 0·51-0·84; p=0·001). Deaths in the treatment period occurred in 156 (11%) patients allocated IPC and 189 (13%) patients allocated no IPC died within the 30 days of treatment period (p=0·057); skin breaks on the legs were reported in 44 (3%) patients allocated IPC and in 20 (1%) patients allocated no IPC (p=0·002); falls with injury were reported in 33 (2%) patients in the IPC group and in 24 (2%) patients in the no-IPC group (p=0·221). IPC is an effective method of reducing the risk of DVT and possibly improving survival in a wide variety of patients who are immobile after stroke. National Institute of Health Research (NIHR) Health Technology Assessment (HTA) programme, UK; Chief Scientist Office of Scottish Government; Covidien (MA, USA). Copyright © 2013 The Authors. Open Access article distributed under the terms of CC BY-NC-ND. Published by Elsevier Ltd. All rights reserved.

Juridification, medicalisation, and the impact of EU Law: patient mobility and the allocation of scarce NHS resources.

PubMed

Veitch, Kenneth

2012-01-01

This article explores the relationship between EU Law and the allocation of scarce NHS resources in the context of the EU's objective of facilitating access to health care for patients within the EU. Focusing on the Watts case and the recently adopted EU Patients' Rights Directive, the article addresses the political and economic aspects of the implications of EU Law for, inter alia, domestic law, medicine, and the NHS. It does so through developing an analytical framework comprising the notions of juridification and medicalisation. Those notions, which are drawn here from the work of Jürgen Habermas, Ivan Illich, and Sheila McLean, are not only helpful as means of thinking through the nature of the specific EU laws considered in the article; by virtue of their broader focus on, and critique of, the welfare state, they offer an opportunity to reflect more generally on the implications of these laws for the role of the welfare state and medical and legal professionals in the development of the EU's internal market in health care services. Having undertaken this analysis, the article argues that, in order to capture the developments and implications of EU Law on patient mobility, it is necessary to update and partially reformulate the notions of medicalisation and juridification.

Tailoring Software for Multiple Processor Systems

DTIC Science & Technology

1982-10-01

resource management decisions . Despite the lack of programming support, the use of multiple processor systems has grown sub- -stantially. Software has...making resource management decisions . Specifically, program- 1 mers need not allocate specific hardware resources to individual program components...Instead, such allocation decisions are automatically made based on high-level resource directives stated by ap- plication programmers, where each directive

Swaps and Chains and Vouchers, Oh My!: Evaluating How Saving More Lives Impacts the Equitable Allocation of Live Donor Kidneys.

PubMed

Tenenbaum, Evelyn M

2018-03-01

Live kidney donation involves a delicate balance between saving the most lives possible and maintaining a transplant system that is fair to the many thousands of patients on the transplant waiting list. Federal law and regulations require that kidney allocation be equitable, but the pressure to save patients subject to ever-lengthening waiting times for a transplant has been swinging the balance toward optimizing utility at the expense of justice. This article traces the progression of innovations created to make optimum use of a patient's own live donors. It starts with the simplest - direct donation by family members - and ends with voucher donations, a very recent and unique innovation because the donor can donate 20 or more years before the intended recipient is expected to need a kidney. In return for the donation, the intended recipient receives a voucher that can be redeemed for a live kidney when it is needed. Other innovations that are discussed include kidney exchanges and list paired donation, which are used to facilitate donor swaps when donor/recipient pairs have incompatible blood types. The discussion of each new innovation shows how the equity issues build on each other and how, with each new innovation, it becomes progressively harder to find an acceptable balance between utility and justice. The article culminates with an analysis of two recent allocation methods that have the potential to save many additional lives, but also affirmatively harm some patients on the deceased donor waiting list by increasing their waiting time for a life-saving kidney. The article concludes that saving additional lives does not justify harming patients on the waiting list unless that harm can be minimized. It also proposes solutions to minimize the harm so these new innovations can equitably perform their intended function of stimulating additional transplants and extending the lives of many transplant patients.

Kidney Transplant Candidates’ Views of the Transplant Allocation System

PubMed Central

Louis, Okiki N; Sankar, Pamela; Ubel, Peter A

1997-01-01

OBJECTIVE The point system used to distribute scarce transplantable kidneys places great emphasis on antigen matching. This contributes to increased waiting times for African Americans, who have a disproportionate share of rare antigens. We conducted a pilot study to explore the understanding and attitudes of kidney transplant candidates toward the way the transplant allocation system trades off between antigen matching and waiting time. MEASUREMENTS MAIN RESULTS We performed semi-structured interviews of a convenience sample of 33 patients awaiting transplants in Philadelphia and its surrounding suburbs. Patients had a number of misconceptions about the transplant allocation system. Many incorrectly thought, for example, that quality of life and financial status influence which patients on the waiting list receive available organs. Despite these and other misconceptions, the majority of patients thought the allocation system was fair. However, many African Americans thought the system was biased against them because of their race. After hearing about how the transplant system factors antigen matching and waiting time into organ allocation, the majority of subjects still felt the system was fair. After hearing that the emphasis on antigen matching causes African Americans to wait twice as long as whites, a larger number of subjects thought the system was unfair. Nevertheless, few thought the system should be changed. Even African American patients who felt the system was unfair still approved of the emphasis on antigen matching out of a desire to have a successful kidney transplant. CONCLUSIONS We found that most of the interviewed patients awaiting kidney transplant thought the system should continue to emphasize antigen matching. Although attitudes toward the allocation system differed by race, with African American patients more suspicious of the system, the importance patients placed on antigen matching did not appear to differ by race. PMID:9276653

Contingent Valuation Analysis of an Otolaryngology and Ophthalmology Emergency Department: The Value of Acute Specialty Care.

PubMed

Naunheim, Matthew R; Kozin, Elliot D; Sethi, Rosh K; Ota, H G; Gray, Stacey T; Shrime, Mark G

2017-03-01

Specialty emergency departments (EDs) provide a unique mechanism of health care delivery, but the value that they add to the medical system is not known. Evaluation of patient preferences to determine value can have a direct impact on resource allocation and direct-to-specialist care. To assess the feasibility of contingent valuation (CV) methodology using a willingness-to-pay (WTP) survey to evaluate specialty emergency services, in the context of an ophthalmology- and otolaryngology-specific ED. Contingent valuation analysis of a standalone otolaryngology and ophthalmology ED. Participants were English-speaking adults presenting to a dedicated otolaryngology and ophthalmology ED. The WTP questions were assessed using a payment card format, with reference to an alternative modality of treatment (ie, general ED), and were analyzed with multivariate regression. Validated WTP survey administered from October 14, 2014, through October 1, 2015. Sociodemographic data, level of distress, referral data, income, and WTP. A total of 327 of 423 (77.3%) ED patients responded to the WTP survey, with 116 ophthalmology and 211 otolaryngology patients included (52.3% female; mean [range] age, 46 [18-90] years). The most common reason for seeking care at this facility was a reputation for specialty care for both ear, nose, and throat (80 [37.9%]) and ophthalmology (43 [37.1%]). Mean WTP for specialty-specific ED services was $377 for ophthalmology patients, and $321 for otolaryngology patients ($340 overall; 95% CI, $294 to $386), without significant difference between groups (absolute difference, $56; 95% CI, $-156 to $43). Self-reported level of distress was higher among ear, nose, and throat vs ophthalmology patients (absolute difference, 0.47 on a Likert scale of 1-7; 95% CI, 0.10 to 0.84). Neither level of distress, income, nor demographic characteristics influenced WTP, but patients with higher estimates of total visit cost were more likely to have higher WTP (β coefficient, 0.27; SE, 0.05; adjusted R2 = 0.17 for model). Patients with eye and ear, nose, and throat complaints place a mean explicit value on specialty emergency services of $340 per visit, relative to general emergency care. Ultimately, CV data using WTP methodology are useful in valuing patient preferences in monetary terms and can help inform state-wide resource allocation and the availability of direct-to-specialist care.

Who gets the gametes? An argument for a points system for fertility patients

PubMed Central

Jenkins, Simon; Ives, Jonathan; Avery, Sue

2017-01-01

Abstract This paper argues that the convention of allocating donated gametes on a ‘first come, first served’ basis should be replaced with an allocation system that takes into account more morally relevant criteria than waiting time. This conclusion was developed using an empirical bioethics methodology, which involved a study of the views of 18 staff members from seven U.K. fertility clinics, and 20 academics, policy‐makers, representatives of patient groups, and other relevant professionals, on the allocation of donated sperm and eggs. Against these views, we consider some nuanced ways of including criteria in a points allocation system. We argue that such a system is more ethically robust than ‘first come, first served’, but we acknowledge that our results suggest that a points system will meet with resistance from those working in the field. We conclude that criteria such as a patient's age, potentially damaging substance use, and parental status should be used to allocate points and determine which patients receive treatment and in what order. These and other factors should be applied according to how they bear on considerations like child welfare, patient welfare, and the effectiveness of the proposed treatment. PMID:29194680

Recovery of motor deficit accompanying sciatica--subgroup analysis of a randomized controlled trial.

PubMed

Overdevest, Gijsbert M; Vleggeert-Lankamp, Carmen L A M; Jacobs, Wilco C H; Brand, Ronald; Koes, Bart W; Peul, Wilco C

2014-09-01

In patients with sciatica due to a lumbar disc herniation, it is generally recommended to reserve surgical treatment for those who suffer from intolerable pain or those who demonstrate persistent symptoms after conservative management. Controversy exists about the necessity of early surgical intervention for those patients that have an additional motor deficit. The aim of this study was to compare the recovery of motor deficit among patients receiving early surgery to those receiving prolonged conservative treatment. Subgroup analysis of a randomized controlled trial. This subgroup analysis focuses on 150 (53%) of 283 patients with sciatica due to a lumbar disc herniation and whose symptoms at baseline (before randomization) were accompanied by a motor deficit. Motor deficit was assessed through manual muscle testing and graded according to the Medical Research Council (MRC) scale. In total, 150 patients with 6 to 12 weeks of sciatica due to a lumbar disc herniation and whose symptoms were accompanied by a moderate (MRC Grade 4) or severe (MRC Grade 3) motor deficit were randomly allocated to early surgery or prolonged conservative treatment. Repeated standardized neurologic examinations were performed at baseline and at 8, 26, and 52 weeks after randomization. This study was supported by a grant from the Netherlands Organization for Health Research and Development (ZonMW) and the Hoelen Foundation The Hague. Sciatica recovered among seven (10%) of the 70 patients assigned to early surgery before surgery could be performed, and of the 80 patients assigned to conservative treatment, 32 patients (40%) were treated surgically because of intolerable pain. Baseline severity of motor deficit was graded moderate in 84% of patients and severe in 16% of patients. Motor deficit recovered significantly faster among patients allocated to early surgery (p=.01), but the difference was no longer significant at 26 (p=.21) or 52 weeks (p=.92). At 1 year, complete recovery of motor deficit was found in 81% of patients allocated to early surgery and in 80% of patients allocated to prolonged conservative treatment. Perceived overall recovery of sciatica was directly related to the presence of an accompanying motor deficit. Severe motor deficit at baseline (odds ratio, 5.4; confidence interval, 1.7-17.4) and a lumbar disc herniation encompassing ≥25% of the cross-sectional area of the spinal canal (odds ratio, 6.4; confidence interval, 1.3-31.8) were the most important risk factors for persistent deficit at 1 year. Early surgery resulted in a faster recovery of motor deficit accompanying sciatica compared with prolonged conservative treatment but the difference was no longer significant during the final follow-up examination at 1 year. Copyright © 2014 Elsevier Inc. All rights reserved.

78 FR 45001 - Self-Regulatory Organizations; Miami International Securities Exchange LLC; Order Approving...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-07-25

... a minimum participation allocation of at least one (1) contract. Specifically, the proposal ensures that the DLMM will be allocated a minimum of one contract in situations where, due to the Exchange's... DLMM being allocated zero contracts. \\5\\ A ``Directed Order'' is an order entered into the System by an...

76 FR 65180 - Proposed Information Collection; Comment Request; Application to Shuck Surf Clams/Ocean Quahogs...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-20

.... Method of Collection Requests from allocation holders to transfer quota use paper applications or an... submitted on or before December 19, 2011. ADDRESSES: Direct all written comments to Diana Hynek... transferable quota (ITQ) allocation holders in order to process and track requests from the allocation holders...

Pre-EDIT: protocol for a randomised feasibility trial of elastance-directed intrapleural catheter or talc pleurodesis (EDIT) in malignant pleural effusion

PubMed Central

Martin, Geoffrey A; Tsim, Selina; Kidd, Andrew C; Foster, John E; McLoone, Philip; Chalmers, Anthony

2018-01-01

Introduction Non-expansile lung (NEL) is a common cause of talc pleurodesis (TP) failure in malignant pleural effusion (MPE), but is often occult prior to drainage. Reliable detection of NEL would allow patients to be allocated between intrapleural catheter (IPC) and TP. High pleural elastance (PEL) has been associated with NEL in observational studies. Pre-EDIT is a randomised feasibility trial of elastance-directed IPC or TP (EDIT) management using a novel, purpose-built digital pleural manometer (Rocket Medical, UK). Methods and analysis Consecutive patients with MPE without prior evidence of NEL or preference for IPC will be randomised 1:1 between EDIT management and standard care (an attempt at TP). The primary objective is to determine whether sufficient numbers of patients (defined as 30 within 12 months (or 15 over 6 months)) can be recruited and randomised to justify a subsequent phase III trial testing the efficacy of EDIT management. Secondary objectives include safety, technical feasibility and validation of study design elements, including the definition of PEL using 4D pleural MRI before and after fluid aspiration. EDIT involves PEL assessment during a large volume pleural fluid aspiration, followed by an attempt at TP or placement of an IPC within 24 hours. Patients will be allocated to IPC if the rolling average PEL sustained over at least 250 mL fluid aspirated (PEL250) is ≥ 14.5 cm H2O/L. Ethics and dissemination Pre-EDIT was approved by the West of Scotland Regional Ethics Committee on 8 March 2017 (Ref: 17/WS/0042). Results will be presented at scientific meetings and published in peer-reviewed journals. Trial registration number NCT03319186; Pre-results. PMID:29862030

Health Care Exceptionalism? Performance and Allocation in the US Health Care Sector

PubMed Central

Chandra, Amitabh; Finkelstein, Amy; Sacarny, Adam; Syverson, Chad

2016-01-01

The conventional wisdom for the healthcare sector is that idiosyncratic features leave little scope for market forces to allocate consumers to higher performance producers. However, we find robust evidence - across several different conditions and performance measures - that higher quality hospitals have higher market shares and grow more over time. The relationship between performance and allocation is stronger among patients who have greater scope for hospital choice, suggesting that patient demand plays an important role in allocation. Our findings suggest that healthcare may have more in common with “traditional” sectors subject to market forces than often assumed. PMID:27784907

Allocating effort and anticipating pleasure in schizophrenia: Relationship with real world functioning.

PubMed

Serper, M; Payne, E; Dill, C; Portillo, C; Taliercio, J

2017-10-01

Poor motivation to engage in goal-oriented behavior has been recognized as a hallmark feature of schizophrenia spectrum disorders (SZ). Low drive in SZ may be related to anticipating rewards as well as to poor working memory. However, few studies to date have examined beliefs about self-efficacy and satisfaction for future rewards (anticipatory pleasure). Additionally, few studies to date have examined how these deficits may impact SZ patients' real world functioning. The present study examined SZ patients' (n=57) anticipatory pleasure, working memory, self-efficacy and real world functioning in relation to their negative symptom severity. Results revealed that SZ patients' negative symptom severity was related to decisions in effort allocation and reward probability, working memory deficits, self-efficacy and anticipatory pleasure for future reward. Effort allocation deficits also predicted patients' daily functioning skills. SZ patients with high levels of negative symptoms are not merely effort averse, but have more difficulty effectively allocating effort and anticipating pleasure engaging in effortful activities. It may be the case that continuously failing to achieve reinforcement from engagement and participation may lead SZ patients to form certain negative beliefs about their abilities which contributes to amotivation and cognitive deficits. Lastly, our findings provide further support for a link between SZ patients functional daily living skills their effort allocation. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Cost of schizophrenia: direct costs and use of resources in the State of São Paulo.

PubMed

Leitão, Raquel Jales; Ferraz, Marcos Bosi; Chaves, Ana Cristina; Mari, Jair J

2006-04-01

To estimate the direct costs of schizophrenia for the public sector. A study was carried out in the state of São Paulo, Brazil, during 1998. Data from the medical literature and governmental research bodies were gathered for estimating the total number of schizophrenia patients covered by the Brazilian Unified Health System. A decision tree was built based on an estimated distribution of patients under different types of psychiatric care. Medical charts from public hospitals and outpatient services were used to estimate the resources used over a one-year period. Direct costs were calculated by attributing monetary values for each resource used. Of all patients, 81.5% were covered by the public sector and distributed as follows: 6.0% in psychiatric hospital admissions, 23.0% in outpatient care, and 71.0% without regular treatment. The total direct cost of schizophrenia was US $191,781,327 (2.2% of the total health care expenditure in the state). Of this total, 11.0% was spent on outpatient care and 79.2% went for inpatient care. Most schizophrenia patients in the state of São Paulo receive no regular treatment. The study findings point out to the importance of investing in research aimed at improving the resource allocation for the treatment of mental disorders in Brazil.

The effect of referral and transfer patients on hospital funding in a capitated health care delivery system.

PubMed

Pietz, Kenneth; Byrne, Margaret M; Daw, Christina; Petersen, Laura A

2007-10-01

(1) To investigate whether inpatients referred or transferred between facilities result in increased financial loss compared with those admitted directly, in a health care delivery system funded by capitation methods. (2) To determine whether the higher cost of those patients transferred or referred is fairly compensated by a diagnosis-based risk adjustment system, and whether tertiary care facilities bear an unfair financial burden for such patients in a capitated financing environment. The study cohort included all Veterans Affairs (VA) beneficiaries who received inpatient care during fiscal year (FY) 2004. Referral was defined as an outpatient visit to 1 facility followed by an admission to another facility. Transfers were consecutive inpatient stays at different hospitals. We defined loss as cost minus the share of budget determined by a Diagnostic Cost Group-based allocation. Both t tests and linear regression were used to compare the effect on cost and loss for patients transferred or not and referred or not. Mean loss to a facility for patients transferred in was 1231 dollars more than for those not transferred. Mean loss for referred patients was 3341 dollars more than for those not referred, controlling for disease burden. For tertiary hospitals, the difference in losses for transfer patients was less than for other hospitals but greater for referral patients. Patients referred or transferred from other facilities are more costly than those who are not. The difference may not be compensated by a diagnosis-based allocation system. A capitated health care system may consider additional funding to cover the cost of such patients.

Integration and Task Allocation: Evidence from Patient Care*

PubMed Central

David, Guy; Rawley, Evan; Polsky, Daniel

2013-01-01

Using the universe of patient transitions from inpatient hospital care to skilled nursing facilities and home health care in 2005, we show how integration eliminates task misallocation problems between organizations. We find that vertical integration allows hospitals to shift patient recovery tasks downstream to lower-cost organizations by discharging patients earlier (and in poorer health) and increasing post-hospitalization service intensity. While integration facilitates a shift in the allocation of tasks and resources, health outcomes either improved or were unaffected by integration on average. The evidence suggests that integration solves coordination problems that arise in market exchange through improvements in the allocation of tasks across care settings. PMID:24415893

Integrated Nuclear and Conventional Theater Warfare Simulation (INWARS) Documentation. Part IV. User’s Manual Component. Volume III. EAD C2I Inputs.

DTIC Science & Technology

1980-02-08

hours 0 Input Format: Integer b. Creatina Rescource Allocation Blocks The creation of a specific resource allocation block as a directive component is...is directed. 0 Range: N/A . Input Format: INT/NUC/CHM b. Creatina Employment Packages An employment package block has the structure portrayed in Figure

Gender in Cohabitation and Marriage: The Influence of Gender Ideology on Housework Allocation over the Life Course

ERIC Educational Resources Information Center

Cunningham, Mick

2005-01-01

The analysis examines the direct and indirect influences of early gender socialization on the allocation of routine housework later in the life course. The study articulates hypotheses suggesting that the relationship between gender socialization early in adulthood and housework allocation later in adulthood is moderated by gender and union type…

Resource Allocation Models and Accountability: A Jamaican Case Study

ERIC Educational Resources Information Center

Nkrumah-Young, Kofi K.; Powell, Philip

2008-01-01

Higher education institutions (HEIs) may be funded privately, by the state or by a mixture of the two. Nevertheless, any state financing of HE necessitates a mechanism to determine the level of support and the channels through which it is to be directed; that is, a resource allocation model. Public funding, through resource allocation models,…

The Wire-Grasping Method as a New Technique for Forceps Biopsy of Biliary Strictures: A Prospective Randomized Controlled Study of Effectiveness

PubMed Central

Yamashita, Yasunobu; Ueda, Kazuki; Kawaji, Yuki; Tamura, Takashi; Itonaga, Masahiro; Yoshida, Takeichi; Maeda, Hiroki; Magari, Hirohito; Maekita, Takao; Iguchi, Mikitaka; Tamai, Hideyuki; Ichinose, Masao; Kato, Jun

2016-01-01

Background/Aims Transpapillary forceps biopsy is an effective diagnostic technique in patients with biliary stricture. This prospective study aimed to determine the usefulness of the wire-grasping method as a new technique for forceps biopsy. Methods Consecutive patients with biliary stricture or irregularities of the bile duct wall were randomly allocated to either the direct or wire-grasping method group. In the wire-grasping method, forceps in the duodenum grasps a guide-wire placed into the bile duct beforehand, and then, the forceps are pushed through the papilla without endoscopic sphincterotomy. In the direct method, forceps are directly pushed into the bile duct alongside a guide-wire. The primary endpoint was the success rate of obtaining specimens suitable for adequate pathological examination. Results In total, 32 patients were enrolled, and 28 (14 in each group) were eligible for analysis. The success rate was significantly higher using the wire-grasping method than the direct method (100% vs 50%, p=0.016). Sensitivity and accuracy for the diagnosis of cancer were comparable in patients with the successful procurement of biopsy specimens between the two methods (91% vs 83% and 93% vs 86%, respectively). Conclusions The wire-grasping method is useful for diagnosing patients with biliary stricture or irregularities of the bile duct wall. PMID:27021502

A time-driven activity-based costing model to improve health-care resource use in Mirebalais, Haiti.

PubMed

Mandigo, Morgan; O'Neill, Kathleen; Mistry, Bipin; Mundy, Bryan; Millien, Christophe; Nazaire, Yolande; Damuse, Ruth; Pierre, Claire; Mugunga, Jean Claude; Gillies, Rowan; Lucien, Franciscka; Bertrand, Karla; Luo, Eva; Costas, Ainhoa; Greenberg, Sarah L M; Meara, John G; Kaplan, Robert

2015-04-27

In resource-limited settings, efficiency is crucial to maximise resources available for patient care. Time driven activity-based costing (TDABC) estimates costs directly from clinical and administrative processes used in patient care, thereby providing valuable information for process improvements. TDABC is more accurate and simpler than traditional activity-based costing because it assigns resource costs to patients based on the amount of time clinical and staff resources are used in patient encounters. Other costing approaches use somewhat arbitrary allocations that provide little transparency into the actual clinical processes used to treat medical conditions. TDABC has been successfully applied in European and US health-care settings to facilitate process improvements and new reimbursement approaches, but it has not been used in resource-limited settings. We aimed to optimise TDABC for use in a resource-limited setting to provide accurate procedure and service costs, reliably predict financing needs, inform quality improvement initiatives, and maximise efficiency. A multidisciplinary team used TDABC to map clinical processes for obstetric care (vaginal and caesarean deliveries, from triage to post-partum discharge) and breast cancer care (diagnosis, chemotherapy, surgery, and support services, such as pharmacy, radiology, laboratory, and counselling) at Hôpital Universitaire de Mirebalais (HUM) in Haiti. The team estimated the direct costs of personnel, equipment, and facilities used in patient care based on the amount of time each of these resources was used. We calculated inpatient personnel costs by allocating provider costs per staffed bed, and assigned indirect costs (administration, facility maintenance and operations, education, procurement and warehouse, bloodbank, and morgue) to various subgroups of the patient population. This study was approved by the Partners in Health/Zanmi Lasante Research Committee. The direct cost of an uncomplicated vaginal delivery at HUM was US$62 and the direct cost of a caesarean delivery was US$249. The direct costs of breast cancer care (including diagnostics, chemotherapy, and mastectomy) totalled US$1393. A mastectomy, including post-anaesthesia recovery and inpatient stay, totalled US$282 in direct costs. Indirect costs comprised 26-38% of total costs, and salaries were the largest percentage of total costs (51-72%). Accurate costing of health services is vital for financial officers and funders. TDABC showed opportunities at HUM to optimise use of resources and reduce costs-for instance, by streamlining sterilisation procedures and redistributing certain tasks to improve teamwork. TDABC has also improved budget forecasting and informed financing decisions. HUM leadership recognised its value to improve health-care delivery and expand access in low-resource settings. Boston Children's Hospital, Harvard Business School, and Partners in Health. Copyright © 2015 Elsevier Ltd. All rights reserved.

15 CFR 923.92 - Allocation.

Code of Federal Regulations, 2011 CFR

2011-01-01

... intergovernmental cooperation in that a state, in accordance with its coastal zone management program, may allocate some of its coastal zone management responsibilities to several agencies, including local governments... could directly affect the State's coastal zone. ...

State Budgets, Unit Allocations, and Unit Emissions Rates

EPA Pesticide Factsheets

This Technical Support Document (TSD) provides information that supports EPA’s determination of state emissions budgets, unit-level allocations, direct control rate limits, and new unit set-asides for the Transport Rule proposal.

Chronic Kidney Disease and Related Long-term Complications Following Liver Transplantation

PubMed Central

Sharma, Pratima; Bari, Khurram

2015-01-01

Liver transplantation (LT) is the standard of care for patients with decompensated cirrhosis. LT recipients have excellent short-term and long-term outcomes including patient and graft survival. Since the adoption of model for end-stage liver disease (MELD) - based allocation policy, the incidence of post-transplant end stage renal disease has risen significantly. Occurrence of stage 4 chronic kidney disease and end stage renal disease substantially increase the risk of post-transplant deaths. Since majority of late post-transplant mortality is due to non-hepatic post-transplant comorbidities, personalized care directed towards risk factor modification may further improve post-transplant survival. PMID:26311603

Concept for individualized patient allocation: ReCompare--remote comparison of particle and photon treatment plans.

PubMed

Lühr, Armin; Löck, Steffen; Roth, Klaus; Helmbrecht, Stephan; Jakobi, Annika; Petersen, Jørgen B; Just, Uwe; Krause, Mechthild; Enghardt, Wolfgang; Baumann, Michael

2014-02-18

Identifying those patients who have a higher chance to be cured with fewer side effects by particle beam therapy than by state-of-the-art photon therapy is essential to guarantee a fair and sufficient access to specialized radiotherapy. The individualized identification requires initiatives by particle as well as non-particle radiotherapy centers to form networks, to establish procedures for the decision process, and to implement means for the remote exchange of relevant patient information. In this work, we want to contribute a practical concept that addresses these requirements. We proposed a concept for individualized patient allocation to photon or particle beam therapy at a non-particle radiotherapy institution that bases on remote treatment plan comparison. We translated this concept into the web-based software tool ReCompare (REmote COMparison of PARticlE and photon treatment plans). We substantiated the feasibility of the proposed concept by demonstrating remote exchange of treatment plans between radiotherapy institutions and the direct comparison of photon and particle treatment plans in photon treatment planning systems. ReCompare worked with several tested standard treatment planning systems, ensured patient data protection, and integrated in the clinical workflow. Our concept supports non-particle radiotherapy institutions with the patient-specific treatment decision on the optimal irradiation modality by providing expertise from a particle therapy center. The software tool ReCompare may help to improve and standardize this personalized treatment decision. It will be available from our website when proton therapy is operational at our facility.

77 FR 42349 - Self-Regulatory Organizations; NYSE Amex LLC; Order Approving a Proposed Rule Change Defining a...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-07-18

... size pro-rata basis, and do not compete for the allocation of non-Directed Orders of five contracts or... than a round robin allocation of non-Directed Orders for five contracts or fewer, all such orders would... Specialist's quote size is less than the order of five contracts or fewer, any remaining contracts after the...

Patients' views on priority setting in neurosurgery: A qualitative study.

PubMed

Gunaratnam, Caroline; Bernstein, Mark

2016-01-01

Accountability for Reasonableness is an ethical framework which has been implemented in various health care systems to improve and evaluate the fairness of priority setting. This framework is grounded on four mandatory conditions: relevance, publicity, appeals, and enforcement. There have been few studies which have evaluated the patient stakeholders' acceptance of this framework; certainly no studies have been done on patients' views on the prioritization system for allocating patients for operating time in a system with pressure on the resource of inpatient beds. The aim of this study is to examine neurosurgical patients' views on the prioritization of patients for operating theater (OT) time on a daily basis at a tertiary and quaternary referral neurosurgery center. Semi-structured face-to-face interviews were conducted with thirty-seven patients, recruited from the neurosurgery clinic at Toronto Western Hospital. Family members and friends who accompanied the patient to their clinic visit were encouraged to contribute to the discussion. Interviews were audio recorded, transcribed verbatim, and subjected to thematic analysis using open and axial coding. Overall, patients are supportive of the concept of a priority-setting system based on fairness, but felt that a few changes would help to improve the fairness of the current system. These changes include lowering the level of priority given to volume-funded cases and providing scheduled surgeries that were previously canceled a higher level of prioritization. Good communication, early notification, and rescheduling canceled surgeries as soon as possible were important factors that directly reflected the patients' confidence level in their doctor, the hospital, and the health care system. This study is the first clinical qualitative study of patients' perspective on a prioritization system used for allocating neurosurgical patients for OT time on a daily basis in a socialized not-for-profit health care system with fixed resources.

Perceived state of self during motion can differentially modulate numerical magnitude allocation.

PubMed

Arshad, Q; Nigmatullina, Y; Roberts, R E; Goga, U; Pikovsky, M; Khan, S; Lobo, R; Flury, A-S; Pettorossi, V E; Cohen-Kadosh, R; Malhotra, P A; Bronstein, A M

2016-09-01

Although a direct relationship between numerical allocation and spatial attention has been proposed, recent research suggests that these processes are not directly coupled. In keeping with this, spatial attention shifts induced either via visual or vestibular motion can modulate numerical allocation in some circumstances but not in others. In addition to shifting spatial attention, visual or vestibular motion paradigms also (i) elicit compensatory eye movements which themselves can influence numerical processing and (ii) alter the perceptual state of 'self', inducing changes in bodily self-consciousness impacting upon cognitive mechanisms. Thus, the precise mechanism by which motion modulates numerical allocation remains unknown. We sought to investigate the influence that different perceptual experiences of motion have upon numerical magnitude allocation while controlling for both eye movements and task-related effects. We first used optokinetic visual motion stimulation (OKS) to elicit the perceptual experience of either 'visual world' or 'self'-motion during which eye movements were identical. In a second experiment, we used a vestibular protocol examining the effects of perceived and subliminal angular rotations in darkness, which also provoked identical eye movements. We observed that during the perceptual experience of 'visual world' motion, rightward OKS-biased judgments towards smaller numbers, whereas leftward OKS-biased judgments towards larger numbers. During the perceptual experience of 'self-motion', judgments were biased towards larger numbers irrespective of the OKS direction. Contrastingly, vestibular motion perception was found not to modulate numerical magnitude allocation, nor was there any differential modulation when comparing 'perceived' vs. 'subliminal' rotations. We provide a novel demonstration that numerical magnitude allocation can be differentially modulated by the perceptual state of self during visual but not vestibular mediated motion. © 2016 Federation of European Neuroscience Societies and John Wiley & Sons Ltd.

Total Belowground Carbon Allocation in a Fast-growing Eucalyptus Plantation Estimated Using a Carbon Balance Approach

Treesearch

Christian P. Giardina; Michael G. Ryan

2002-01-01

Trees allocate a large portion of gross primary production belowground for the production and maintenance of roots and mycorrhizae. The difficulty of directly measuring total belowground carbon allocation (TBCA) has limited our understanding of belowground carbon (C) cycling and the factors that control this important flux. We measured TBCA over 4 years using a...

Effects of intravenous magnesium in suspected acute myocardial infarction: overview of randomised trials.

PubMed Central

Teo, K K; Yusuf, S; Collins, R; Held, P H; Peto, R

1991-01-01

OBJECTIVE--To investigate the effect of intravenous magnesium on mortality in suspected acute myocardial infarction. DESIGN--Systematic overview of all available randomised trials in which patients were allocated to receive either intravenous magnesium or otherwise similar treatment without magnesium. SETTING--Coronary care units of several hospitals. PATIENTS--1301 patients in seven randomised trials. MAIN OUTCOME MEASURE--Short term mortality. RESULTS--Considering the seven trials collectively there were 25 (3.8%) deaths among 657 patients allocated to receive magnesium and 53 (8.2%) deaths among 644 patients allocated control, generally during hospital follow up. This represents a 55% reduction in the odds of death (p less than 0.001) with 95% confidence intervals ranging from about one third to about two thirds. 70 of 648 patients allocated magnesium compared with 109 of 641 controls had serious ventricular arrhythmias, suggesting that magnesium reduces the incidence, though the definition varied among trials. Other adverse effects were rare in the limited number of patients for whom this data were available. CONCLUSION--Despite the limited number of patients randomised this overview suggests that intravenous magnesium therapy may reduce mortality in patients with acute myocardial infarction. Further large scale trials to confirm (or refute) these findings are desirable. PMID:1838289

Comparison of patients' experiences in public and private primary care clinics in Malta.

PubMed

Pullicino, Glorianne; Sciortino, Philip; Calleja, Neville; Schäfer, Willemijn; Boerma, Wienke; Groenewegen, Peter

2015-06-01

Demographic changes, technological developments and rising expectations require the analysis of public-private primary care (PC) service provision to inform policy makers. We conducted a descriptive, cross-sectional study using the dataset of the Maltese arm of the QUALICOPC Project to compare the PC patients' experiences provided by public-funded and private (independent) general practitioners in Malta. Seven hundred patients from 70 clinics completed a self-administered questionnaire. Direct logistic regression showed that patients visiting the private sector experienced better continuity of care with more difficulty in accessing out-of-hours care. Such findings help to improve (primary) healthcare service provision and resource allocation. © The Author 2014. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.

Motion-related resource allocation in dynamic wireless visual sensor network environments.

PubMed

Katsenou, Angeliki V; Kondi, Lisimachos P; Parsopoulos, Konstantinos E

2014-01-01

This paper investigates quality-driven cross-layer optimization for resource allocation in direct sequence code division multiple access wireless visual sensor networks. We consider a single-hop network topology, where each sensor transmits directly to a centralized control unit (CCU) that manages the available network resources. Our aim is to enable the CCU to jointly allocate the transmission power and source-channel coding rates for each node, under four different quality-driven criteria that take into consideration the varying motion characteristics of each recorded video. For this purpose, we studied two approaches with a different tradeoff of quality and complexity. The first one allocates the resources individually for each sensor, whereas the second clusters them according to the recorded level of motion. In order to address the dynamic nature of the recorded scenery and re-allocate the resources whenever it is dictated by the changes in the amount of motion in the scenery, we propose a mechanism based on the particle swarm optimization algorithm, combined with two restarting schemes that either exploit the previously determined resource allocation or conduct a rough estimation of it. Experimental simulations demonstrate the efficiency of the proposed approaches.

Physician and Patient and Caregiver Health Attitudes and Their Effect on Medicare Resource Allocation for Patients With Advanced Cancer.

PubMed

Rocke, Daniel J; Beumer, Halton W; Taylor, Donald H; Thomas, Steven; Puscas, Liana; Lee, Walter T

2014-06-01

Physicians must participate in end-of-life discussions, but they understand poorly their patients' end-of-life values and preferences. A better understanding of these preferences and the effect of baseline attitudes will improve end-of-life discussions. To determine how baseline attitudes toward quality vs quantity of life affect end-of-life resource allocation. Otolaryngology-head and neck surgery (OHNS) physicians were recruited to use a validated online tool to create a Medicare health plan for advanced cancer patients. During the exercise, participants allocated a limited pool of resources among 15 benefit categories. These data were compared with preliminary data from patients with cancer and their caregivers obtained from a separate study using the same tool. Attitudes toward quality vs quantity of life were assessed for both physicians and patients and caregivers. Participation in online assessment exercise. Medicare resource allocation. Of 9120 OHNS physicians e-mailed, 767 participated. Data collected from this group were compared with data collected from 146 patients and 114 caregivers. Compared with patients and caregivers, OHNS physician allocations differed significantly in all 15 benefit categories except home care. When stratified by answers to 3 questions about baseline attitudes toward quality vs quantity of life, there were 3 categories in which allocations of patients and caregivers differed significantly from the group with the opposite attitude for at least 2 questions: other medical care (question 1, P < .001; question 2, P = .005), palliative care (question 1, P = .008; question 2, P = .006; question 3, P = .009), and treatment for cancer (questions 1 and 2, P < .001). In contrast, physician preferences showed significant differences in only 1, nonmatching category for each attitude question: cash (question 1, P = .02), drugs (question 2, P = .03), and home care (question 3, P = .048). Patients with cancer and their caregivers have different preferences from physicians. These preferences are, for these patients and their caregivers, affected by their baseline health attitudes, but physician preferences are not. Understanding the effect of baseline attitudes is important for effective end-of-life discussions.

Perioperative Aspirin for Prevention of Venous Thromboembolism: The PeriOperative ISchemia Evaluation-2 Trial and a Pooled Analysis of the Randomized Trials.

PubMed

Eikelboom, John W; Kearon, Clive; Guyatt, Gordon; Sessler, Daniel I; Yusuf, Salim; Cook, Deborah; Douketis, James; Patel, Ameen; Kurz, Andrea; Allard, Rene; Jones, Philip M; Dennis, Rodolfo J; Painter, Thomas W; Bergese, Sergio D; Leslie, Kate; Wijeysundera, Duminda N; Balasubramanian, Kumar; Duceppe, Emmanuelle; Miller, Scott; Diedericks, Johan; Devereaux, P J

2016-12-01

The PeriOperative ISchemia Evaluation-2 (POISE-2) trial compared aspirin with placebo after noncardiac surgery. The authors randomly assigned 10,010 patients undergoing noncardiac surgery to receive 200 mg aspirin or placebo 2 to 4 h before surgery and then 100 mg aspirin daily or placebo daily for up to 30 days after surgery. Herein, the authors report the effect of aspirin on venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, as well as an updated pooled analysis of randomized trials of antiplatelet therapy for VTE prevention in noncardiac surgery patients. Six thousand five hundred forty-eight patients (65.4%) received anticoagulant prophylaxis. VTE occurred in 53 patients (1.1%) allocated to aspirin and in 60 patients (1.2%) allocated to placebo (hazard ratio, 0.89; 95% CI, 0.61 to 1.28). Major or life-threatening bleeding occurred in 312 patients (6.3%) allocated to aspirin and in 256 patients (5.1%) allocated to placebo (hazard ratio, 1.22; 95% CI, 1.04 to 1.44). Concomitant use of anticoagulant prophylaxis did not modify the effect of aspirin on VTE or bleeding. Pooled analysis of the POISE-2 and Pulmonary Embolism Prevention trials demonstrated that symptomatic VTE occurred in 173 (1.3%) of 13,724 patients allocated to aspirin and in 246 (1.8%) of 13,730 patients allocated to placebo (odds ratio, 0.71; 95% CI, 0.56 to 0.89; heterogeneity P = 0.27; I = 17%); the impact of aspirin was very similar in those who did and did not receive pharmacologic prophylaxis. Pooled estimates for symptomatic VTE were similar to the pooled estimates for any deep vein thrombosis and pulmonary embolism from the POISE-2 trial, Pulmonary Embolism Prevention trial, and the Antiplatelet Trialists' Collaboration meta-analysis. Aspirin in the POISE-2 trial did not reduce VTE, but two thirds of patients received anticoagulant prophylaxis, there were few VTE events, and results were consistent with a wide range of aspirin effects. A pooled analysis of the randomized trials demonstrates evidence for the efficacy of aspirin for VTE prevention in hospitalized surgical patients.

Direct and indirect medical costs incurred by Canadian patients with rheumatoid arthritis: a 12 year study.

PubMed

Clarke, A E; Zowall, H; Levinton, C; Assimakopoulos, H; Sibley, J T; Haga, M; Shiroky, J; Neville, C; Lubeck, D P; Grover, S A; Esdaile, J M

1997-06-01

To perform the first prospective longitudinal study of direct (health services utilized) and indirect costs (diminished productivity represented by income loss) incurred by patients with rheumatoid arthritis (RA) in Saskatoon and Montreal, followed for up to 12 and 4 years, respectively. 1063 patients reported on health status, health services utilization, and diminished productivity every 6 months. Annual direct costs were $3788 (1994 Canadian dollars) in the late 1980s and $4656 in the early 1990s. Given that the average age exceeded 60 years, few participated in labor force activities or considered themselves disabled from the labor force and their indirect costs were substantially less, $2165 in the late 1980s and $1597 in the early 1990s. Institutional stays and medications made up at least 80% of total direct costs. Lengths of stay in acute care facilities remained constant, but the rate of hospitalization increased in the early 1990s, increasing average hospital costs per patient from $1563 in the late 1980s to $2023 in the early 1990s. For nonacute care facilities, rate of admission as well as length of stay increased over time, increasing costs per patient in Saskatoon 5-fold, from $291 to $1605. Those with greater functional disability incurred substantially higher direct and those under 65 years incurred higher indirect costs. Direct costs are higher than indirect costs. The major component is due to institutional stays that, in contrast to other direct cost components, is increased in the older and more disabled. Measures to reduce longterm disability by earlier, more aggressive intervention have the potential to produce considerable cost savings. However, it is unknown which strategies will have the greatest effect on outcome and accordingly, how resources can be optimally allocated.

Determining research priorities for young people with haematological cancer: a value-weighting approach.

PubMed

Clinton-McHarg, Tara; Paul, Christine; Sanson-Fisher, Rob; D'Este, Catherine; Williamson, Anna

2010-12-01

Haematological malignancies account for a third of all cancers affecting adolescents and young adults (AYAs). Funding agencies are regularly faced with the dilemma of how to deploy resources in order to provide the greatest possible benefit to this patient group. This study used a value-weighting approach to quantify the stakeholders' perceptions about how resources should be allocated to best improve outcomes for AYA patients and their families. One hundred and fifty seven participants (112 health care providers, researchers and other professionals and 45 patients and carers) were invited to complete a web-based value-weighting questionnaire and indicate how they would allocate 100 units of funding among various research approaches, areas and populations. Eighty participants (51%) completed the questionnaire. Strategic research was allocated a significantly higher proportion of funding than investigator-driven research. For research areas, clinical medicine and psychosocial research were allocated the highest proportion of funding. Within research populations, AYAs who were newly diagnosed, relapsed or finished treatment were allocated the largest proportion of funds. Psychosocial research which focussed on identifying risk and resilience, developing psychosocial measures, translating research into practice and improving the treatment centre was allocated funding slightly above other items, however the difference was not significant. To improve potential congruence between the views of stakeholders and funding agencies, research funding for AYA haematological cancer patients and their families could be targeted towards newly diagnosed patients and those who have relapsed. Research in the areas of clinical medicine and psychosocial care is perceived to be of utmost value. Copyright © 2010 Elsevier Ltd. All rights reserved.

Time allocation and dietary habits in the United States: Time for re-evaluation?

PubMed

Fiese, Barbara H

2018-02-21

In this non-exhaustive narrative review, time allocation and its relation to dietary habits are discussed. Drawing from reports relying on time use surveys, the amount of time dedicated to cooking and dining is found to be associated with health outcomes such as BMI and cardiovascular risk. Important modifiers include gender, race, ethnicity and household income. Perception of time intensity is also discussed. Individuals who perceive time pressure or strain may be less likely to engage in healthy food related activities and be at greater risk for poor health outcomes. Finally, the direct observation of allocation during meal occasions is discussed. The author calls for a socio-ecological approach to the study of time allocation and dietary habits in the United States and further consideration of direct observation of time use. Copyright © 2018 Elsevier Inc. All rights reserved.

Costs and cost-effectiveness of different DOT strategies for the treatment of tuberculosis in Pakistan. Directly Observed Treatment.

PubMed

Khan, M A; Walley, J D; Witter, S N; Imran, A; Safdar, N

2002-06-01

An economic study was conducted alongside a clinical trial at three sites in Pakistan to establish the costs and effectiveness of different strategies for implementing directly observed treatment (DOT) for tuberculosis. Patients were randomly allocated to one of three arms: DOTS with direct observation by health workers (at health centres or by community health workers); DOTS with direct observation by family members; and DOTS without direct observation. The clinical trial found no statistically significant difference in cure rate for the different arms. The economic study collected data on the full range of health service costs and patient costs of the different treatment arms. Data were also disaggregated by gender, rural and urban patients, by treatment site and by economic categories, to investigate the costs of the different strategies, their cost-effectiveness and the impact that they might have on patient compliance with treatment. The study found that direct observation by health centre-based health workers was the least cost-effective of the strategies tested (US dollars 310 per case cured). This is an interesting result, as this is the model recommended by the World Health Organization and International Union against Tuberculosis and Lung Disease. Attending health centres daily during the first 2 months generated high patient costs (direct and in terms of time lost), yet cure rates for this group fell below those of the non-observed group (58%, compared with 62%). One factor suggested by this study is that the high costs of attending may be deterring patients, and in particular, economically active patients who have most to lose from the time taken by direct observation. Without stronger evidence of benefits, it is hard to justify the costs to health services and patients that this type of direct observation imposes. The self-administered group came out as most cost-effective (164 dollars per case cured). The community health worker sub-group achieved the highest cure rates (67%), with a cost per case only slightly higher than the self-administered group (172 dollars per case cured). This approach should be investigated further, along with other approaches to improving patient compliance.

Makalu: fast recoverable allocation of non-volatile memory

DOE PAGES

Bhandari, Kumud; Chakrabarti, Dhruva R.; Boehm, Hans-J.

2016-10-19

Byte addressable non-volatile memory (NVRAM) is likely to supplement, and perhaps eventually replace, DRAM. Applications can then persist data structures directly in memory instead of serializing them and storing them onto a durable block device. However, failures during execution can leave data structures in NVRAM unreachable or corrupt. In this paper, we present Makalu, a system that addresses non-volatile memory management. Makalu offers an integrated allocator and recovery-time garbage collector that maintains internal consistency, avoids NVRAM memory leaks, and is efficient, all in the face of failures. We show that a careful allocator design can support a less restrictive andmore » a much more familiar programming model than existing persistent memory allocators. Our allocator significantly reduces the per allocation persistence overhead by lazily persisting non-essential metadata and by employing a post-failure recovery-time garbage collector. Experimental results show that the resulting online speed and scalability of our allocator are comparable to well-known transient allocators, and significantly better than state-of-the-art persistent allocators.« less

Makalu: fast recoverable allocation of non-volatile memory

DOE Office of Scientific and Technical Information (OSTI.GOV)

Bhandari, Kumud; Chakrabarti, Dhruva R.; Boehm, Hans-J.

Byte addressable non-volatile memory (NVRAM) is likely to supplement, and perhaps eventually replace, DRAM. Applications can then persist data structures directly in memory instead of serializing them and storing them onto a durable block device. However, failures during execution can leave data structures in NVRAM unreachable or corrupt. In this paper, we present Makalu, a system that addresses non-volatile memory management. Makalu offers an integrated allocator and recovery-time garbage collector that maintains internal consistency, avoids NVRAM memory leaks, and is efficient, all in the face of failures. We show that a careful allocator design can support a less restrictive andmore » a much more familiar programming model than existing persistent memory allocators. Our allocator significantly reduces the per allocation persistence overhead by lazily persisting non-essential metadata and by employing a post-failure recovery-time garbage collector. Experimental results show that the resulting online speed and scalability of our allocator are comparable to well-known transient allocators, and significantly better than state-of-the-art persistent allocators.« less

Liver transplant center variability in accepting organ offers and its impact on patient survival

PubMed Central

Goldberg, David S.; French, Benjamin; Lewis, James D.; Scott, Frank I; Mamtani, Ronac; Gilroy, Richard; Halpern, Scott D.; Abt, Peter L

2015-01-01

Background & Aims Despite an allocation system designed to give deceased-donor livers to the sickest patients, many transplantable livers are declined by U.S. transplant centers. It is unknown whether centers vary in their propensities to decline organs for the highest-priority patients, and how these decisions directly impact patient outcomes. Methods We analyzed Organ Procurement and Transplantation Network (OPTN) data from 5/1/07-6/17/13, and included all adult liver-alone waitlist candidates offered an organ that was ultimately transplanted. We evaluated acceptance rates of liver offers for the highest-ranked patients and their subsequent waitlist mortality. Results Of the 23,740 unique organ offers, 8,882 (37.4%) were accepted for the first-ranked patient. Despite adjusting for organ quality and recipient severity of illness, transplant centers within and across geographic regions varied strikingly (p<0.001) in the percentage of organ offers they accepted for the highest-priority patients. Among all patients ranked first on waitlists, the adjusted center-specific organ acceptance rates ranged from 15.7% to 58.1%. In multivariable models, there was a 27% increased odds of waitlist mortality for every 5% absolute decrease in a center’s adjusted organ offer acceptance rate (adjusted OR: 1.27, 95% CI: 1.20–1.32). However, the absolute difference in median 5-year adjusted graft survival was 4% between livers accepted for the first-ranked patient, compared to those declined and transplanted at a lower position. Discussion There is marked variability in center practices regarding accepting livers allocated to the highest-priority patients. Center-level decisions to decline organs substantially increased patients’ odds of dying on the waitlist without a transplant. PMID:26626495

An Integrated Model of Patient and Staff Satisfaction Using Queuing Theory

PubMed Central

Mousavi, Ali; Clarkson, P. John; Young, Terry

2015-01-01

This paper investigates the connection between patient satisfaction, waiting time, staff satisfaction, and service time. It uses a variety of models to enable improvement against experiential and operational health service goals. Patient satisfaction levels are estimated using a model based on waiting (waiting times). Staff satisfaction levels are estimated using a model based on the time spent with patients (service time). An integrated model of patient and staff satisfaction, the effective satisfaction level model, is then proposed (using queuing theory). This links patient satisfaction, waiting time, staff satisfaction, and service time, connecting two important concepts, namely, experience and efficiency in care delivery and leading to a more holistic approach in designing and managing health services. The proposed model will enable healthcare systems analysts to objectively and directly relate elements of service quality to capacity planning. Moreover, as an instrument used jointly by healthcare commissioners and providers, it affords the prospect of better resource allocation. PMID:27170899

An Integrated Model of Patient and Staff Satisfaction Using Queuing Theory.

PubMed

Komashie, Alexander; Mousavi, Ali; Clarkson, P John; Young, Terry

2015-01-01

This paper investigates the connection between patient satisfaction, waiting time, staff satisfaction, and service time. It uses a variety of models to enable improvement against experiential and operational health service goals. Patient satisfaction levels are estimated using a model based on waiting (waiting times). Staff satisfaction levels are estimated using a model based on the time spent with patients (service time). An integrated model of patient and staff satisfaction, the effective satisfaction level model, is then proposed (using queuing theory). This links patient satisfaction, waiting time, staff satisfaction, and service time, connecting two important concepts, namely, experience and efficiency in care delivery and leading to a more holistic approach in designing and managing health services. The proposed model will enable healthcare systems analysts to objectively and directly relate elements of service quality to capacity planning. Moreover, as an instrument used jointly by healthcare commissioners and providers, it affords the prospect of better resource allocation.

A Meta-Analysis of Self-Administered vs Directly Observed Therapy Effect on Microbiologic Failure, Relapse, and Acquired Drug Resistance in Tuberculosis Patients

PubMed Central

Pasipanodya, Jotam G.; Gumbo, Tawanda

2013-01-01

Background Preclinical studies and Monte Carlo simulations have suggested that there is a relatively limited role of adherence in acquired drug resistance (ADR) and that very high levels of nonadherence are needed for therapy failure. We evaluated the superiority of directly observed therapy (DOT) for tuberculosis patients vs self-administered therapy (SAT) in decreasing ADR, microbiologic failure, and relapse in meta-analyses. Methods Prospective studies performed between 1965 and 2012 in which adult patients with microbiologically proven pulmonary Mycobacterium tuberculosis were separately assigned to either DOT or SAT as part of short-course chemotherapy were chosen. Endpoints were microbiologic failure, relapse, and ADR in patients on either DOT or SAT. Results Ten studies, 5 randomized and 5 observational, met selection criteria: 8774 patients were allocated to DOT and 3708 were allocated to SAT. For DOT vs SAT, the pooled risk difference for microbiologic failure was .0 (95% confidence interval [CI], −.01 to .01), for relapse .01 (95% CI, −.03 to .06), and for ADR 0.0 (95% CI, −0.01 to 0.01). The incidence rates for DOT vs SAT were 1.5% (95% CI, 1.3%–1.8%) vs 1.7% (95% CI, 1.2%–2.2%) for microbiologic failure, 3.7% (95% CI, 0.7%–17.6%) vs 2.3% (95% CI, 0.7%–7.2%) for relapse, and 1.5% (95% CI, 0.2%–9.90%) vs 0.9% (95% CI, 0.4%–2.3%) for ADR, respectively. There was no evidence of publication bias. Conclusions DOT was not significantly better than SAT in preventing microbiologic failure, relapse, or ADR, in evidence-based medicine. Resources should be shifted to identify other causes of poor microbiologic outcomes. PMID:23487389

Gene expression information improves reliability of receptor status in breast cancer patients

PubMed Central

Kenn, Michael; Schlangen, Karin; Castillo-Tong, Dan Cacsire; Singer, Christian F.; Cibena, Michael; Koelbl, Heinz; Schreiner, Wolfgang

2017-01-01

Immunohistochemical (IHC) determination of receptor status in breast cancer patients is frequently inaccurate. Since it directs the choice of systemic therapy, it is essential to increase its reliability. We increase the validity of IHC receptor expression by additionally considering gene expression (GE) measurements. Crisp therapeutic decisions are based on IHC estimates, even if they are borderline reliable. We further improve decision quality by a responsibility function, defining a critical domain for gene expression. Refined normalization is devised to file any newly diagnosed patient into existing data bases. Our approach renders receptor estimates more reliable by identifying patients with questionable receptor status. The approach is also more efficient since the rate of conclusive samples is increased. We have curated and evaluated gene expression data, together with clinical information, from 2880 breast cancer patients. Combining IHC with gene expression information yields a method more reliable and also more efficient as compared to common practice up to now. Several types of possibly suboptimal treatment allocations, based on IHC receptor status alone, are enumerated. A ‘therapy allocation check’ identifies patients possibly miss-classified. Estrogen: false negative 8%, false positive 6%. Progesterone: false negative 14%, false positive 11%. HER2: false negative 2%, false positive 50%. Possible implications are discussed. We propose an ‘expression look-up-plot’, allowing for a significant potential to improve the quality of precision medicine. Methods are developed and exemplified here for breast cancer patients, but they may readily be transferred to diagnostic data relevant for therapeutic decisions in other fields of oncology. PMID:29100391

Physiotherapy after arthroscopic partial meniscectomy surgery: an assessment of costs to the National Health Service, patients, and society.

PubMed

Goodwin, Peter Charles; Ratcliffe, Julie; Morrissey, Matthew Charles

2005-01-01

The purpose of this study was to determine and inform clinicians, managers, and budget allocators of the costs incurred to the British National Health Service (NHS), patient, and society when attending clinic-based physiotherapy compared with not attending clinic-based physiotherapy after arthroscopic partial meniscectomy surgery. The valuation principle used in this study was the economic concept of opportunity cost. Costs were referred to as direct medical (NHS), direct nonmedical (patient), and indirect (societal) costs. Due to the difficulties of their measurement and valuation, intangible costs, in the form of pain and anxiety related to the effect of receiving or not receiving treatment, have not been considered in this analysis. Providing clinic-based physiotherapy after knee arthroscopic partial meniscectomy surgery is more costly to the NHS and patient, but no more costly to society than when not providing it and does not result in reduced contact with the NHS. Clinic-based physiotherapy after knee arthroscopic partial meniscectomy surgery is costly and evidence is needed that its effectiveness is high enough to support its use.

Use of the ‘Accountability for Reasonableness’ Approach to Improve Fairness in Accessing Dialysis in a Middle-Income Country

PubMed Central

Maree, Jonathan David; Chirehwa, Maxwell T.; Benatar, Solomon R.

2016-01-01

Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the ‘Accountability for Reasonableness’ (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible. PMID:27701466

Optimizing utilization of kidneys from deceased donors over 60 years: five-year outcomes after implementation of a combined clinical and histological allocation algorithm.

PubMed

Pierobon, Elisa Sefora; Sefora, Pierobon Elisa; Sandrini, Silvio; Silvio, Sandrini; De Fazio, Nicola; Nicola, De Fazio; Rossini, Giuseppe; Giuseppe, Rossini; Fontana, Iris; Iris, Fontana; Boschiero, Luigino; Luigino, Boschiero; Gropuzzo, Maria; Maria, Gropuzzo; Gotti, Eliana; Eliana, Gotti; Donati, Donato; Donato, Donati; Minetti, Enrico; Enrico, Minetti; Gandolfo, Maria Teresa; Teresa, Gandolfo Maria; Brunello, Anna; Anna, Brunello; Libetta, Carmelo; Carmelo, Libetta; Secchi, Antonio; Antonio, Secchi; Chiaramonte, Stefano; Stefano, Chiaramonte; Rigotti, Paolo; Paolo, Rigotti

2013-08-01

This 5 year observational multicentre study conducted in the Nord Italian Transplant programme area evaluated outcomes in patients receiving kidneys from donors over 60 years allocated according to a combined clinical and histological algorithm. Low-risk donors 60-69 years without risk factors were allocated to single kidney transplant (LR-SKT) based on clinical criteria. Biopsy was performed in donors over 70 years or 60-69 years with risk factors, allocated to Single (HR-SKT) or Dual kidney transplant (HR-DKT) according to the severity of histological damage. Forty HR-DKTs, 41 HR-SKTs and 234 LR-SKTs were evaluated. Baseline differences generally reflected stratification and allocation criteria. Patient and graft (death censored) survival were 90% and 92% for HR-DKT, 85% and 89% for HR-SKT, 88% and 87% for LR-SKT. The algorithm appeared user-friendly in daily practice and was safe and efficient, as demonstrated by satisfactory outcomes in all groups at 5 years. Clinical criteria performed well in low-risk donors. The excellent outcomes observed in DKTs call for fine-tuning of cut-off scores for allocation to DKT or SKT in high-risk patients. © 2013 Steunstichting ESOT. Published by John Wiley & Sons Ltd.

Art viewing directives in hospital settings effect on mood.

PubMed

Ho, Rainbow T H; Potash, Jordan S; Fang, Fan; Rollins, Judy

2015-01-01

The purpose of this study was to determine the effect viewing directives can have when encountering art in hospitals. A secondary objective of the study was to understand the responses of viewers to an art exhibit on the theme of medical student empathy toward patient pain and suffering. Displaying art in hospitals has been credited with increasing well-being of patients, visitors, and staff. Generally, hospital curators have focused on the type of art to display (natural, symbolic, and abstract). This focus has neglected the possibility that in addition to the type of art, the way that viewers engage art may also be responsible for the healing effect. Participants (n = 97) were randomly allocated into one of the viewing directives: (1) reflecting on one artwork, (2) creating a drawing or poem in response to one artwork, or (3) no direction. Prior to looking at the art and immediately after, participants were administered the Brief Mood Introspection Scale (BMIS) and offered an opportunity to participate in an interview. Pre-post results of the BMIS demonstrated that viewers who received directions achieved some therapeutic effect. Qualitative themes from the post-exhibit interviews identified that the empathy themed exhibit was well received, although there were differences among responses from patients, visitors, and staff. The results imply that hospitals may consider offering prompts to help viewers engage with art to enhance mood and exhibiting art that demonstrates empathy for patient suffering. © The Author(s) 2015.

Single-room usage patterns and allocation decision-making in an Australian public hospital: a sequential exploratory study.

PubMed

Bloomer, Melissa J; Lee, Susan F; Lewis, David P; Biro, Mary Anne; Moss, Cheryle

2016-08-01

The aims are to (1) measure occupancy rates of single and shared rooms; (2) compare single room usage patterns and (3) explore the practice, rationale and decision-making processes associated with single rooms; across one Australian public health service. There is a tendency in Australia and internationally to increase the proportion of single patient rooms in hospitals. To date there have been no Australian studies that investigate the use of single rooms in clinical practice. This study used a sequential exploratory design with data collected in 2014. A descriptive survey was used to measure the use of single rooms across a two-week time frame. Semi-structured interviews were undertaken with occupancy decision-makers to explore the practices, rationale decision-making process associated with single-room allocation. Total bed occupancy did not fall below 99·4% during the period of data collection. Infection control was the primary reason for patients to be allocated to a single room, however, the patterns varied according to ward type and single-room availability. For occupancy decision-makers, decisions about patient allocation was a complex and challenging process, influenced and complicated by numerous factors including occupancy rates, the infection status of the patient/s, funding and patient/family preference. Bed moves were common resulting from frequent re-evaluation of need. Apart from infection control mandates, there was little tangible evidence to guide decision-making about single-room allocation. Further work is necessary to assist nurses in their decision-making. There is a trend towards increasing the proportion of single rooms in new hospital builds. Coupled with the competing clinical demands for single room care, this study highlights the complexity of nursing decision-making about patient allocation to single rooms, an issue urgently requiring further attention. © 2016 John Wiley & Sons Ltd.

The impact of the lung allocation score on short-term transplantation outcomes: a multicenter study.

PubMed

Kozower, Benjamin D; Meyers, Bryan F; Smith, Michael A; De Oliveira, Nilto C; Cassivi, Stephen D; Guthrie, Tracey J; Wang, Honkung; Ryan, Beverly J; Shen, K Robert; Daniel, Thomas M; Jones, David R

2008-01-01

The lung allocation score restructured the distribution of scarce donor lungs for transplantation. The algorithm ranks waiting list patients according to medical urgency and expected benefit after transplantation. The purpose of this study was to evaluate the impact of the lung allocation score on short-term outcomes after lung transplantation. A multicenter retrospective cohort study was performed with data from 5 academic medical centers. Results of patients undergoing transplantation on the basis of the lung allocation score (May 4, 2005 to May 3, 2006) were compared with those of patients receiving transplants the preceding year before the lung allocation score was implemented (May 4, 2004, to May 3, 2005). The study reports on 341 patients (170 before the lung allocation score and 171 after). Waiting time decreased from 680.9 +/- 528.3 days to 445.6 +/- 516.9 days (P < .001). Recipient diagnoses changed with an increase in idiopathic pulmonary fibrosis and a decrease in emphysema and cystic fibrosis (P = .002). Postoperatively, primary graft dysfunction increased from 14.1% (24/170) to 22.9% (39/171) (P = .04) and intensive care unit length of stay increased from 5.7 +/- 6.7 days to 7.8 +/- 9.6 days (P = .04). Hospital mortality and 1-year survival were the same between groups (5.3% vs 5.3% and 90% vs 89%, respectively; P > .6) This multicenter retrospective review of short-term outcomes supports the fact that the lung allocation score is achieving its objectives. The lung allocation score reduced waiting time and altered the distribution of lung diseases for which transplantation was done on the basis of medical necessity. After transplantation, recipients have significantly higher rates of primary graft dysfunction and intensive care unit lengths of stay. However, hospital mortality and 1-year survival have not been adversely affected.

Joint Rhythmic Movement Increases 4-Year-Old Children's Prosocial Sharing and Fairness Toward Peers.

PubMed

Rabinowitch, Tal-Chen; Meltzoff, Andrew N

2017-01-01

The allocation of resources to a peer partner is a prosocial act that is of fundamental importance. Joint rhythmic movement, such as occurs during musical interaction, can induce positive social experiences, which may play a role in developing and enhancing young children's prosocial skills. Here, we investigated whether joint rhythmic movement, free of musical context, increases 4-year-olds' sharing and sense of fairness in a resource allocation task involving peers. We developed a precise procedure for administering joint synchronous experience, joint asynchronous experience, and a baseline control involving no treatment. Then we tested how participants allocated resources between self and peer. We found an increase in the generous allocation of resources to peers following both synchronous and asynchronous movement compared to no treatment. At a more theoretical level, this result is considered in relation to previous work testing other aspects of child prosociality, for example, peer cooperation, which can be distinguished from judgments of fairness in resource allocation tasks. We draw a conceptual distinction between two types of prosocial behavior: resource allocation (an other-directed individual behavior) and cooperation (a goal-directed collaborative endeavor). Our results highlight how rhythmic interactions, which are prominent in joint musical engagements and synchronized activity, influence prosocial behavior between preschool peers.

Joint Rhythmic Movement Increases 4-Year-Old Children’s Prosocial Sharing and Fairness Toward Peers

PubMed Central

Rabinowitch, Tal-Chen; Meltzoff, Andrew N.

2017-01-01

The allocation of resources to a peer partner is a prosocial act that is of fundamental importance. Joint rhythmic movement, such as occurs during musical interaction, can induce positive social experiences, which may play a role in developing and enhancing young children’s prosocial skills. Here, we investigated whether joint rhythmic movement, free of musical context, increases 4-year-olds’ sharing and sense of fairness in a resource allocation task involving peers. We developed a precise procedure for administering joint synchronous experience, joint asynchronous experience, and a baseline control involving no treatment. Then we tested how participants allocated resources between self and peer. We found an increase in the generous allocation of resources to peers following both synchronous and asynchronous movement compared to no treatment. At a more theoretical level, this result is considered in relation to previous work testing other aspects of child prosociality, for example, peer cooperation, which can be distinguished from judgments of fairness in resource allocation tasks. We draw a conceptual distinction between two types of prosocial behavior: resource allocation (an other-directed individual behavior) and cooperation (a goal-directed collaborative endeavor). Our results highlight how rhythmic interactions, which are prominent in joint musical engagements and synchronized activity, influence prosocial behavior between preschool peers. PMID:28694786

The Clots in Legs Or sTockings after Stroke (CLOTS) 3 trial: a randomised controlled trial to determine whether or not intermittent pneumatic compression reduces the risk of post-stroke deep vein thrombosis and to estimate its cost-effectiveness.

PubMed

Dennis, Martin; Sandercock, Peter; Graham, Catriona; Forbes, John; Smith, J

2015-09-01

Venous thromboembolism (VTE) is a common cause of death and morbidity in stroke patients. There are few data concerning the effectiveness of intermittent pneumatic compression (IPC) in treating patients with stroke. To establish whether or not the application of IPC to the legs of immobile stroke patients reduced their risk of deep vein thrombosis (DVT). Clots in Legs Or sTockings after Stroke (CLOTS) 3 was a multicentre, parallel-group, randomised controlled trial which allocated patients via a central randomisation system to IPC or no IPC. A technician blinded to treatment allocation performed compression duplex ultrasound (CDU) of both legs at 7-10 days and 25-30 days after enrolment. We followed up patients for 6 months to determine survival and later symptomatic VTE. Patients were analysed according to their treatment allocation. We enrolled 2876 patients in 94 UK hospitals between 8 December 2008 and 6 September 2012. patients admitted to hospital within 3 days of acute stroke and who were immobile on the day of admission (day 0) to day 3. age < 16 years; subarachnoid haemorrhage; and contra-indications to IPC including dermatitis, leg ulcers, severe oedema, severe peripheral vascular disease and congestive cardiac failure. Participants were allocated to routine care or routine care plus IPC for 30 days, or until earlier discharge or walking independently. The primary outcome was DVT in popliteal or femoral veins, detected on a screening CDU, or any symptomatic DVT in the proximal veins, confirmed by imaging, within 30 days of randomisation. The secondary outcomes included death, any DVTs, symptomatic DVTs, pulmonary emboli, skin breaks on the legs, falls with injury or fractures and duration of IPC use occurring within 30 days of randomisation and survival, symptomatic VTE, disability (as measured by the Oxford Handicap Scale), quality of life (as measured by the European Quality of Life-5 Dimensions 3 Level questionnaire) and length of initial hospital stay measured 6 months after randomisation. We allocated 1438 patients to IPC and 1438 to no IPC. The primary outcome occurred in 122 (8.5%) of 1438 patients allocated to IPC and 174 (12.1%) of 1438 patients allocated to no IPC, giving an absolute reduction in risk of 3.6% [95% confidence interval (CI) 1.4% to 5.8%] and a relative risk reduction of 0.69 (95% CI 0.55 to 0.86). After excluding 323 patients who died prior to any primary outcome and 41 who had no screening CDU, the primary outcome occurred in 122 of 1267 IPC participants compared with 174 of 1245 no-IPC participants, giving an adjusted odds ratio of 0.65 (95% CI 0.51 to 0.84; p = 0.001). Secondary outcomes in IPC compared with no-IPC participants were death in the treatment period in 156 (10.8%) versus 189 (13.1%) (p = 0.058); skin breaks in 44 (3.1%) versus 20 (1.4%) (p = 0.002); and falls with injury in 33 (2.3%) versus 24 (1.7%) (p = 0.221). Among patients treated with IPC, there was a statistically significant improvement in survival to 6 months (hazard ratio 0.86, 95% CI 0.73 to 0.99; p = 0.042), but no improvement in disability. The direct cost of preventing a DVT was £1282 per event (95% CI £785 to £3077). IPC is an effective and inexpensive method of reducing the risk of DVT and improving survival in immobile stroke patients. Further research should test whether or not IPC improves survival in other groups of high-risk hospitalised medical patients. In addition, research into methods to improve adherence to IPC might increase the benefits of IPC in stroke patients. Current Controlled Trials ISRCTN93529999. The start-up phase of the trial (December 2008-March 2010) was funded by the Chief Scientist Office of the Scottish Government (reference number CZH/4/417). The main phase of the trial was funded by the National Institute for Health Research Health Technology Assessment programme (reference number 08/14/03). Covidien Ltd (Mansfield, MA, USA) lent its Kendall SCD™ Express sequential compression system controllers to the 105 centres involved in the trial and donated supplies of its sleeves. It also provided logistical help in keeping our centres supplied with sleeves and training materials relevant to the use of their devices. Recruitment and follow-up were supported by the National Institute for Health Research-funded UK Stroke Research Network and by the Scottish Stroke Research Network, which was supported by NHS Research Scotland.

Concept for individualized patient allocation: ReCompare—remote comparison of particle and photon treatment plans

PubMed Central

2014-01-01

Background Identifying those patients who have a higher chance to be cured with fewer side effects by particle beam therapy than by state-of-the-art photon therapy is essential to guarantee a fair and sufficient access to specialized radiotherapy. The individualized identification requires initiatives by particle as well as non-particle radiotherapy centers to form networks, to establish procedures for the decision process, and to implement means for the remote exchange of relevant patient information. In this work, we want to contribute a practical concept that addresses these requirements. Methods We proposed a concept for individualized patient allocation to photon or particle beam therapy at a non-particle radiotherapy institution that bases on remote treatment plan comparison. We translated this concept into the web-based software tool ReCompare (REmote COMparison of PARticlE and photon treatment plans). Results We substantiated the feasibility of the proposed concept by demonstrating remote exchange of treatment plans between radiotherapy institutions and the direct comparison of photon and particle treatment plans in photon treatment planning systems. ReCompare worked with several tested standard treatment planning systems, ensured patient data protection, and integrated in the clinical workflow. Conclusions Our concept supports non-particle radiotherapy institutions with the patient-specific treatment decision on the optimal irradiation modality by providing expertise from a particle therapy center. The software tool ReCompare may help to improve and standardize this personalized treatment decision. It will be available from our website when proton therapy is operational at our facility. PMID:24548333

Dynamic Changes in Phase-Amplitude Coupling Facilitate Spatial Attention Control in Fronto-Parietal Cortex

PubMed Central

Szczepanski, Sara M.; Crone, Nathan E.; Kuperman, Rachel A.; Auguste, Kurtis I.; Parvizi, Josef; Knight, Robert T.

2014-01-01

Attention is a core cognitive mechanism that allows the brain to allocate limited resources depending on current task demands. A number of frontal and posterior parietal cortical areas, referred to collectively as the fronto-parietal attentional control network, are engaged during attentional allocation in both humans and non-human primates. Numerous studies have examined this network in the human brain using various neuroimaging and scalp electrophysiological techniques. However, little is known about how these frontal and parietal areas interact dynamically to produce behavior on a fine temporal (sub-second) and spatial (sub-centimeter) scale. We addressed how human fronto-parietal regions control visuospatial attention on a fine spatiotemporal scale by recording electrocorticography (ECoG) signals measured directly from subdural electrode arrays that were implanted in patients undergoing intracranial monitoring for localization of epileptic foci. Subjects (n = 8) performed a spatial-cuing task, in which they allocated visuospatial attention to either the right or left visual field and detected the appearance of a target. We found increases in high gamma (HG) power (70–250 Hz) time-locked to trial onset that remained elevated throughout the attentional allocation period over frontal, parietal, and visual areas. These HG power increases were modulated by the phase of the ongoing delta/theta (2–5 Hz) oscillation during attentional allocation. Critically, we found that the strength of this delta/theta phase-HG amplitude coupling predicted reaction times to detected targets on a trial-by-trial basis. These results highlight the role of delta/theta phase-HG amplitude coupling as a mechanism for sub-second facilitation and coordination within human fronto-parietal cortex that is guided by momentary attentional demands. PMID:25157678

Social communication with virtual agents: The effects of body and gaze direction on attention and emotional responding in human observers.

PubMed

Marschner, Linda; Pannasch, Sebastian; Schulz, Johannes; Graupner, Sven-Thomas

2015-08-01

In social communication, the gaze direction of other persons provides important information to perceive and interpret their emotional response. Previous research investigated the influence of gaze by manipulating mutual eye contact. Therefore, gaze and body direction have been changed as a whole, resulting in only congruent gaze and body directions (averted or directed) of another person. Here, we aimed to disentangle these effects by using short animated sequences of virtual agents posing with either direct or averted body or gaze. Attention allocation by means of eye movements, facial muscle response, and emotional experience to agents of different gender and facial expressions were investigated. Eye movement data revealed longer fixation durations, i.e., a stronger allocation of attention, when gaze and body direction were not congruent with each other or when both were directed towards the observer. This suggests that direct interaction as well as incongruous signals increase the demands of attentional resources in the observer. For the facial muscle response, only the reaction of muscle zygomaticus major revealed an effect of body direction, expressed by stronger activity in response to happy expressions for direct compared to averted gaze when the virtual character's body was directed towards the observer. Finally, body direction also influenced the emotional experience ratings towards happy expressions. While earlier findings suggested that mutual eye contact is the main source for increased emotional responding and attentional allocation, the present results indicate that direction of the virtual agent's body and head also plays a minor but significant role. Copyright © 2015 Elsevier B.V. All rights reserved.

The ontogeny of postmaturation resource allocation in turtles.

PubMed

Bowden, R M; Paitz, Ryan T; Janzen, Fredric J

2011-01-01

Resource-allocation decisions vary with life-history strategy, and growing evidence suggests that long-lived endothermic vertebrates direct resources toward growth and self-maintenance when young, increasing allocation toward reproductive effort over time. Few studies have tracked the ontogeny of resource allocation (energy, steroid hormones, etc.) in long-lived ectothermic vertebrates, limiting our understanding of the generality of life-history strategies among vertebrates. We investigated how reproductively mature female painted turtles (Chrysemys picta) from two distinct age classes allocated resources over a 4-yr period and whether resource-allocation patterns varied with nesting experience. We examined age-related variation in body size, egg mass, reproductive frequency, and yolk steroids and report that younger females were smaller and allocated fewer resources to reproduction than did older females. Testosterone levels were higher in eggs from younger females, whereas eggs from second (seasonal) clutches contained higher concentrations of progesterone and estradiol. These allocation patterns resulted in older, larger females laying larger eggs and producing second clutches more frequently than their younger counterparts. We conclude that resource-allocation patterns do vary with age in a long-lived ectotherm.

Risk and the physics of clinical prediction.

PubMed

McEvoy, John W; Diamond, George A; Detrano, Robert C; Kaul, Sanjay; Blaha, Michael J; Blumenthal, Roger S; Jones, Steven R

2014-04-15

The current paradigm of primary prevention in cardiology uses traditional risk factors to estimate future cardiovascular risk. These risk estimates are based on prediction models derived from prospective cohort studies and are incorporated into guideline-based initiation algorithms for commonly used preventive pharmacologic treatments, such as aspirin and statins. However, risk estimates are more accurate for populations of similar patients than they are for any individual patient. It may be hazardous to presume that the point estimate of risk derived from a population model represents the most accurate estimate for a given patient. In this review, we exploit principles derived from physics as a metaphor for the distinction between predictions regarding populations versus patients. We identify the following: (1) predictions of risk are accurate at the level of populations but do not translate directly to patients, (2) perfect accuracy of individual risk estimation is unobtainable even with the addition of multiple novel risk factors, and (3) direct measurement of subclinical disease (screening) affords far greater certainty regarding the personalized treatment of patients, whereas risk estimates often remain uncertain for patients. In conclusion, shifting our focus from prediction of events to detection of disease could improve personalized decision-making and outcomes. We also discuss innovative future strategies for risk estimation and treatment allocation in preventive cardiology. Copyright © 2014 Elsevier Inc. All rights reserved.

Stochastic resource allocation in emergency departments with a multi-objective simulation optimization algorithm.

PubMed

Feng, Yen-Yi; Wu, I-Chin; Chen, Tzu-Li

2017-03-01

The number of emergency cases or emergency room visits rapidly increases annually, thus leading to an imbalance in supply and demand and to the long-term overcrowding of hospital emergency departments (EDs). However, current solutions to increase medical resources and improve the handling of patient needs are either impractical or infeasible in the Taiwanese environment. Therefore, EDs must optimize resource allocation given limited medical resources to minimize the average length of stay of patients and medical resource waste costs. This study constructs a multi-objective mathematical model for medical resource allocation in EDs in accordance with emergency flow or procedure. The proposed mathematical model is complex and difficult to solve because its performance value is stochastic; furthermore, the model considers both objectives simultaneously. Thus, this study develops a multi-objective simulation optimization algorithm by integrating a non-dominated sorting genetic algorithm II (NSGA II) with multi-objective computing budget allocation (MOCBA) to address the challenges of multi-objective medical resource allocation. NSGA II is used to investigate plausible solutions for medical resource allocation, and MOCBA identifies effective sets of feasible Pareto (non-dominated) medical resource allocation solutions in addition to effectively allocating simulation or computation budgets. The discrete event simulation model of ED flow is inspired by a Taiwan hospital case and is constructed to estimate the expected performance values of each medical allocation solution as obtained through NSGA II. Finally, computational experiments are performed to verify the effectiveness and performance of the integrated NSGA II and MOCBA method, as well as to derive non-dominated medical resource allocation solutions from the algorithms.

TraPy-MAC: Traffic Priority Aware Medium Access Control Protocol for Wireless Body Area Network.

PubMed

Ullah, Fasee; Abdullah, Abdul Hanan; Kaiwartya, Omprakash; Cao, Yue

2017-06-01

Recently, Wireless Body Area Network (WBAN) has witnessed significant attentions in research and product development due to the growing number of sensor-based applications in healthcare domain. Design of efficient and effective Medium Access Control (MAC) protocol is one of the fundamental research themes in WBAN. Static on-demand slot allocation to patient data is the main approach adopted in the design of MAC protocol in literature, without considering the type of patient data specifically the level of severity on patient data. This leads to the degradation of the performance of MAC protocols considering effectiveness and traffic adjustability in realistic medical environments. In this context, this paper proposes a Traffic Priority-Aware MAC (TraPy-MAC) protocol for WBAN. It classifies patient data into emergency and non-emergency categories based on the severity of patient data. The threshold value aided classification considers a number of parameters including type of sensor, body placement location, and data transmission time for allocating dedicated slots patient data. Emergency data are not required to carry out contention and slots are allocated by giving the due importance to threshold value of vital sign data. The contention for slots is made efficient in case of non-emergency data considering threshold value in slot allocation. Moreover, the slot allocation to emergency and non-emergency data are performed parallel resulting in performance gain in channel assignment. Two algorithms namely, Detection of Severity on Vital Sign data (DSVS), and ETS Slots allocation based on the Severity on Vital Sign (ETS-SVS) are developed for calculating threshold value and resolving the conflicts of channel assignment, respectively. Simulations are performed in ns2 and results are compared with the state-of-the-art MAC techniques. Analysis of results attests the benefit of TraPy-MAC in comparison with the state-of-the-art MAC in channel assignment in realistic medical environments.

"Not clinically indicated": patients' interests or resource allocation?

PubMed Central

Hope, T; Sprigings, D; Crisp, R

1993-01-01

The decision that a particular intervention is not clinically indicated may conceal two quite different ethical assumptions. The first assumption is that the intervention is not of overall benefit to this patient. The second is that limited resources should not be used for this patient. These issues are discussed with reference to cardiac surgery in elderly patients with reference to the main theories of allocation: QALYs, needs theories, the sanctity of life theory, the lottery theory, and market forces. Images p380-a PMID:8461686

Randomised clinical trials with clinician-preferred treatment.

PubMed

Korn, E L; Baumrind, S

1991-01-19

The standard design for randomised clinical trials may be inappropriate when the clinician believes that one of the treatments being tested is superior for the patient, or when the clinician has a preference for one of the treatments. For such instances the suggestion is that the patient is randomly allocated to treatment only when there is clinical disagreement about treatment of choice for that patient, and then the patient is assigned to a clinician who had thought that the regimen allocated is the one most appropriate for that patient.

78 FR 15705 - Proposed Information Collection; Comment Request; American Fisheries Act (AFA): Permits

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-12

... 13, 2013. ADDRESSES: Direct all written comments to Jennifer Jessup, Departmental Paperwork Clearance... allocations to eligible entities representing the catcher/processor sector, the mothership sector, inshore cooperatives, and Community Development Quota (CDQ) groups. Transferable allocations provide the pollock fleet...

Specific cognitive-neurophysiological processes predict impulsivity in the childhood attention-deficit/hyperactivity disorder combined subtype.

PubMed

Bluschke, A; Roessner, V; Beste, C

2016-04-01

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent neuropsychiatric disorders in childhood. Besides inattention and hyperactivity, impulsivity is the third core symptom leading to diverse and serious problems. However, the neuronal mechanisms underlying impulsivity in ADHD are still not fully understood. This is all the more the case when patients with the ADHD combined subtype (ADHD-C) are considered who are characterized by both symptoms of inattention and hyperactivity/impulsivity. Combining high-density electroencephalography (EEG) recordings with source localization analyses, we examined what information processing stages are dysfunctional in ADHD-C (n = 20) compared with controls (n = 18). Patients with ADHD-C made more impulsive errors in a Go/No-go task than healthy controls. Neurophysiologically, different subprocesses from perceptual gating to attentional selection, resource allocation and response selection processes are altered in this patient group. Perceptual gating, stimulus-driven attention selection and resource allocation processes were more pronounced in ADHD-C, are related to activation differences in parieto-occipital networks and suggest attentional filtering deficits. However, only response selection processes, associated with medial prefrontal networks, predicted impulsive errors in ADHD-C. Although the clinical picture of ADHD-C is complex and a multitude of processing steps are altered, only a subset of processes seems to directly modulate impulsive behaviour. The present findings improve the understanding of mechanisms underlying impulsivity in patients with ADHD-C and might help to refine treatment algorithms focusing on impulsivity.

How the definition of acceptable antigens and epitope analysis can facilitate transplantation of highly sensitized patients with excellent long-term graft survival.

PubMed

Heidt, Sebastiaan; Haasnoot, Geert W; Claas, Frans H J

2018-05-24

Highly sensitized patients awaiting a renal transplant have a low chance of receiving an organ offer. Defining acceptable antigens and using this information for allocation purposes can vastly enhance transplantation of this subgroup of patients, which is the essence of the Eurotransplant Acceptable Mismatch program. Acceptable antigens can be determined by extensive laboratory testing, as well as on basis of human leukocyte antigen (HLA) epitope analyses. Within the Acceptable Mismatch program, there is no effect of HLA mismatches on long-term graft survival. Furthermore, patients transplanted through the Acceptable Mismatch program have similar long-term graft survival to nonsensitized patients transplanted through regular allocation. Although HLA epitope analysis is already being used for defining acceptable HLA antigens for highly sensitized patients in the Acceptable Mismatch program, increasing knowledge on HLA antibody - epitope interactions will pave the way toward the definition of acceptable epitopes for highly sensitized patients in the future. Allocation based on acceptable antigens can facilitate transplantation of highly sensitized patients with excellent long-term graft survival.

23 CFR 660.107 - Allocations.

Code of Federal Regulations, 2011 CFR

2011-04-01

... HIGHWAY ADMINISTRATION, DEPARTMENT OF TRANSPORTATION ENGINEERING AND TRAFFIC OPERATIONS SPECIAL PROGRAMS (DIRECT FEDERAL) Forest Highways § 660.107 Allocations. On October 1 of each fiscal year, the FHWA will... requirements of the FHWA and the FS; the necessary costs of FH planning studies; and the FH share of costs for...

75 FR 33384 - Proposed Collection; Comment Request for Regulation Project

Federal Register 2010, 2011, 2012, 2013, 2014

2010-06-11

... 8228; TD 8410), Allocation and Apportionment of Interest Expense and Certain Other Expenses (Sec. Sec... to be assured of consideration. ADDRESSES: Direct all written comments to Gerald J. Shields, Internal...: Allocation and Apportionment of Interest Expense and Certain Other Expenses. OMB Number: 1545-1072...

Direct Hospital Cost of Outcome Pathways in Implant-Based Reconstruction with Acellular Dermal Matrices.

PubMed

Qureshi, Ali A; Broderick, Kristen; Funk, Susan; Reaven, Nancy; Tenenbaum, Marissa M; Myckatyn, Terence M

2016-08-01

Current cost data on tissue expansion followed by exchange for permanent implant (TE/I) reconstruction lack a necessary assessment of the experience of a heterogenous breast cancer patient population and their multiple outcome pathways. We extend our previous analysis to that of direct hospital cost as bundling of payments is likely to follow the changing centralization of cancer care at the hospital level. We performed a retrospective analysis (2003-2009) of TE/I reconstructions with or without an acellular dermal matrix (ADM), namely Alloderm RTM. Postreconstructive events were analyzed and organized into outcome pathways as previously described. Aggregated and normalized inpatient and outpatient hospital direct costs and physician reimbursement were generated for each outcome pathway with or without ADM. Three hundred sixty-seven patients were analyzed. The average 2-year hospital direct cost per TE/I breast reconstruction patient was $11,862 in the +ADM and $12,319 in the -ADM groups (P > 0.05). Initial reconstructions were costlier in the +ADM ($6,868) than in the -ADM ($5,615) group, but the average cost of subsequent postreconstructive events within 2 years was significantly lower in +ADM ($5,176) than -ADM ($6,704) patients (P < 0.05). When a complication occurred, but reconstruction was still completed within 2 years, greater costs were incurred in the -ADM than in the +ADM group for most scenarios, leading to a net equalization of cost between study groups. Although direct hospital cost is an important factor for resource and fund allocation, it should not remain the sole factor when deciding to use ADM in TE/I reconstruction.

How much time does it take to prescribe a new medication?

PubMed

Tarn, Derjung M; Paterniti, Debora A; Kravitz, Richard L; Heritage, John; Liu, Honghu; Kim, Sue; Wenger, Neil S

2008-08-01

To measure the length of time spent discussing all aspects of new prescriptions and guideline-recommended aspects of counseling, and to evaluate factors associated with duration of discussion. We analyzed tape recordings in which 181 patients received 234 new medication prescriptions from 16 family physicians, 18 internists, and 11 cardiologists in 2 healthcare systems in Sacramento, California between January and November 1999. Of the mean total visit time of 15.9min (S.D.=434s), a mean of 26s (S.D.=28s) was allocated to guideline-recommended components and a mean of 23s (S.D.=25s) was allocated to discussion of all other aspects of new prescription medications. The majority of time spent discussing individual new prescriptions was dedicated to: medication purpose or justification, directions and duration of use, and side effects. On average, more complete discussion of these components was associated with more time. More time was spent talking about guideline-recommended information if patients were in better health, if there was a third party in the room, and if the medication belonged to a psychiatric, compared to an ear, nose, throat medication class. Less time was spent discussing over-the-counter (OTC) medications and those prescribed to patients with a previous visit to the physician. Higher quality information transmission between physicians and patients about new medications requires more time, and may be difficult to achieve in short office visits. Time-compressed office visits may need to be redesigned to promote improved provider-patient communication about new medications.

How Much Time Does It Take to Prescribe a New Medication?

PubMed Central

Tarn, Derjung M.; Paterniti, Debora A.; Kravitz, Richard L.; Heritage, John; Liu, Honghu; Kim, Sue; Wenger, Neil S.

2008-01-01

Objective To measure the length of time spent discussing all aspects of new prescriptions and guideline-recommended aspects of counseling, and to evaluate factors associated with duration of discussion. Methods We analyzed tape recordings in which 181 patients received 234 new medication prescriptions from 16 family physicians, 18 internists, and 11 cardiologists in 2 healthcare systems in Sacramento, California between January and November 1999. Results Of the mean total visit time of 15.9 minutes (SD=434 seconds), a mean of 26 seconds (SD=28 seconds) was allocated to guideline-recommended components and a mean of 23 seconds (SD=25 seconds) was allocated to discussion of all other aspects of new prescription medications. The majority of time spent discussing individual new prescriptions was dedicated to: medication purpose or justification, directions and duration of use, and side effects. On average, more complete discussion of these components was associated with more time. More time was spent talking about guideline-recommended information if patients were in better health, if there was a third party in the room, and if the medication belonged to a psychiatric, compared to an ear, nose, throat medication class. Less time was spent discussing over-the-counter medications and those prescribed to patients with a previous visit to the physician. Conclusion Higher quality information transmission between physicians and patients about new medications requires more time, and may be difficult to achieve in short office visits. Practice Implications Time-compressed office visits may need to be redesigned to promote improved provider-patient communication about new medications. PMID:18406562

eHealth literacy, Internet and eHealth service usage: a survey among cancer patients and their relatives.

PubMed

Halwas, Nikolaus; Griebel, Lena; Huebner, Jutta

2017-11-01

The aim of our study was to investigate Internet and eHealth usage, with respect to eHealth literacy, by cancer patients and their relatives. Using a standardized questionnaire we asked patients who attended lectures on complementary medicine in 2016. We received 142 questionnaires. The frequency of general Internet usage was directly associated with younger age and better Internet connection. Younger participants were not only more confident in allocating health-related Internet information into reliable or unreliable facts, but also more confident and capable of gaining medical knowledge through eHealth services. A regular use of eHealth services facilitated the decision-making process. Reading ability was associated with a better understanding regarding eHealth offers. In a modern health care system, emphasis should be on skills contributing to eHealth literacy among patients to improve their ability to profit from eHealth offers and improve health care.

Representing target motion: the role of the right hemisphere in the forward displacement bias.

PubMed

McGeorge, Peter; Beschin, Nicoletta; Della Sala, Sergio

2006-11-01

Patients with left spatial neglect, patients with right hemisphere damage but no neglect, and a control group were asked to judge the final position of a series of moving targets. Both patient groups showed attentional deficits. All 3 groups demonstrated a forward displacement bias, overestimating the final target position along the object trajectory. However, in both patient groups the size of this forward displacement bias decreased as the distance the target traveled before vanishing increased. For horizontally moving targets, at the maximum distance only the control group showed significant forward displacement. For all 3 groups, the direction in which the target traveled had no influence, but the size of the forward displacement increased as target speed increased. Several attentional explanations of these results are considered, including the differential allocation of spatial attention between central and peripheral locations, differences between exogenous and endogenous attention, and deficits in sustained attention.

Organ Allocation for Liver Transplantation According to the Public Opinion

PubMed Central

Danesh, Ahmad; Nedjat, Saharnaz; Asghari, Fariba; Jafarian, Ali; Fotouhi, Akbar

2012-01-01

Background Although liver transplantation is the last resort for treating end stage liver diseases, this medical procedure is not available for all needful patients because of inadequate organ supply. Therefore, guidelines have been developed by medical experts to regulate the process. Some professionals believe that medical criteria are inadequate for organ allocation in all situations and may not secure fairness of organ allocation. Objectives The current study has been designed to identify decision criteria about allocation of donated liver to potential recipients from public points of view. Patients and Methods This is a qualitative study that was conducted through individual interviews and Focus Group Discussions. Individual interviews were conducted among patients’ companions and nurses in one of the two liver transplant centers in Iran. Group discussions were conducted among groups of ordinary people who had not dealt previously with the subject. Data was analyzed by Thematic Analysis method. Results Most of the participants in this study believe that in equal medical conditions, some individual and societal criteria could be used to prioritize patients for receiving donated livers. The criteria include psychological acceptance, ability to pay post-operative care costs, being breadwinner of the family, family support, being socially valued, ability to be instructed, lack of mental disorders, young age of the recipient, being on waiting list for a long time, lack of patient’s role in causing the illness, first time transplant recipient, critical medical condition, high success rate of transplantation, lack of concurrent medical illnesses, not being an inmate at the time of receiving transplant, and bearing Iranian nationality. Conclusions Taking public opinion into consideration may smooth the process of organ allocation to needful patients with equal medical conditions. It seems that considering these viewpoints in drafting organ allocation guidelines may increase confidence of the society to the equity of organ allocation in the country. This strategy may also persuade people to donate organs particularly after death. PMID:23087752

Patient education-level affects treatment allocation and prognosis in esophageal- and gastroesophageal junctional cancer in Sweden.

PubMed

Linder, Gustav; Sandin, Fredrik; Johansson, Jan; Lindblad, Mats; Lundell, Lars; Hedberg, Jakob

2018-02-01

Low socioeconomic status and poor education elevate the risk of developing esophageal- and junctional cancer. High education level also increases survival after curative surgery. The present study aimed to investigate associations, if any, between patient education-level and treatment allocation after diagnosis of esophageal- and junctional cancer and its subsequent impact on survival. A nation-wide cohort study was undertaken. Data from a Swedish national quality register for esophageal cancer (NREV) was linked to the National Cancer Register, National Patient Register, Prescribed Drug Register, Cause of Death Register and educational data from Statistics Sweden. The effect of education level (low; ≤9 years, intermediate; 10-12 years and high >12 years) on the probability of allocation to curative treatment was analyzed with logistic regression. The Kaplan-Meier-method and Cox proportional hazard models were used to assess the effect of education on survival. A total of 4112 patients were included. In a multivariate logistic regression model, high education level was associated with greater probability of allocation to curative treatment (adjusted OR: 1.48, 95% CI: 1.08-2.03, p = 0,014) as was adherence to a multidisciplinary treatment-conference (adjusted OR: 3.13, 95% CI: 2.40-4.08, p < 0,001). High education level was associated with improved survival in the patients allocated to curative treatment (HR: 0.82, 95% CI: 0.69-0.99, p = 0,036). In this nation-wide cohort of esophageal- and junctional cancer patients, including data regarding many confounders, high education level was associated with greater probability of being offered curative treatment and improved survival. Copyright © 2017 Elsevier Ltd. All rights reserved.

Probabilistic resource allocation system with self-adaptive capability

NASA Technical Reports Server (NTRS)

Yufik, Yan M. (Inventor)

1996-01-01

A probabilistic resource allocation system is disclosed containing a low capacity computational module (Short Term Memory or STM) and a self-organizing associative network (Long Term Memory or LTM) where nodes represent elementary resources, terminal end nodes represent goals, and directed links represent the order of resource association in different allocation episodes. Goals and their priorities are indicated by the user, and allocation decisions are made in the STM, while candidate associations of resources are supplied by the LTM based on the association strength (reliability). Reliability values are automatically assigned to the network links based on the frequency and relative success of exercising those links in the previous allocation decisions. Accumulation of allocation history in the form of an associative network in the LTM reduces computational demands on subsequent allocations. For this purpose, the network automatically partitions itself into strongly associated high reliability packets, allowing fast approximate computation and display of allocation solutions satisfying the overall reliability and other user-imposed constraints. System performance improves in time due to modification of network parameters and partitioning criteria based on the performance feedback.

Cost of care of haemophilia with inhibitors.

PubMed

Di Minno, M N D; Di Minno, G; Di Capua, M; Cerbone, A M; Coppola, A

2010-01-01

In Western countries, the treatment of patients with inhibitors is presently the most challenging and serious issue in haemophilia management, direct costs of clotting factor concentrates accounting for >98% of the highest economic burden absorbed for the healthcare of patients in this setting. Being designed to address questions of resource allocation and effectiveness, decision models are the golden standard to reliably assess the overall economic implications of haemophilia with inhibitors in terms of mortality, bleeding-related morbidity, and severity of arthropathy. However, presently, most data analyses stem from retrospective short-term evaluations, that only allow for the analysis of direct health costs. In the setting of chronic diseases, the cost-utility analysis, that takes into account the beneficial effects of a given treatment/healthcare intervention in terms of health-related quality of life, is likely to be the most appropriate approach. To calculate net benefits, the quality adjusted life year, that significantly reflects such health gain, has to be compared with specific economic impacts. Differences in data sources, in medical practice and/or in healthcare systems and costs, imply that most current pharmacoeconomic analyses are confined to a narrow healthcare payer perspective. Long-term/lifetime prospective or observational studies, devoted to a careful definition of when to start a treatment; of regimens (dose and type of product) to employ, and of inhibitor population (children/adults, low-responding/high responding inhibitors) to study, are thus urgently needed to allow for newer insights, based on reliable data sources into resource allocation, effectiveness and cost-utility analysis in the treatment of haemophiliacs with inhibitors.

Influence of temperature on patch residence time in parasitoids: physiological and behavioural mechanisms

NASA Astrophysics Data System (ADS)

Moiroux, Joffrey; Abram, Paul K.; Louâpre, Philippe; Barrette, Maryse; Brodeur, Jacques; Boivin, Guy

2016-04-01

Patch time allocation has received much attention in the context of optimal foraging theory, including the effect of environmental variables. We investigated the direct role of temperature on patch time allocation by parasitoids through physiological and behavioural mechanisms and its indirect role via changes in sex allocation and behavioural defences of the hosts. We compared the influence of foraging temperature on patch residence time between an egg parasitoid, Trichogramma euproctidis, and an aphid parasitoid, Aphidius ervi. The latter attacks hosts that are able to actively defend themselves, and may thus indirectly influence patch time allocation of the parasitoid. Patch residence time decreased with an increase in temperature in both species. The increased activity levels with warming, as evidenced by the increase in walking speed, partially explained these variations, but other mechanisms were involved. In T. euproctidis, the ability to externally discriminate parasitised hosts decreased at low temperature, resulting in a longer patch residence time. Changes in sex allocation with temperature did not explain changes in patch time allocation in this species. For A. ervi, we observed that aphids frequently escaped at intermediate temperature and defended themselves aggressively at high temperature, but displayed few defence mechanisms at low temperature. These defensive behaviours resulted in a decreased patch residence time for the parasitoid and partly explained the fact that A. ervi remained for a shorter time at the intermediate and high temperatures than at the lowest temperature. Our results suggest that global warming may affect host-parasitoid interactions through complex mechanisms including both direct and indirect effects on parasitoid patch time allocation.

26 CFR 1.512(a)-1 - Definition.

Code of Federal Regulations, 2013 CFR

2013-04-01

... costs such as rent, heat and electricity may be allocated on the basis of the portion of space devoted to each activity; and depreciation may be allocated on the basis of space occupied and the portion of... direct selling costs, such as transportation and travel expenses, office salaries, promotion and research...

26 CFR 1.512(a)-1 - Definition.

Code of Federal Regulations, 2011 CFR

2011-04-01

... costs such as rent, heat and electricity may be allocated on the basis of the portion of space devoted to each activity; and depreciation may be allocated on the basis of space occupied and the portion of... direct selling costs, such as transportation and travel expenses, office salaries, promotion and research...

Impression Management Messages and Reactions to Organizational Reward Allocations: The Mediating Influence of Fairness and Responsibility.

ERIC Educational Resources Information Center

Tata, Jasmine; Rhodes, Susan R.

1996-01-01

Examines relationships among impression-management messages, evaluations of reward allocations (fairness and responsibility), and reaction to rewards (anger, approval of manager, and overall job satisfaction). Finds that impression-management messages directly influence fairness and responsibility, and indirectly influence anger and approval. (SR)

50 CFR 648.293 - Tilefish accountability measures.

Code of Federal Regulations, 2013 CFR

2013-10-01

... Measures for the Tilefish Fishery § 648.293 Tilefish accountability measures. (a) If the ACL is exceeded, the amount of the ACL overage that cannot be directly attributed to IFQ allocation holders having exceeded their IFQ allocation will be deducted from the ACL in the following fishing year. All overages...

50 CFR 648.293 - Tilefish accountability measures.

Code of Federal Regulations, 2012 CFR

2012-10-01

... Measures for the Tilefish Fishery § 648.293 Tilefish accountability measures. (a) If the ACL is exceeded, the amount of the ACL overage that cannot be directly attributed to IFQ allocation holders having exceeded their IFQ allocation will be deducted from the ACL in the following fishing year. All overages...

50 CFR 648.293 - Tilefish accountability measures.

Code of Federal Regulations, 2014 CFR

2014-10-01

... Measures for the Tilefish Fishery § 648.293 Tilefish accountability measures. (a) If the ACL is exceeded, the amount of the ACL overage that cannot be directly attributed to IFQ allocation holders having exceeded their IFQ allocation will be deducted from the ACL in the following fishing year. All overages...

76 FR 53450 - Transmission Planning and Cost Allocation by Transmission Owning and Operating Public Utilities...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-26

... Planning and Cost Allocation by Transmission Owning and Operating Public Utilities; Notice of Staff Informational Conferences Take notice that Commission staff will convene three informational conferences to discuss the requirements of Order No. 1000.\\1\\ The Commission directed its staff to hold the informational...

78 FR 16916 - Proposed Collection; Comment Request for Regulation Project

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-19

... allocation and apportionment of deduction for state income. DATES: Written comments should be received on or before May 20, 2013 to be assured of consideration. ADDRESSES: Direct all written comments to Yvette... INFORMATION: Title: Allocation and Apportionment of Deduction for State Income Taxes. OMB Number: 1545-1224...

26 CFR 1.148-0 - Scope and table of contents.

Code of Federal Regulations, 2010 CFR

2010-04-01

... method. (b) Allocation of gross proceeds to an issue. (1) One-issue rule and general ordering rules. (2... for which the bonds were issued. To accomplish these purposes, section 148 restricts the direct and... substance. (4) Reasonable charge. (5) Guarantee of purpose investments. (6) Allocation of qualified...

29 CFR 4211.1 - Purpose and scope.

Code of Federal Regulations, 2010 CFR

2010-07-01

... presumptive method (section 4211(c)(2)); the rolling-5 method (section 4211(c)(3)); and the direct attribution... approve the adoption of an alternative allocation method. On September 25, 1984, 49 FR 37686, the PBGC... allocation methods. Section 4211(c)(5) of ERISA also permits certain modifications to the statutory...

76 FR 3090 - Proposed Information Collection; Comment Request; Alaska Region; Bering Sea and Aleutian Islands...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-01-19

... submitted on or before March 21, 2011. ADDRESSES: Direct all written comments to Diana Hynek, Departmental... fisheries. Program components include quota share allocation, processor quota share allocation, individual... Binding Arbitration process, and fee collection. II. Method of Collection Responses are mailed, except the...

Shared and Disorder-Specific Prefrontal Abnormalities in Boys with Pure Attention-Deficit/Hyperactivity Disorder Compared to Boys with Pure CD during Interference Inhibition and Attention Allocation

ERIC Educational Resources Information Center

Rubia, Katya; Halari, Rozmin; Smith, Anna B.; Mohammad, Majeed; Scott, Stephen; Brammer, Michael J.

2009-01-01

Background: Inhibitory and attention deficits have been suggested to be shared problems of disruptive behaviour disorders. Patients with attention deficit hyperactivity disorder (ADHD) and patients with conduct disorder (CD) show deficits in tasks of attention allocation and interference inhibition. However, functional magnetic resonance imaging…

The effect of telephone reminders on attendance in respiratory outpatient clinics.

PubMed

Roberts, Nicola; Meade, Karen; Partridge, Martyn

2007-04-01

Patient non-attendance is an area of concern for all health care providers. A randomized controlled trial was undertaken to investigate whether reminder telephone calls improved attendance at respiratory outpatient clinics in the English National Health Service (NHS). Patients were randomly allocated into one of two groups, either telephone reminder group or usual care. The telephone reminder group received a reminder telephone call between 9 am and 5 pm during the week prior to their appointment. Attendance and demographic information (age, sex, diagnosis and home postcode) were recorded. A total of 504 patients were recruited, 258 patients were allocated to the control group and 246 patients were allocated to the telephone reminder group. Fifty-eight percent of the patients allocated to the telephone reminder group were not contactable. Within the telephone reminder group, of the 104 patients who could be contacted, 86% attended. There was a significant 15% increase in attendance in the contacted group (n = 104) when compared both with the control group (71%, n = 258) and with the patients who could not be contacted (68%, n = 142) (P = 0.007; P = 0.004). It was estimated that the cost of telephoning 200 patients could be offset by preventing one non-attendance. Routine telephoning of outpatients should become standard practice if reducing non-attendance is thought to be desirable, but general practitioner (GP) referral letters and hospital records of current hospital outpatients need to include an up-to-date telephone number. Consideration should be given to 'out-of-hours' reminder calls to maximize the contact rate.

Effect of the lung allocation score on lung transplantation in the United States.

PubMed

Egan, Thomas M; Edwards, Leah B

2016-04-01

On May 4, 2005, the system for allocation of deceased donor lungs for transplant in the United States changed from allocation based on waiting time to allocation based on the lung allocation score (LAS). We sought to determine the effect of the LAS on lung transplantation in the United States. Organ Procurement and Transplantation Network data on listed and transplanted patients were analyzed for 5 calendar years before implementation of the LAS (2000-2004), and compared with data from 6 calendar years after implementation (2006-2011). Counts were compared between eras using the Wilcoxon rank sum test. The rates of transplant increase within each era were compared using an F-test. Survival rates computed using the Kaplan-Meier method were compared using the log-rank test. After introduction of the LAS, waitlist deaths decreased significantly, from 500/year to 300/year; the number of lung transplants increased, with double the annual increase in rate of lung transplants, despite no increase in donors; the distribution of recipient diagnoses changed dramatically, with significantly more patients with fibrotic lung disease receiving transplants; age of recipients increased significantly; and 1-year survival had a small but significant increase. Allocating lungs for transplant based on urgency and benefit instead of waiting time was associated with fewer waitlist deaths, more transplants performed, and a change in distribution of recipient diagnoses to patients more likely to die on the waiting list. Copyright © 2016 International Society for Heart and Lung Transplantation. All rights reserved.

Ethical and professional challenges posed by patients with genetic concerns: a report of focus group discussions with genetic counselors, physicians, and nurses.

PubMed

Veach, P M; Bartels, D M; LeRoy, B S

2001-04-01

Ninety-seven physicians, nurses, and genetic counselors from four regions within the United States participated in focus groups to identify the types of ethical and professional challenges that arise when their patients have genetic concerns. Responses were taped and transcribed and then analyzed using the Hill et al. (1997, Counsel Psychol 25:517-522) Consensual Qualitative Research method of analysis. Sixteen major ethical and professional domains and 63 subcategories were identified. Major domains are informed consent; withholding information; facing uncertainty; resource allocation; value conflicts, directiveness/nondirectiveness; determining the primary patient; professional identity issues; emotional responses; diversity issues; confidentiality; attaining/maintaining proficiency; professional misconduct; discrimination; colleague error; and documentation. Implications for practitioners who deal with genetic issues and recommendations for additional research are given.

Comprehensive reliability allocation method for CNC lathes based on cubic transformed functions of failure mode and effects analysis

NASA Astrophysics Data System (ADS)

Yang, Zhou; Zhu, Yunpeng; Ren, Hongrui; Zhang, Yimin

2015-03-01

Reliability allocation of computerized numerical controlled(CNC) lathes is very important in industry. Traditional allocation methods only focus on high-failure rate components rather than moderate failure rate components, which is not applicable in some conditions. Aiming at solving the problem of CNC lathes reliability allocating, a comprehensive reliability allocation method based on cubic transformed functions of failure modes and effects analysis(FMEA) is presented. Firstly, conventional reliability allocation methods are introduced. Then the limitations of direct combination of comprehensive allocation method with the exponential transformed FMEA method are investigated. Subsequently, a cubic transformed function is established in order to overcome these limitations. Properties of the new transformed functions are discussed by considering the failure severity and the failure occurrence. Designers can choose appropriate transform amplitudes according to their requirements. Finally, a CNC lathe and a spindle system are used as an example to verify the new allocation method. Seven criteria are considered to compare the results of the new method with traditional methods. The allocation results indicate that the new method is more flexible than traditional methods. By employing the new cubic transformed function, the method covers a wider range of problems in CNC reliability allocation without losing the advantages of traditional methods.

Report from a forum on US heart allocation policy.

PubMed

Kobashigawa, J A; Johnson, M; Rogers, J; Vega, J D; Colvin-Adams, M; Edwards, L; Meyer, D; Luu, M; Reinsmoen, N; Dipchand, A I; Feldman, D; Kormos, R; Mancini, D; Webber, S

2015-01-01

Since the latest revision in US heart allocation policy (2006), the landscape and volume of transplant waitlists have changed considerably. Advances in mechanical circulatory support (MCS) prolong survival, but Status 1A mortality remains high. Several patient subgroups may be disadvantaged by current listing criteria and geographical disparity remains in waitlist time. This forum on US heart allocation policy was organized to discuss these issues and highlight concepts for consideration in the policy development process. A 25-question survey on heart allocation policy was conducted. Among attendees/respondents were 84 participants with clinical/published experience in heart transplant representing 51 US transplant centers, and OPTN/UNOS and SRTR representatives. The survey results and forum discussions demonstrated very strong interest in change to a further-tiered system, accounting for disadvantaged subgroups and lowering use of exceptions. However, a heart allocation score is not yet viable due to the long-term viability of variables (used in the score) in an ever-developing field. There is strong interest in more refined prioritization of patients with MCS complications, highly sensitized patients and those with severe arrhythmias or restrictive physiology. There is also strong interest in distribution by geographic boundaries modified according to population. Differences of opinion exist between small and large centers.

Engaging the public in healthcare decision-making: results from a Citizens' Jury on emergency care services.

PubMed

Scuffham, P A; Moretto, N; Krinks, R; Burton, P; Whitty, J A; Wilson, A; Fitzgerald, G; Littlejohns, P; Kendall, E

2016-11-01

Policies addressing ED crowding have failed to incorporate the public's perspectives; engaging the public in such policies is needed. This study aimed at determining the public's recommendations related to alternative models of care intended to reduce crowding, optimising access to and provision of emergency care. A Citizens' Jury was convened in Queensland, Australia, to consider priority setting and resource allocation to address ED crowding. Twenty-two jurors were recruited from the electoral roll, who were interested and available to attend the jury from 15 to 17 June 2012. Juror feedback was collected via a survey immediately following the end of the jury. The jury considered that all patients attending the ED should be assessed with a minority of cases diverted for assistance elsewhere. Jurors strongly supported enabling ambulance staff to treat patients in their homes without transporting them to the ED, and allowing non-medical staff to treat some patients without seeing a doctor. Jurors supported (in principle) patient choice over aspects of their treatment (when, where and type of health professional) with some support for patients paying towards treatment but unanimous opposition for patients paying to be prioritised. Most of the jurors were satisfied with their experience of the Citizens' Jury process, but some jurors perceived the time allocated for deliberations as insufficient. These findings suggest that the general public may be open to flexible models of emergency care. The jury provided clear recommendations for direct public input to guide health policy to tackle ED crowding. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

A tyre slip-based integrated chassis control of front/rear traction distribution and four-wheel independent brake from moderate driving to limit handling

NASA Astrophysics Data System (ADS)

Joa, Eunhyek; Park, Kwanwoo; Koh, Youngil; Yi, Kyongsu; Kim, Kilsoo

2018-04-01

This paper presents a tyre slip-based integrated chassis control of front/rear traction distribution and four-wheel braking for enhanced performance from moderate driving to limit handling. The proposed algorithm adopted hierarchical structure: supervisor - desired motion tracking controller - optimisation-based control allocation. In the supervisor, by considering transient cornering characteristics, desired vehicle motion is calculated. In the desired motion tracking controller, in order to track desired vehicle motion, virtual control input is determined in the manner of sliding mode control. In the control allocation, virtual control input is allocated to minimise cost function. The cost function consists of two major parts. First part is a slip-based tyre friction utilisation quantification, which does not need a tyre force estimation. Second part is an allocation guideline, which guides optimally allocated inputs to predefined solution. The proposed algorithm has been investigated via simulation from moderate driving to limit handling scenario. Compared to Base and direct yaw moment control system, the proposed algorithm can effectively reduce tyre dissipation energy in the moderate driving situation. Moreover, the proposed algorithm enhances limit handling performance compared to Base and direct yaw moment control system. In addition to comparison with Base and direct yaw moment control, comparison the proposed algorithm with the control algorithm based on the known tyre force information has been conducted. The results show that the performance of the proposed algorithm is similar with that of the control algorithm with the known tyre force information.

Economic Burden of Hepatitis B Virus-Related Diseases: Evidence From Iran

PubMed Central

Keshavarz, Khosro; Kebriaeezadeh, Abbas; Alavian, Seyed Moayed; Akbari Sari, Ali; Abedin Dorkoosh, Farid; Keshvari, Maryam; Malekhosseini, Seyed Ali; Nikeghbalian, Saman; Nikfar, Shekoufeh

2015-01-01

Background: Hepatitis B infection is still the main cause of chronic liver disease in Iran, which is associated with significant economic and social costs. Objectives: This study aimed to estimate the financial burden caused by CHB infection and its complications in Iran. Patients and Methods: Prevalence-based and bottom-up approaches were used to collect the data. Data on direct medical costs were extracted from outpatient medical records in a referral gastroenterology and hepatology research center, inpatient medical records in several major hospitals in Tehran and Shiraz in 2013, and the self-reports of specialists. Data on direct non-medical and indirect costs were collected based on the patients’ self-reports through face-to-face interviews performed in the mentioned centers. To calculate the indirect costs, friction cost approach was used. To calculate the total cost-of-illness in Iran, the total cost per patient at each stage of the disease was estimated and multiplied by the total number of patients. Results: The total annual cost for the activate population of CHB patients and for those receiving treatment at various disease stages were respectively 450 million and 226 million dollars, with 64% and 70% of which allocated to direct costs respectively, and 36% and 30% to indirect costs respectively. The total direct costs alone for each group were respectively 1.17% and 0.6% of the total health expenditure. Furthermore, the cost spent on drugs encompasses the largest proportion of the direct medical cost for all stages of the disease. Conclusions: According to the perspectives of payers, patients, and community, CHB infection can be considered as one of the diseases with a substantial economic burden; the disease, specifically in extreme cases, can be too expensive and costly for patients. Therefore, patients should be protected against more severe stages of the disease through proper treatment and early diagnosis. PMID:25977694

Using Excel's Solver Function to Facilitate Reciprocal Service Department Cost Allocations

ERIC Educational Resources Information Center

Leese, Wallace R.

2013-01-01

The reciprocal method of service department cost allocation requires linear equations to be solved simultaneously. These computations are often so complex as to cause the abandonment of the reciprocal method in favor of the less sophisticated and theoretically incorrect direct or step-down methods. This article illustrates how Excel's Solver…

Using Excel's Matrix Operations to Facilitate Reciprocal Cost Allocations

ERIC Educational Resources Information Center

Leese, Wallace R.; Kizirian, Tim

2009-01-01

The reciprocal method of service department cost allocation requires linear equations to be solved simultaneously. These computations are often so complex as to cause the abandonment of the reciprocal method in favor of the less sophisticated direct or step-down methods. Here is a short example demonstrating how Excel's sometimes unknown matrix…

77 FR 16209 - Proposed Information Collection; Comment Request; Tilefish Individual Fishing Quota Program

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-20

... Northeastern U.S. EEZ. II. Method of Collection The IFQ Allocation permit application, IFQ ownership cap form... before May 21, 2012. ADDRESSES: Direct all written comments to Jennifer Jessup, Departmental Paperwork... applications to ensure that IFQ allocation owners are provided a statement of their annual catch quota, and for...

77 FR 16210 - Proposed Information Collection; Comment Request; Tilefish Individual Fishing Quota Program

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-20

... Northeastern U.S. EEZ. II. Method of Collection The IFQ Allocation permit application, IFQ ownership cap form... before May 21, 2012. ADDRESSES: Direct all written comments to Jennifer Jessup, Departmental Paperwork... applications to ensure that IFQ allocation owners are provided a statement of their annual catch quota, and for...

78 FR 30865 - Proposed Information Collection; Comment Request; Tilefish Individual Fishing Quota Program

Federal Register 2010, 2011, 2012, 2013, 2014

2013-05-23

... Northeastern U.S. EEZ. II. Method of Collection The IFQ Allocation permit application, IFQ holder cap form, and... before July 22, 2013. ADDRESSES: Direct all written comments to Jennifer Jessup, Departmental Paperwork... applications to ensure that IFQ allocation holders are provided a statement of their annual catch quota, and...

Effects of sensorimotor foot training on the symmetry of weight distribution on the lower extremities of patients in the chronic phase after stroke

PubMed Central

Goliwas, Magdalena; Kocur, Piotr; Furmaniuk, Lech; Majchrzycki, Marian; Wiernicka, Marzena; Lewandowski, Jacek

2015-01-01

[Purpose] To assess the effects of sensorimotor foot stimulation on the symmetry of weight distribution on the feet of patients in the chronic post-stroke phase. [Subjects and Methods] This study was a prospective, single blind, randomized controlled trial. In the study we examined patients with chronic stroke (post-stroke duration > 1 year). They were randomly allocated to the study group (n=8) or to the control group (n=12). Both groups completed a standard six-week rehabilitation programme. In the study group, the standard rehabilitation programme was supplemented with sensorimotor foot stimulation training. Each patient underwent two assessments of symmetry of weight distribution on the lower extremities with and without visual control, on a treadmill, with stabilometry measurements, and under static conditions. [Results] Only the study group demonstrated a significant increase in the weight placed on the leg directly affected by stroke, and a reduction in asymmetry of weight-bearing on the lower extremities. [Conclusion] Sensorimotor stimulation of the feet enhanced of weight bearing on the foot on the side of the body directly affected by stroke, and a decreased asymmetry of weight distribution on the lower extremities of patients in the chronic post-stroke phase. PMID:26504326

Effects of sensorimotor foot training on the symmetry of weight distribution on the lower extremities of patients in the chronic phase after stroke.

PubMed

Goliwas, Magdalena; Kocur, Piotr; Furmaniuk, Lech; Majchrzycki, Marian; Wiernicka, Marzena; Lewandowski, Jacek

2015-09-01

[Purpose] To assess the effects of sensorimotor foot stimulation on the symmetry of weight distribution on the feet of patients in the chronic post-stroke phase. [Subjects and Methods] This study was a prospective, single blind, randomized controlled trial. In the study we examined patients with chronic stroke (post-stroke duration > 1 year). They were randomly allocated to the study group (n=8) or to the control group (n=12). Both groups completed a standard six-week rehabilitation programme. In the study group, the standard rehabilitation programme was supplemented with sensorimotor foot stimulation training. Each patient underwent two assessments of symmetry of weight distribution on the lower extremities with and without visual control, on a treadmill, with stabilometry measurements, and under static conditions. [Results] Only the study group demonstrated a significant increase in the weight placed on the leg directly affected by stroke, and a reduction in asymmetry of weight-bearing on the lower extremities. [Conclusion] Sensorimotor stimulation of the feet enhanced of weight bearing on the foot on the side of the body directly affected by stroke, and a decreased asymmetry of weight distribution on the lower extremities of patients in the chronic post-stroke phase.

Do hormone treatments for prostate cancer cause anxiety and depression?

PubMed

Sharpley, Christopher F; Christie, David R H; Bitsika, Vicki

2014-01-01

To investigate the relationship between hormone therapy (HT) and incidence of anxiety and depression among prostate cancer patients (PCa). 526 PCa patients completed a survey about their cancer status, treatment received, anxiety, and depression status. Total scores on anxiety and depression inventories, plus symptom profiles that discriminated between patients with current HT, past HT, and never having received HT, were compiled for analysis. Patients who were currently receiving HT had significantly higher total anxiety and depression scores than patients who had previously received HT or who had never received HT. Analysis of the symptoms of anxiety and depression which distinguished between these groups of patients suggested that patients who had never received HT had significantly lower scores than current or past HT patients. Although several symptoms could be directly allocated to PCa and/or HT, symptom profiles were indicative of clinically significant anxiety and/or depression in patients who were currently receiving, or who had previously received, HT. Current HT may lead to symptoms of anxiety and/or depression which require clinical attention. These effects seem to decrease after completion of HT.

Neural Network Based Modeling and Analysis of LP Control Surface Allocation

NASA Technical Reports Server (NTRS)

Langari, Reza; Krishnakumar, Kalmanje; Gundy-Burlet, Karen

2003-01-01

This paper presents an approach to interpretive modeling of LP based control allocation in intelligent flight control. The emphasis is placed on a nonlinear interpretation of the LP allocation process as a static map to support analytical study of the resulting closed loop system, albeit in approximate form. The approach makes use of a bi-layer neural network to capture the essential functioning of the LP allocation process. It is further shown via Lyapunov based analysis that under certain relatively mild conditions the resulting closed loop system is stable. Some preliminary conclusions from a study at Ames are stated and directions for further research are given at the conclusion of the paper.

A comparison of GlideScope(®) videolaryngoscopy and direct laryngoscopy for nasotracheal intubation in children.

PubMed

Kim, Hyun-Jung; Kim, Jin-Tae; Kim, Hee-Soo; Kim, Chong-Sung; Kim, Seong-Deok

2011-04-01

The relative effectiveness of GlideScope(®) videolaryngoscopy (GV) for nasotracheal intubation in pediatric patients is unclear. The purpose of this study is to evaluate the usefulness of GV for nasotracheal intubation compared with direct laryngoscopy (DL) in pediatric patients. Our patient cohort consisted of 80 children <10 years of age who required nasotracheal intubation for elective dental or facial surgery. The patients were randomly allocated to GV (n = 40) or DL (n = 40) group. The time to intubation (TTI), glottic view grade, frequency of Magill forceps use, and degree of difficulty in intubation were evaluated. The median TTI was similar between the groups. The TTI of the former 20 patients was faster in the DL group (53.3 s, interquartile range: 42.0-64.3) than GV group (65.9 s, interquartile range: 56.0-93.9) (P = 0.007), whereas the TTI of the latter 20 patients was comparable between the groups. There were no significant differences in glottic view grade, frequency of Magill forceps use, and degree of difficulty in intubation between the two groups. GV can provide similar intubation performance characteristics compared with DL when used for nasotracheal intubation in pediatric patients. However, experience is needed to be skillful in the GV to acquire comparable TTI with DL. © 2011 Blackwell Publishing Ltd.

Development of a behaviour change communication tool for medical students: the 'Tent Pegs' booklet.

PubMed

Chisholm, Anna; Hart, Jo; Mann, Karen; Peters, Sarah

2014-01-01

To describe the development and validation of a behaviour change communication tool for medical students. Behaviour change techniques (BCTs) were identified within the literature and used to inform a communication tool to support medical students in discussing health-related behaviour change with patients. BCTs were organized into an accessible format for medical students (the 'Tent Pegs' booklet) and validated using discriminant content validity methods with 11 expert judges. One-sample t-tests showed that judges reliably mapped BCTs onto six of the seven Tent Pegs domains (confidence rating means ranged from 4.0 to 5.1 out of 10, all p≤0.002). Only BCTs within the 'empowering people to change' domain were not significantly different from the value zero (mean confidence rating=1.2, p>0.05); these BCTs were most frequently allocated to the 'addressing thoughts and emotions' domain instead. BCTs within the Tent Pegs booklet are reliably allocated to corresponding behaviour change domains with the exception of those within the 'empowering people to change' domain. The existing evidence-base on BCTs can be used to directly inform development of a communication tool to support medical students facilitate health behaviour change with patients. Crown Copyright © 2013. Published by Elsevier Ireland Ltd. All rights reserved.

Definitions and methods of cost assessment: an intensivist's guide. ESICM section on health research and outcome working group on cost effectiveness.

PubMed

Jegers, M; Edbrooke, D L; Hibbert, C L; Chalfin, D B; Burchardi, H

2002-06-01

To define the different types of costs incurred in the care of critically ill patients and to describe some of the most commonly used methods for measuring and allocating these costs. Literature review. Definitions for opportunity, direct and indirect, fixed, variable, marginal, and total costs are described and interpreted in the context of the critical care setting. Two main methods of costing are described: the 'top-down' and 'bottom-up' methods together with a number of cost proxies, such as the use of weighted hospital days, diagnosis-related groups, severity and activity scores, and effective costs per survivor. The assessment and allocation of costs to critically ill patients is complex and as a result of the different definitions and methods used, meaningful comparisons between studies are plagued with difficulty. When undertaking a study looking to measure costs, it is important to state: (a) the aim of the cost assessment study; (b) the perspective (point of view); (c) the type of costs that need to be measured; and (d) the time span of assessment. By being explicit about the rationale of the study and the methods used, it is hoped that the results of economic evaluations will be better understood, and hence implemented within the critical care setting.

[Organ allocation system: between efficiency and equity].

PubMed

Antoine, Corinne

2007-02-15

Despite considerable efforts to promote organ donation and increase the amount of organ retrieval, demand for grafts is increasing and remains much higher then availability. This short supply is noticeable for all organ transplantation whether for heart, lungs, liver or pancreas but mainly for kidneys. The objective of graft allocation and attribution rules is to insure an allocation as fair as possible, to find the best recipient, to take into account the emergency of the need for grafting or the access difficulty for certain patients, and to seek optimal graft usage. These rules are based on the setting up of priority categories for patients whose lives are threatened on a very short-term basis or for those having difficult access to transplantation. This implies the issue of seeking the balance between an allocation as fair as possible and technical constraints associated with organ retrieval, transportation and graft quality preservation.

HLA matching and the United Network for Organ Sharing Allocation System: impact of HLA matching on African-American recipients of cadaveric kidney transplants.

PubMed

Rebellato, Lorita M; Arnold, Angelo N; Bozik, Karen M; Haisch, Carl E

2002-12-15

A recent proposal supports the elimination of allocation points for human leukocyte antigen (HLA) mismatches (MM) in cadaveric kidney transplantation. The intent is to increase access for some racial groups that might be disadvantaged by the representation of race-specific HLA in a largely white donor pool. We report our experience from two transplant centers that serve a large African American (AA) patient population. All cadaveric transplants into AA recipients from 1994 to 2000 (n=162) were included in a retrospective review. Superior graft survival was observed in AA recipients of 0 MM transplants. When induction therapy was used, the graft survival at 3 years for the human leukocyte antigen (HLA)-BDR MM grades given allocation points (0,1,2 MM) was 82% versus only 49% for BDR MM grades not given points (3,4 MM: =0.0022). Our collective experience demonstrates that AA patients having HLA-BDR MM grades given allocation points had better graft survival. Removing points for HLA from the national allocation system may result in significantly poorer outcome in AA kidney recipients.

Optimizing resource allocation for breast cancer prevention and care among Hong Kong Chinese women.

PubMed

Wong, Irene O L; Tsang, Janice W H; Cowling, Benjamin J; Leung, Gabriel M

2012-09-15

Recommendations about funding of interventions through the full spectrum of the disease often have been made in isolation. The authors of this report optimized budgetary allocations by comparing cost-effectiveness data for different preventive and management strategies throughout the disease course for breast cancer in Hong Kong (HK) Chinese women. Nesting a state-transition Markov model within a generalized cost-effectiveness analytic framework, costs and quality-adjusted life-years (QALYs) were compared to estimate average cost-effectiveness ratios for the following interventions at the population level: biennial mass mammography (ages 40-69 years or ages 40-79 years), reduced waiting time for postoperative radiotherapy (by 15% or by 25%), adjuvant endocrine therapy (either upfront aromatase inhibitor [AI] therapy or sequentially with tamoxifen followed by AI) in postmenopausal women with estrogen receptor-positive disease, targeted immunotherapy in those with tumors that over express human epidermal growth factor receptor 2, and enhanced palliative services (either at home or as an inpatient). Usual care for eligible patients in the public sector was the comparator. In descending order, the optimal allocation of additional resources for breast cancer would be the following: a 25% reduction in waiting time for postoperative radiotherapy (in US dollars: $5000 per QALY); enhanced, home-based palliative care ($7105 per QALY); adjuvant, sequential endocrine therapy ($17,963 per QALY); targeted immunotherapy ($62,092 per QALY); and mass mammography screening of women ages 40 to 69 years ($72,576 per QALY). Given the lower disease risk and different age profiles of patients in HK Chinese, among other newly emergent and emerging economies with similar transitioning epidemiologic profiles, the current findings provided direct evidence to support policy decisions that may be dissimilar to current Western practice. Copyright © 2012 American Cancer Society.

Comparison of methods for estimating the cost of human immunodeficiency virus-testing interventions.

PubMed

Shrestha, Ram K; Sansom, Stephanie L; Farnham, Paul G

2012-01-01

The Centers for Disease Control and Prevention (CDC), Division of HIV/AIDS Prevention, spends approximately 50% of its $325 million annual human immunodeficiency virus (HIV) prevention funds for HIV-testing services. An accurate estimate of the costs of HIV testing in various settings is essential for efficient allocation of HIV prevention resources. To assess the costs of HIV-testing interventions using different costing methods. We used the microcosting-direct measurement method to assess the costs of HIV-testing interventions in nonclinical settings, and we compared these results with those from 3 other costing methods: microcosting-staff allocation, where the labor cost was derived from the proportion of each staff person's time allocated to HIV testing interventions; gross costing, where the New York State Medicaid payment for HIV testing was used to estimate program costs, and program budget, where the program cost was assumed to be the total funding provided by Centers for Disease Control and Prevention. Total program cost, cost per person tested, and cost per person notified of new HIV diagnosis. The median costs per person notified of a new HIV diagnosis were $12 475, $15 018, $2697, and $20 144 based on microcosting-direct measurement, microcosting-staff allocation, gross costing, and program budget methods, respectively. Compared with the microcosting-direct measurement method, the cost was 78% lower with gross costing, and 20% and 61% higher using the microcosting-staff allocation and program budget methods, respectively. Our analysis showed that HIV-testing program cost estimates vary widely by costing methods. However, the choice of a particular costing method may depend on the research question being addressed. Although program budget and gross-costing methods may be attractive because of their simplicity, only the microcosting-direct measurement method can identify important determinants of the program costs and provide guidance to improve efficiency.

Efficacy of tamoxifen and radiotherapy for prevention and treatment of gynaecomastia and breast pain caused by bicalutamide in prostate cancer: a randomised controlled trial.

PubMed

Perdonà, Sisto; Autorino, Riccardo; De Placido, Sabino; D'Armiento, Massimo; Gallo, Antonio; Damiano, Rocco; Pingitore, Domenico; Gallo, Luigi; De Sio, Marco; Bianco, Angelo Raffaele; Di Lorenzo, Giuseppe

2005-05-01

Gynaecomastia and breast pain are frequent adverse events with bicalutamide monotherapy, and might cause some patients to withdraw from treatment. We aimed to compare tamoxifen with radiotherapy for prevention and treatment of gynaecomastia, breast pain, or both during bicalutamide monotherapy for prostate cancer. 51 patients were randomly assigned to 150 mg bicalutamide per day, 50 patients to 150 mg bicalutamide per day and to 10 mg tamoxifen per day for 24 weeks, and 50 patients to 150 mg bicalutamide per day and radiotherapy (one 12-Gy fraction on the day of starting bicalutamide). 35 of the 51 patients allocated bicalutamide alone developed gynaecomastia or breast pain and were subsequently randomly allocated to tamoxifen (n=17) or radiotherapy (n=18) soon after symptoms started (median 180 days, range 160-195). Gynaecomastia and breast pain were assessed once a month. Severity of gynaecomastia was scored on the basis of the largest diameter. Breast pain was scored as none, mild, moderate, or severe. The primary outcome was frequency of gynaecomastia or breast pain; secondary outcomes were safety and tolerability, relapse-free survival, as assessed by concentration of prostate specific antigen, and quality of life. Analyses were by intention to treat. 35 of 51 patients assigned bicalutamide alone developed gynaecomastia, compared with four of 50 assigned bicalutamide and tamoxifen (odds ratio [OR] 0.1 [95% CI 0.08-0.12], p=0.0009), and with 17 of 50 assigned bicalutamide and radiotherapy (0.51 [0.47-0.54], p=0.008). Breast pain was seen in 29 of 51 patients allocated bicalutamide alone, compared with three allocated bicalutamide and tamoxifen (0.1 [0.07-0.11], p=0.009), and with 15 allocated bicalutamide and radiotherapy (0.43 [0.40-0.45], p=0.02) In 35 patients assigned bicalutamide alone who subsequently developed gynaecomastia, breast pain, or both, tamoxifen significantly reduced the frequency of gynaecomastia (0.2 [0.18-0.22], p=0.02). Antioestrogen treatment with tamoxifen could help patients with prostate cancer to tolerate the hypergonadotropic effects of bicalutamide monotherapy.

28 CFR 100.13 - Directly assignable costs.

Code of Federal Regulations, 2010 CFR

2010-07-01

... cost may be treated as a directly allocable cost if the accounting treatment is consistently applied within the carrier's accounting system and the application produces substantially the same results as...

Rituximab after lymphoma-directed conditioning and allogeneic stem-cell transplantation for relapsed and refractory aggressive non-Hodgkin lymphoma (DSHNHL R3): an open-label, randomised, phase 2 trial.

PubMed

Glass, Bertram; Hasenkamp, Justin; Wulf, Gerald; Dreger, Peter; Pfreundschuh, Michael; Gramatzki, Martin; Silling, Gerda; Wilhelm, Christian; Zeis, Matthias; Görlitz, Anke; Pfeiffer, Sebastian; Hilgers, Reinhard; Truemper, Lorenz; Schmitz, Norbert

2014-06-01

Allogeneic stem-cell transplantation has had limited success for patients with refractory and relapsed aggressive B-cell or T-cell lymphoma. We investigated the effect of adding rituximab to standard prophylaxis for graft-versus-host disease after transplantation and estimated overall survival when using a lymphoma-directed myeloablative conditioning regimen. We did this randomised, open-label, phase 2 study at seven German transplantation centres. We enrolled patients with aggressive B-cell or T-cell lymphoma and primary refractory disease, early relapse (<12 months after first-line treatment), or relapse after autologous transplantation. Conditioning with fludarabine (125 mg/m(2)), busulfan (12 mg/kg oral or 9·6 mg/kg intravenous), and cyclophosphamide (120 mg/kg) was followed by allogeneic stem-cell transplantation. Patients were randomly assigned (1:1) to receive rituximab (375 mg/m(2) on days 21, 28, 35, 42, 175, 182, 189, and 196) or not. Allocation was done with a centralised computer-generated procedure; patients were stratified by histological subtype (B-cell vs T-cell lymphoma) and donor match (HLA-identical vs non-identical). Neither investigators nor patients were masked to allocation. The primary endpoints were the incidence of acute graft-versus-host disease grade 2-4 in each treatment group and overall survival at 1 year in both groups combined. All analyses were done for the intention-to-treat population. The study is registered with ClinicalTrials.gov, number NCT00785330. Between June 16, 2004, and March 24, 2009, we screened 86 patients and enrolled 84; 42 were randomly assigned to each group. The cumulative incidence of grade 2-4 acute graft-versus-host disease was 46% (95% CI 32-62) in the rituximab group and 42% (95% CI 29-59) in the no rituximab group (hazard ratio [HR] 0·91, 95% CI 0·52-1·60; p=0·74). Overall survival at 1 year for the whole study population was 52% (95% CI 41-62). Grade 4 haematological toxic effects and grade 3 alopecia occurred in all patients. The most common non-haematological grade 5 toxic effects were pneumonia (nine in the no rituximab group vs ten in the rituximab group) and other infections (seven vs four). The lymphoma-directed myeloablative conditioning regimen developed here is promising for patients with refractory and relapsed aggressive B-cell and T-cell lymphomas. However, the addition of rituximab did not affect the incidence of graft-versus-host disease or overall survival. Hoffmann-La Roche, Amgen, Astellas Pharma. Copyright © 2014 Elsevier Ltd. All rights reserved.

Benefit in liver transplantation: a survey among medical staff, patients, medical students and non-medical university staff and students.

PubMed

Englschalk, Christine; Eser, Daniela; Jox, Ralf J; Gerbes, Alexander; Frey, Lorenz; Dubay, Derek A; Angele, Martin; Stangl, Manfred; Meiser, Bruno; Werner, Jens; Guba, Markus

2018-02-12

The allocation of any scarce health care resource, especially a lifesaving resource, can create profound ethical and legal challenges. Liver transplant allocation currently is based upon urgency, a sickest-first approach, and does not utilize capacity to benefit. While urgency can be described reasonably well with the MELD system, benefit encompasses multiple dimensions of patients' well-being. Currently, the balance between both principles is ill-defined. This survey with 502 participants examines how urgency and benefit are weighted by different stakeholders (medical staff, patients on the liver transplant list or already transplanted, medical students and non-medical university staff and students). Liver transplant patients favored the sickest-first allocation, although all other groups tended to favor benefit. Criteria of a successful transplantation were a minimum survival of at least 1 year and recovery of functional status to being ambulatory and capable of all self-care (ECOG 2). An individual delisting decision was accepted when the 1-year survival probability would fall below 50%. Benefit was found to be a critical variable that may also trigger the willingness to donate organs. The strong interest of stakeholder for successful liver transplants is inadequately translated into current allocation rules.

Pre- Versus Posttransplant Treatment of Hepatitis C Virus With Direct-Acting Antivirals in Liver Transplant Recipients: More Issues to be Solved.

PubMed

Abdelqader, Abdelhai; Kabacam, Gokhan; Woreta, Tinsay A; Hamilton, James P; Luu, Harry; Al Khalloufi, Kawtar; Saberi, Behnam; Philosophe, Benjamin; Cameron, Andrew M; Gurakar, Ahmet

2017-02-01

Our goal was to investigate wait times related to hepatitis C virus treatment with direct acting antivirals before versus after liver transplant at a single center as well as wait times for insurance approval for preemptive treatment with these agents after liver transplant. We retrospectively evaluated hepatitis C virus infections in transplant recipients of deceased liver donations in 2014 and 2015. Demographics, hepatocellular carcinoma incidence, Model for End-Stage Liver Disease scores, and transplant wait times were compared between patients treated before or after liver transplant. Wait times to approval of direct-acting antiviral treatment were evaluated in those untreated before transplant. During our study period, of 67 deceased-donor liver transplants, 21 patients received hepatitis C virus treatment pretransplant (treated group) and 46 patients were not treated pretransplant (untreated group). Twenty-five patients in the untreated group received hepatitis C virus-positive donations, with all in this group treated with direct-acting antivirals. We found no statistically significant differences regarding age, sex, race, donation after cardiac death, or incidence of hepatocellular carcinoma between groups. The treated group had a longer median wait time (287 vs 172 days; P = .02). Twelve of the 46 untreated patients (26.1%) developed biopsy-proven hepatitis C virus-related relapse (median 87 days; range, 55-383 days). Preemptive direct-acting antiviral therapy was initiated at a median of 81 days in the untreated group. Although treatment of hepatitis C virus before liver transplant is an attractive option to eliminate the risk of complications, it can limit the donor pool for recipients to uninfected donors, significantly increasing wait times in regions with large hepatitis C virus-positive donor pools. Allocation of Model for End-Stage Liver Disease score was not different between the treated and untreated groups. Insurance companies should revise their policies for rapid approval of preemptive direct-acting antiviral treatment after liver transplant.

A New UK 2006 National Kidney Allocation Scheme for deceased heart-beating donor kidneys.

PubMed

Johnson, Rachel J; Fuggle, Susan V; Mumford, Lisa; Bradley, J Andrew; Forsythe, John L R; Rudge, Chris J

2010-02-27

In 2004, it was agreed that a new allocation scheme for kidneys from deceased heart-beating donors was required in the United Kingdom to address observed inequities in access to transplant. The 2006 National Kidney Allocation Scheme (2006 NKAS) was developed to meet agreed objectives and preparatory work included a review of the criteria for human leukocyte antigen (HLA) matching and simulation evidence about the effectiveness of alternative schemes. ALGORITHM FOR 2006 NKAS: The 2006 NKAS gives absolute priority to all 000 HLA-A, -B, -DR-mismatched patients and well-matched pediatric patients (<18 years), and then a points score defines priorities for allocation with waiting time being most influential. Points for age and HLA mismatch are linked in a novel approach to ensure well-matched transplants for younger patients while recognizing that HLA matching is less important for older patients as retransplantation is less likely to be required. To improve equity for difficult to match patients, rare HLA specificities were defaulted to more common, related specificities. IMPACT OF 2006 NKAS: After 3 years, the scheme is already making good progress in achieving its objectives, with overall results similar to those observed in the simulations. There has been a significant benefit for patients waiting more than 5 years for transplant. A number of other advantages of the scheme are also apparent with equity of access improving in many respects, including the achievement of equity of access to transplant for HLA-DR homozygous patients, but geographical inequity of access will take a number of years to address fully.

The coordination of allocation: Logistics of kidney organ allocation to highly sensitized patients.

PubMed

Lunz, John; Hinsdale, Lisa; King, Casey; Pastush, Robin; Buenvenida, Magnolia; Harmon, Michael

2017-01-01

Since implementation, the new UNOS OPTN kidney allocation system (KAS) has drastically expanded the pool of available kidneys to candidates that may have previously waited extended periods for an organ offer. This is particularly true for highly sensitized patients. The changes to the KAS have had ramifications throughout the transplant process, including for organ procurement organizations (OPO) and local transplant hospital call centers. Here, we will examine the impact of the new KAS on the organ donation process and highlight the necessary interactions between the OPO and transplant centers to best match donor kidneys and highly sensitized recipients. Copyright © 2016 American Society for Histocompatibility and Immunogenetics. Published by Elsevier Inc. All rights reserved.

Clinical factors of response in patients with advanced ovarian cancer participating in early phase clinical trials.

PubMed

George, Angela; Kristeleit, Rebecca; Rafii, Saeed; Michie, Caroline O; Bowen, Rebecca; Michalarea, Vasiliki; van Hagen, Tom; Wong, Mabel; Rallis, Grigorios; Molife, L Rhoda; Lopez, Juanita; Banerji, Udai; Banerjee, Susana N; Gore, Martin E; de Bono, Johann S; Kaye, Stan B; Yap, Timothy A

2017-05-01

Drug resistance to conventional anticancer therapies is almost inevitable in patients with advanced ovarian cancer (AOC), limiting their available treatment options. Novel phase I trial therapies within a dedicated drug development unit may represent a viable alternative; however, there is currently little evidence for patient outcomes in such patients. To address this, we undertook a retrospective review of patients with AOC allocated to phase I trials in the Drug Development Unit at Royal Marsden Hospital (RMH) between June 1998 and October 2010. A total of 200 AOC patients with progressive disease were allocated to ≥1 trial each, with a total of 281 allocations. Of these, 135 (68%) patients commenced ≥1 trial (mean 1.4 [1-8]), totaling 216 allocated trials; 65 (32%) patients did not start due to deterioration resulting from rapidly progressive disease (63 patients) or patient choice (2 patients). Response Evaluation Criteria in Solid Tumours (RECIST) complete/partial responses (CR/PR) were observed in 43 (20%) of those starting trials, including those on poly(ADP-ribose) polymerase (PARP) inhibitors (18/79 [23%]), antiangiogenics (9/65 [14%]) and chemotherapy combinations (14/43 [33%]). Factors associated with CR/PR included: fewer prior treatments, platinum-sensitive disease, CR/PR with prior therapy, (the United States-based) Eastern Cooperative Oncology Group (ECOG) performance status score, fewer metastatic sites, higher albumin and haemoglobin levels, lower white cell counts and baseline CA125 levels, germline BRCA1/2 mutations and better RMH Prognostic Score. Mean survival was 32° months for patients who achieved CR/PR. Treatments were generally well tolerated. Most patients with AOC (134/200 [67%]) received ≥1 subsequent line of therapy after phase I trials. Our data suggest that phase I trial referrals should be considered earlier in the AOC treatment pathway and before the onset of rapid disease progression particularly with the emergence of promising novel agents in the era of precision medicine. Copyright © 2017 Elsevier Ltd. All rights reserved.

A case study exploring the ethical and policy dimensions of allocating acute care resources to a dying patient.

PubMed

Cooke, Mary; Hurley, Ciarán

2008-05-01

We aimed to identify policy, process and ethical issues related to allocation of National Health Service resources when patients with end-of-life illness are referred to acute care services. Sharing healthcare decisions denotes a different partnership between professionals and patients when patients are empowered to define their needs. Implementation of a transition from professional to patient decision-making appears to be dependent upon its interpretation by personnel delivering care using the local trust policy. The outcome of this is a reformation of responsibility for budget allocation, choice of acute care provider and selecting services, currently in the realm of primary care; be it the general practitioner, community practitioners, or the patient. We used a 'lens' approach to case study analysis in which the lens is constructed of a model of policy analysis and four principles of biomedical ethics. A patient's decision to decline care proposed by an Accident and Emergency department nurse and the nurse's response to that decision expose a policy that restricts the use of ambulance transport and with that, flexibility in responses to patients' decisions. End-of-life care partnership decisions require sensitivity and flexibility from all healthcare practitioners. We found that policy-based systems currently used to deliver care across the primary care - hospital care border are far from seamless and can lead to foreseeable problems. Health professionals responsible for the care of a patient at the end of life should consider the holistic outcomes of resource allocation decisions for patients. Government and health professional agenda suggest that patients should be given a greater element of control over their healthcare than has historically been the case. When patients take responsibility for their decisions, healthcare personnel should recognize that this signals a shift in the nature of the professional-patient relationship to one of partnership.

29 CFR 4211.13 - Modifications to the direct attribution method.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 29 Labor 9 2010-07-01 2010-07-01 false Modifications to the direct attribution method. 4211.13... Changes Not Subject to PBGC Approval § 4211.13 Modifications to the direct attribution method. (a) Error in direct attribution method. The unfunded vested benefits allocated to a withdrawing employer under...

Association between pain severity and health care resource use, health status, productivity and related costs in painful diabetic peripheral neuropathy patients.

PubMed

DiBonaventura, Marco Dacosta; Cappelleri, Joseph C; Joshi, Ashish V

2011-05-01

Research has shown that painful diabetic peripheral neuropathy (pDPN) is associated with worse health outcomes. However, among pDPN patients, few studies have examined the relationship between the severity of pain and health outcomes. The current project included pDPN patients (N=1506) from the 2006, 2007, and 2008 waves of the National Health and Wellness Survey. Health status (Short Form [SF]-12), work productivity (Work Productivity and Activity Impairment questionnaire), and health care resource use in the past 6 months were compared among pDPN patients with mild, moderate, and severe pain, adjusting for demographics and clinical characteristics. More than half (51.2%) of the patients reported their pain as severe, 45.2% reported moderate pain, and 3.7% reported mild pain. Those with severe pain reported significantly lower levels of health status, higher levels of work and activity impairment, and higher levels of resource use relative to the other groups. Annual per-patient costs for those with severe pain were $12,856, $3927, and $16,783 for direct, indirect, and total costs, respectively. Both direct and total costs were significantly higher in this group relative to both mild and moderate pain patients. These results suggest that pain severity contributes substantially to the health outcomes of pDPN patients and that greater resources should be allocated to the management of patients with severe pain. Wiley Periodicals, Inc.

High emergency organ allocation rule in lung transplantation: a simulation study.

PubMed

Riou, Julien; Boëlle, Pierre-Yves; Christie, Jason D; Thabut, Gabriel

2017-10-01

The scarcity of suitable organ donors leads to protracted waiting times and mortality in patients awaiting lung transplantation. This study aims to assess the short- and long-term effects of a high emergency organ allocation policy on the outcome of lung transplantation. We developed a simulation model of lung transplantation waiting queues under two allocation strategies, based either on waiting time only or on additional criteria to prioritise the sickest patients. The model was informed by data from the United Network for Organ Sharing. We compared the impact of these strategies on waiting time, waiting list mortality and overall survival in various situations of organ scarcity. The impact of a high emergency allocation strategy depends largely on the organ supply. When organ supply is sufficient (>95 organs per 100 patients), it may prevent a small number of early deaths (1 year survival: 93.7% against 92.4% for waiting time only) without significant impact on waiting times or long-term survival. When the organ/recipient ratio is lower, the benefits in early mortality are larger but are counterbalanced by a dramatic increase of the size of the waiting list. Consequently, we observed a progressive increase of mortality on the waiting list (although still lower than with waiting time only), a deterioration of patients' condition at transplant and a decrease of post-transplant survival times. High emergency organ allocation is an effective strategy to reduce mortality on the waiting list, but causes a disruption of the list equilibrium that may have detrimental long-term effects in situations of significant organ scarcity.

System Resource Allocation Requests | High-Performance Computing | NREL

Science.gov Websites

Account to utilize the online allocation request system. If you need a HPC User Account, please request one online: Visit User Accounts. Click the green "Request Account" Button - this will direct . Follow the online instructions provided in the DocuSign form. Write "Need HPC User Account to use

Estimation of the prevalence and direct medical costs of chronic myeloid leukemia in the I.R. of Iran in the era of tyrosine kinase inhibitors.

PubMed

Daroudi, Rajabali; Mirzania, Mehrzad; Nikravanfard, Nazila; Sadighi, Sanambar; Sedighi, Zahra; Zendehdel, Kazem

2017-10-01

After the introduction of tyrosine kinase inhibitors for chronic myeloid leukemia (CML), the survival of these patients has increased significantly. However, these new drugs are expensive and impose considerable expense to patients and governments. Epidemiologic and economic evaluation studies provide good information for resource allocation and decision making. We estimated the incidence, prevalence and direct medical cost of CML in Iran. We used the National Cancer Registry (NCR) data from 2006 to 2009 to estimate the incidence rate of CML (ICD-10 code C92.1). After adjustment for the underestimation of incidence rates, we used survival rates of CML and estimated the 5-year prevalence for these patients. In addition, we used clinical practice guideline, expert opinions and medical tariffs to estimate the direct medical costs through the prevalence approach. After an adjustment for the underestimation, the incidence rate of CML was 0.5 per 100 000 in the I.R. of Iran. The 5-year prevalence was about 2263 cases (2.98 per 100 000). The total direct medical cost of CML was $23 089 323 and the majority of the cost (97%) was related to drug costs. The total cost will increase considerably to $40 728 869 if all patients use the new drug nilotinib (800 mg/day) as a second-line treatment. The increased survival of CML patients and a possible increase in incidence of CML in Iran will most likely lead to a considerable rise in its prevalence and economic burden. © 2016 John Wiley & Sons Australia, Ltd.

The economic burden of schizophrenia in Malaysia.

PubMed

Teoh, Siew Li; Chong, Huey Yi; Abdul Aziz, Salina; Chemi, Norliza; Othman, Abdul Razak; Md Zaki, Nurzuriana; Vanichkulpitak, Possatorn; Chaiyakunapruk, Nathorn

2017-01-01

Schizophrenia (SCZ) is a highly debilitating disease despite its low prevalence. The economic burden associated with SCZ is substantial and mainly attributed to productivity loss. To improve the understanding of economic burden of SCZ in the low- and middle-income country regions, we aimed to determine the economic burden of SCZ in Malaysia. A retrospective study was conducted using a prevalence-based approach from a societal perspective in Malaysia with a 1 year period from 2013. We used micro-costing technique with bottom-up method and included direct medical cost, direct non-medical cost, and indirect cost. The main data source was medical chart review which was conducted in Hospital Kuala Lumpur (HKL). The medical charts were identified electronically by matching the unique patient's identification number registered under the National Mental Health Schizophrenia Registry and the list of patients in HKL in 2013. Other data sources were government documents, literatures, and local websites. To ensure robustness of result, probabilistic sensitivity analysis was conducted. The total estimated number of treated SCZ cases in Malaysia in 2015 was 15,104 with the total economic burden of USD 100 million (M) which was equivalent to 0.04% of the national gross domestic product. On average, the mean cost per patient was USD 6,594. Of the total economic burden of SCZ, 72% was attributed to indirect cost, costing at USD 72M, followed by direct medical cost (26%), costing at USD 26M, and direct non-medical cost (2%), costing at USD 1.7M. This study highlights the magnitude of economic burden of SCZ and informs the policy-makers that there is an inadequate support for SCZ patients. More resources should be allocated to improve the condition of SCZ patients and to reduce the economic burden.

Long-term prosthetic aftercare of direct vs. indirect attachment incorporation techniques to mandibular implant-supported overdenture.

PubMed

Nissan, Joseph; Oz-Ari, Beni; Gross, Ora; Ghelfan, Oded; Chaushu, Gavriel

2011-06-01

The aim of this long-term study was to compare the need for prosthetic aftercare of direct vs. indirect attachment incorporation techniques to mandibular implant-supported overdenture. Forty-five consecutive patients were included (130 implants were placed). Treatment was randomly allocated, resulting in 22 patients (group A) to be treated with direct ball attachment incorporation and 23 patients (group B) to be treated with indirect ball attachment incorporation. All patients were treated by experienced oral-maxillofacial surgeons/periodontists and experienced prosthodontists/residents. From the first day that the patients visited the clinic up to 20 years after the first treatment session, all surgical or prosthetic therapeutic interventions were recorded. The recorded data for the present study included the number of aftercare visits and dental treatment received (pressure sores relieve, liner changes due to loss of retention and attachment replacement due to wear). The mean follow-up was 93±57 months. No implants were lost. Statistical analysis revealed a statistically significantly (P<0.001) greater need for prosthetic interventions in group B vs. group A. The mean number of visits dedicated to - pressure sores relieve (7.04±1.4 vs. 3.63±0.84); liner exchange due to loss of retention (3.6±1.3 vs. 1.09±1.06) was significantly higher in group B. Attachment replacement due to wear occurred only in group B (11/23 - 47.8%). The direct technique for attachment incorporation in mandibular implant-supported overdentures using ball attachments is superior to the indirect technique from the aftercare perspective during a long-term evaluation period. © 2010 John Wiley & Sons A/S.

Ethical and Clinical Considerations at the Intersection of Functional Neuroimaging and Disorders of Consciousness.

PubMed

Byram, Adrian C; Lee, Grace; Owen, Adrian M; Ribary, Urs; Stoessl, A Jon; Townson, Andrea; Illes, Judy

2016-10-01

Recent neuroimaging research on disorders of consciousness provides direct evidence of covert consciousness otherwise not detected clinically in a subset of severely brain-injured patients. These findings have motivated strategic development of binary communication paradigms, from which researchers interpret voluntary modulations in brain activity to glean information about patients' residual cognitive functions and emotions. The discovery of such responsiveness raises ethical and legal issues concerning the exercise of autonomy and capacity for decisionmaking on matters such as healthcare, involvement in research, and end of life. These advances have generated demands for access to the technology against a complex background of continued scientific advancement, questions about just allocation of healthcare resources, and unresolved legal issues. Interviews with professionals whose work is relevant to patients with disorders of consciousness reveal priorities concerning further basic research, legal and policy issues, and clinical considerations.

A Cost Analysis of Kidney Replacement Therapy Options in Palestine

PubMed Central

Jabr, Samer; Al-Khatib, Abdallah; Forgione, Dana; Hartmann, Michael; Kisa, Adnan

2015-01-01

This study provides a cost analysis of kidney replacement therapy options in Palestine. It informs evidence-based resource allocation decisions for government-funded kidney disease services where transplant donors are limited, and some of the common modalities, i.e., peritoneal dialysis (PD) and home hemodialysis (HD), are not widely available due to shortages of qualified staff, specialists, and centers to follow the patient cases, provide training, make home visits, or provide educational programs for patients. The average cost of kidney transplant was US$16 277 for the first year; the estimated cost of HD per patient averaged US$16 085 per year—nearly as much as a transplant. Consistent with prior literature and experience, while live, related kidney donors are scarce, we found that kidney transplant was more adequate and less expensive than HD. These results have direct resource allocation implications for government-funded kidney disease services under Palestinian Ministry of Health. Our findings strongly suggest that investing in sufficient qualified staff, equipment, and clinical infrastructure to replace HD services with transplantation whenever medically indicated and suitable kidney donors are available, as well as deploying PD programs and Home HD programs, will result in major overall cost savings. Our results provide a better understanding of the costs of kidney disease and will help to inform Ministry of Health and related policy makers as they develop short- and long-term strategies for the population, in terms of both cost savings and enhanced quality of life. PMID:25765018

A cost analysis of kidney replacement therapy options in Palestine.

PubMed

Younis, Mustafa; Jabr, Samer; Al-Khatib, Abdallah; Forgione, Dana; Hartmann, Michael; Kisa, Adnan

2015-01-01

This study provides a cost analysis of kidney replacement therapy options in Palestine. It informs evidence-based resource allocation decisions for government-funded kidney disease services where transplant donors are limited, and some of the common modalities, i.e., peritoneal dialysis (PD) and home hemodialysis (HD), are not widely available due to shortages of qualified staff, specialists, and centers to follow the patient cases, provide training, make home visits, or provide educational programs for patients. The average cost of kidney transplant was US$16,277 for the first year; the estimated cost of HD per patient averaged US$16,085 per year--nearly as much as a transplant. Consistent with prior literature and experience, while live, related kidney donors are scarce, we found that kidney transplant was more adequate and less expensive than HD. These results have direct resource allocation implications for government-funded kidney disease services under Palestinian Ministry of Health. Our findings strongly suggest that investing in sufficient qualified staff, equipment, and clinical infrastructure to replace HD services with transplantation whenever medically indicated and suitable kidney donors are available, as well as deploying PD programs and Home HD programs, will result in major overall cost savings. Our results provide a better understanding of the costs of kidney disease and will help to inform Ministry of Health and related policy makers as they develop short- and long-term strategies for the population, in terms of both cost savings and enhanced quality of life. © The Author(s) 2015.

Communal Sharing and the Provision of Low-Volume High-Cost Health Services: Results of a Survey.

PubMed

Richardson, Jeff; Iezzi, Angelo; Chen, Gang; Maxwell, Aimee

2017-03-01

This paper suggests and tests a reason why the public might support the funding of services for rare diseases (SRDs) when the services are effective but not cost effective, i.e. when more health could be produced by allocating funds to other services. It is postulated that the fairness of funding a service is influenced by a comparison of the average patient benefit with the average cost to those who share the cost. Survey respondents were asked to allocate a budget between cost-effective services that had a small effect upon a large number of relatively well patients and SRDs that benefited a small number of severely ill patients but were not cost effective because of their high cost. Part of the budget was always allocated to the SRDs. The budget share rose with the number sharing the cost. Sharing per se appears to characterise preferences. This has been obscured in studies that focus upon cost per patient rather than cost per person sharing the cost.

Comparison of the effects of Truview PCD™ video laryngoscopy and Macintosh blade direct laryngoscopy in geriatric patients.

PubMed

Kurnaz, Muhammed M; Sarıtaş, Aykut

2016-12-01

To compare the effects of Truview PCD™ video laryngoscopy (TVL) and Macintosh blade direct laryngoscopy (MDL) on hemodynamic responses observed during laryngoscopy and orotracheal intubation conditions in geriatric patients. Randomized prospective study. Operating room. One hundred patients in the risk group American Society of Anesthesiologists I to III aged 65 years and older underwent elective surgery under general anesthesia. This prospective study was performed between January 2014 and February 2015 after institutional ethics committee approval. Patients were randomly allocated to 2 groups, namely, TVL and MDL. Hemodynamic parameters, modified Cormack-Lehane grade, intubation period, and preoperative examination (age, sex, American Society of Anesthesiologists, modified Mallampati test score, and thyromental and sternomental distances) of patients were evaluated. There were no statistically significant differences in hemodynamic responses (heart rates and mean arterial pressure) between the 2 groups (P>.05). The median intubation period in the TVL group was significantly higher than observed in the MDL group (t=4.594; P<.05). The laryngoscopy views in TVL group were better than the views in MDL group. The Cormack-Lehane grade in the TVL group was lower when compared to the MDL group. The TVL system does not provide significant hemodynamic response sparing or shorten orotracheal intubation times when compared to MDL in geriatric patients. Copyright © 2016 Elsevier Inc. All rights reserved.

Effectiveness of Different Bristle Designs of Toothbrushes and Periodontal Status among Fixed Orthodontic Patients: A Double-blind Crossover Design.

PubMed

Naik, Sandhya P; Punathil, Sameer; Shetty, Praveena; Jayanti, Ipsita; Jalaluddin, Md; Avijeeta, Anisha

2018-02-01

The aim of the present study was to evaluate the effectiveness of different bristle designs of toothbrushes and the periodontal status among patients undergoing fixed orthodontic treatment. This randomized controlled trial (RCT) consisted of 45 adolescents (comprising 20 males and 25 females) undergoing fixed orthodontic treatment. The study participants were randomly allocated to three groups, each group being assigned a locally available toothbrush with a particular design of toothbrush bristle. In the first test phase, group I study participants were allocated to toothbrush with flat bristles, group II study subjects were allocated to toothbrush with zigzag bristles, and group III study participants were allocated to toothbrush with crisscross bristles. The study participants were recalled after 4 weeks to check the effectiveness of the allocated toothbrushes. A washout period of 1 week was maintained to ensure that there was no carryover effect of the different bristle designs. In the second test phase, each patient used the opposite toothbrush bristle design (group I: toothbrush with zigzag bristles, group II: toothbrush with crisscross bristles, and group III: toothbrush with flat bristles). Plaque scores were measured using Turesky-Gilmore-Glickman modification of Quigley-Hein plaque index (PI). In both phase 1 and 2 of this RCT, toothbrush with crisscross bristles exhibited maximum plaque reduction among the three different bristle design toothbrushes following 30 days (p = 0.312 ± 0.102 and 0.280 ± 0.110, respectively), which was statistically significant. It was concluded that all the three designs of toothbrushes were effective in removing plaque in patients with fixed orthodontic appliances. But among the three different toothbrushes, toothbrush with crisscross bristles showed the highest mean plaque reduction. Plaque accumulation around the orthodontic brackets and gingival margins is quite common among the fixed orthodontic patients, who encounter difficulty in maintaining good oral hygiene. Specially designed toothbrushes are very essential for effective plaque removal among the patients undergoing fixed orthodontic treatment.

[The challenge of adequate reimbursement for the seriously injured patient in the German DRG system].

PubMed

Franz, D; Lefering, R; Siebert, H; Windolf, J; Roeder, N; Mahlke, L

2013-02-01

Critically injured patients are a very heterogeneous group, medically and economically. Their treatment is a major challenge for both the medical care and the appropriate financial reimbursement. Systematic underfunding can have a significant impact on the quality of patient care. In 2009 the German Trauma Society and the DRG-Research Group of the University Hospital Muenster initialised a DRG evaluation project to analyse the validity of case allocation of critically injured patients within the German DRG system versions 2008 and 2011 with additional consideration of clinical data from the trauma registry of the German Trauma Society. Severe deficits within the G-DRG structure were identified and specific solutions were designed and realised. A retrospective analysis was undertaken of standardised G-DRG data (§ 21 KHEntgG) including case-related cost data from 3 362 critically injured patients in the periods 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals. For 1 241 cases of the sample, complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of critically injured patients within the G-DRG system. Analyses of coding and grouping, performance of case allocation, and the homogeneity of costs in the G-DRG versions 2008 and 2011 were done. The following situations were found: (i) systematic underfunding of trauma patients in the G-DRG-Version 2008, especially trauma patients with acute paraplegia; (ii) participation in the official G-DRG development for 2011 with 13 proposals which were largely realised; (ii) the majority of cases with cost-covering in the G-DRG version 2011; (iv) significant improvements in the quality of statistical criteria; (v) overfunded trauma patients with high intensive care costs; (vi) underfunding for clinically relevant critically injured patients not identified in the G-DRG system. The quality of the G-DRG system is measured by the ability to obtain adequate case allocations for highly complex and heterogeneous cases. Specific modifications of the G-DRG structures could increase the appropriateness of case allocation of critically injured patients. Additional consideration of the ISS clinical data must be further evaluated. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical societies in this process. © Georg Thieme Verlag KG Stuttgart · New York.

Addressing the shortage of kidneys for transplantation: purchase and allocation through chain auctions.

PubMed

Rosen, Lara; Vining, Aidan R; Weimer, David L

2011-08-01

Transplantation is generally the treatment of choice for those suffering from kidney failure. Not only does transplantation offer improved quality of life and increased longevity relative to dialysis, it also reduces end-stage renal disease program expenditures, providing savings to Medicare. Unfortunately, the waiting list for kidney transplants is long, growing, and unlikely to be substantially reduced by increases in the recovery of cadaveric kidneys. Another approach is to obtain more kidneys through payment to living "donors," or vendors. Such direct commodification, in which a price is placed on kidneys, has generally been opposed by medical ethicists. Much of the ethical debate, however, has been in terms of commodification through market exchange. Recognizing that there are different ethical concerns associated with the purchase of kidneys and their allocation, it is possible to design a variety of institutional arrangements for the commodification of kidneys that pose different sets of ethical concerns. We specify three such alternatives in detail sufficient to allow an assessment of their likely consequences and we compare these alternatives to current policy in terms of the desirable goals of promoting human dignity, equity, efficiency, and fiscal advantage. This policy analysis leads us to recommend that kidneys be purchased at administered prices by a nonprofit organization and allocated to the transplant centers that can organize the longest chains of transplants involving willing-but-incompatible donor-patient dyads.

Transplantation of A2 and A2B kidneys from deceased donors into B waiting list candidates increases their transplantation rate.

PubMed

Bryan, Christopher F; Nelson, Paul W; Shield, Charles F; Ross, Gilbert; Warady, Bradley; Murillo, Daniel; Winklhofer, Franz T

2004-01-01

Transplant centers in the Midwest Transplant Network began transplanting kidneys from A2 or A2B donors into blood group B and O patients in 1986. Since 1991, an OPTN/UNOS variance has permitted us to allocate these kidneys preferentially into B and O waiting list patients. With more than 10 years of experience we have noted the following: 1. Thirty-one percent more blood group B patients were transplanted by allocating them A2 or A2B kidneys from our deceased donors. 2. Ten-year graft survival for B recipients of an A2 or A2B kidney (72%) was equivalent to that for B recipients of a B kidney (69%). 3. Type B recipients of simultaneous pancreas-kidney transplants (n=4) also did well with A2 or A2B organs. 4. Non-A recipients were transplanted only when their anti-A IgG titer history was consistently low (< or =4). 5. Most (90%) blood group B patients had a low anti-A IgG titer history; whereas, only one-third of blood group O patients had a low titer history. 6. Neither ethnicity nor HLA class I sensitization level influenced the anti-A IgG titer history. 7. In an OPO with mostly (87%) white donors, nearly 20% of blood group A donors were A2. 8. Waiting time until transplantation was lower for B patients who received an A2 or A2B kidney than for those who received a B or O kidney. 9. Our OPO blood group B waiting list was reduced from 25 low PRA (<40%) B candidates in 1994 to 4 in July, 2004. 10. Blood group A candidates received 6.4% fewer transplants with our A2/A2B--> B allocation algorithm. 11. Minority patients were transplanted at the same rate when using the A2/A2B--> B allocation algorithm as when using the standard UNOS algorithm for allocating B and O kidneys--> B patients.

Control allocation for gimballed/fixed thrusters

NASA Astrophysics Data System (ADS)

Servidia, Pablo A.

2010-02-01

Some overactuated control systems use a control distribution law between the controller and the set of actuators, usually called control allocator. Beyond the control allocator, the configuration of actuators may be designed to be able to operate after a single point of failure, for system optimization and/or decentralization objectives. For some type of actuators, a control allocation is used even without redundancy, being a good example the design and operation of thruster configurations. In fact, as the thruster mass flow direction and magnitude only can be changed under certain limits, this must be considered in the feedback implementation. In this work, the thruster configuration design is considered in the fixed (F), single-gimbal (SG) and double-gimbal (DG) thruster cases. The minimum number of thrusters for each case is obtained and for the resulting configurations a specific control allocation is proposed using a nonlinear programming algorithm, under nominal and single-point of failure conditions.

STEMS pilot trial: a pilot cluster randomised controlled trial to investigate the addition of patient direct access to physiotherapy to usual GP-led primary care for adults with musculoskeletal pain

PubMed Central

Ogollah, Reuben O; Jowett, Sue; Kigozi, Jesse; Tooth, Stephanie; Protheroe, Joanne; Hay, Elaine M; Salisbury, Chris; Foster, Nadine E

2017-01-01

Introduction Around 17% of general practitioner (GP) consultations are for musculoskeletal conditions, which will rise as the population ages. Patient direct access to physiotherapy provides one solution, yet adoption in the National Health Service (NHS) has been slow. Setting A pilot, pragmatic, non-inferiority, cluster randomised controlled trial (RCT) in general practice and physiotherapy services in the UK. Objectives Investigate feasibility of a main RCT. Participants Adult patients registered in participating practices and consulting with a musculoskeletal problem. Interventions 4 general practices (clusters) randomised to provide GP-led care as usual or the addition of a patient direct access to physiotherapy pathway. Outcomes Process outcomes and exploratory analyses of clinical and cost outcomes. Data collection Participant-level data were collected via questionnaires at identification, 2, 6 and 12 months and through medical records. Blinding The study statistician and research nurses were blinded to practice allocation. Results Of 2696 patients invited to complete study questionnaires, 978 participated (intervention group n=425, control arm n=553) and were analysed. Participant recruitment was completed in 6 months. Follow-up rates were 78% (6 months) and 71% (12 months). No evidence of selection bias was observed. The direct access pathway was used by 90% of patients in intervention practices needing physiotherapy. Some increase in referrals to physiotherapy occurred from one practice, although waiting times for physiotherapy did not increase (28 days before, 26 days after introduction of direct access). No safety issues were identified. Clinical and cost outcomes were similar in both groups. Exploratory estimates of between group effect (using 36-item Short Form Health Survey (SF-36) Physical Component Summary (PCS)) at 6 months was −0.28 (95% CI −1.35 to 0.79) and at 12 months 0.12 (95% CI −1.27 to 1.51). Conclusions A full RCT is feasible and will provide trial evidence about the clinical and cost-effectiveness of patient direct access to physiotherapy. Trial registration number ISRCTN23378642. PMID:28286331

Evaluation of a patient navigation program.

PubMed

Koh, Catherine; Nelson, Joan M; Cook, Paul F

2011-02-01

This study examined the value and effectiveness of a patient navigation program in terms of timeliness of access to cancer care, resolution of barriers, and satisfaction in 55 patients over a six-month period. Although not statistically significant, the time interval between diagnostic biopsy to first consultation with a cancer specialist after program implementation was reduced from an average of 14.6 days to 12.8 days. The time interval between diagnostic biopsy to initiation of cancer treatment also was reduced from 30 days to 26.2 days (not statistically significant). In addition, 71% of patient barriers were resolved by the time treatment was initiated. Overall, patients were highly satisfied with their navigated care experience. Consistent evaluation and monitoring of quality-of-care indicators are critical to further develop the program and to direct resource allocation. Oncology nurses participating in patient navigation programs should be encouraged to evaluate their importance and impact in this developing concept. Nurses should seek roles that allow them to optimize the effective use of their specialized knowledge and skills to the benefit of patients along the cancer care continuum.

Practice expenses in the MFS (Medicare fee schedule): the service-class approach.

PubMed

Latimer, E A; Kane, N M

1995-01-01

The practice expense component of the Medicare fee schedule (MFS), which is currently based on historical charges and rewards physician procedures at the expense of cognitive services, is due to be changed by January 1, 1998. The Physician Payment Review Commission (PPRC) and others have proposed microcosting direct costs and allocating all indirect costs on a common basis, such as physician time or work plus direct costs. Without altering the treatment of direct costs, the service-class approach disaggregates indirect costs into six practice function costs. The practice function costs are then allocated to classes of services using cost-accounting and statistical methods. This approach would make the practice expense component more resource-based than other proposed alternatives.

Kidney transplantation in the elderly.

PubMed

Singh, Neeraj; Nori, Uday; Pesavento, Todd

2009-08-01

Recent outcome data, ongoing organ shortage and proposed changes in allocation policies are driving the need to review current practices and possible future course of kidney transplantation in the elderly patients. A proposed new kidney allocation system based on matching donor and recipient characteristics to enable 'age-matched' kidney allocation is currently being discussed in the USA. While this system benefits younger recipients, implications for elderly recipients receiving older grafts remain a matter of debate. Despite improved outcomes, there remain significant challenges to kidney transplantation in the elderly, including organ shortage, poor transplant rate, evolving allocation policies, high wait-list mortality and nonstandardized immunosuppression. Prospective studies are needed to evaluate the strategies to meet these challenges and to study the impact of proposed new allocation system.

Patient- and ward-level determinants of nursing time in nursing facilities.

PubMed

Laine, Juha; Noro, Anja; Finne-Soveri, Harriet; Häkkinen, Unto

2005-10-01

To explore the patient- and ward-level determinants of wage-adjusted nursing time in long-term care wards for the elderly with a view to improving efficiency of the use of labour resources. The wage-adjusted nursing time given to patients was obtained from a time measurement study. Patient characteristics were based on the Minimum Data Set 2.0 of the Resident Assessment Instrument for nursing homes. Ordinary least-squares regression analysis and multilevel modelling were used to disentangle the effect of patient- and ward-level factors on nursing time. A significant difference in wage-adjusted nursing time between wards was detected, which was partly explained by characteristics of patients in wards. The combination of patients' physical functioning and cognition and the Resource Utilization Groups RUG-III/22 resource use classification explained 20-25% of patients' nursing time over a 24-hour period. Variables related to the operational environment of the ward did not explain differences in wage-adjusted nursing time once the patient profile of the ward had been controlled for. The results also showed notable unmeasured patient and ward level effects, inefficiency and randomness in the allocation of nursing time. By improving the allocation and use of labour resources, the substantial variation in nursing time between wards could be diminished. Managers should allocate their staff primarily according to patients' resource needs.

77 FR 23462 - Submission for OMB Review; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2012-04-19

... this law allocates the Aleutian Islands (AI) directed pollock fishery to the Aleut Corporation for... agents for activities necessary for conducting the AI directed pollock fishery. Management provisions for the AI directed pollock fishery include: restrictions on the harvest specifications for the AI...

Health care costs attributable to the treatment of rheumatoid arthritis.

PubMed

Sørensen, J

2004-01-01

A 'programme budget' for the resources used in the treatment and care of patients with rheumatoid arthritis (RA) was developed with a view of helping decision-makers assess the appropriateness of the current use of resources and to discuss future resource allocation. The programme budget was developed using data from several national administrative registers. Patients with RA were identified by hospital diagnostic codes. The incremental cost of treating RA was defined as the difference in resource use for patients with and without RA. Incremental mortality due to RA was defined in similar way. Cost data were estimated for 5-year age groups. Patients with RA used on average 3.2 times as many health care resources as people without RA. The average 1997 incremental costs of primary and hospital care were EUR 253 and EUR 2.660 per patient respectively, corresponding to a national incremental cost of EUR 30 million (2000 price level). RA resulted in an annual loss of 1,549 life years. The programme budget approach is a useful tool in resource allocation decision-making, but discussions of alternative resource allocations must be based on robust studies of effectiveness and cost-effectiveness in the treatment of patients with RA.

Does Distraction Reduce the Alcohol-Aggression Relation? A Cognitive and Behavioral Test of the Attention-Allocation Model

ERIC Educational Resources Information Center

Gallagher, Kathryn E.; Parrott, Dominic J.

2011-01-01

Objective: This study provided the first direct test of the cognitive underpinnings of the attention-allocation model and attempted to replicate and extend past behavioral findings for this model as an explanation for alcohol-related aggression. Method: A diverse community sample (55% African American) of men (N = 159) between 21 and 35 years of…

Cost Allocation Plans for Municipalities for Internal Management and Grant Programs.

DTIC Science & Technology

1981-03-01

21 3. Indirect Cost --------------------------------- 23 4. S ummary--------------------------------------- 25 D. RESPONSIBILITY ACCOUNTING ...depart- ments or operating units. Z-7:6747 In Cost Accounting - A Managerial Emphasis by Charles T. Horngren the word direct refers to the practicable...INDIRECT COST POOL -- COST ALLOCATION BASE -- COST FINDING In Cost Accounting : A Managerial Emphasis, Charles T. Horngren states: There are

76 FR 6083 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pollock in the Bering Sea...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-02-03

... annual AI pollock TAC, after subtracting first for the CDQ directed fishing allowance (10 percent) and... AI subarea, the A season is allocated 40 percent of the ABC and the B season is allocated the... to the public interest as it would prevent NMFS from responding to the most recent fisheries data in...

76 FR 466 - Fisheries of the Exclusive Economic Zone Off Alaska; Inseason Adjustment to the 2011 Bering Sea...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-01-05

... annual AI pollock TAC, after subtracting first for the CDQ directed fishing allowance (10 percent) and... AI subarea, the A season is allocated 40 percent of the ABC and the B season is allocated the... it would prevent NMFS from responding to the most recent fisheries data in a timely fashion and would...

75 FR 54792 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pollock in the Bering Sea...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-09-09

... applicable BSAI sectors and, (2) the harvest capacity and stated intent on future harvesting patterns of... (ii), the annual AI pollock TAC, after subtracting first for the CDQ directed fishing allowance--10.... In the AI subarea, the A season is allocated 40 percent of the ABC and the B season is allocated the...

77 FR 57192 - Proposed Collection; Comment Request for Form 5735 and Schedule P (Form 5735)

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-17

... Schedule P (Form 5735), Allocation of Income and Expenses Under Section 936(h)(5). DATES: Written comments should be received on or before November 16, 2012 to be assured of consideration. ADDRESSES: Direct all... and 30A), and Allocation of Income and Expenses Under Section 936(h)(5). OMB Number: 1545-0217. Form...

77 FR 34262 - Fisheries of the Exclusive Economic Zone Off Alaska; Pacific Ocean Perch in the Western Aleutian...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-11

.... 111213751-2102-02] RIN 0648-XC061 Fisheries of the Exclusive Economic Zone Off Alaska; Pacific Ocean Perch.... ACTION: Temporary rule; closure. SUMMARY: NMFS is prohibiting directed fishing for Pacific ocean perch in... allocation of Pacific ocean perch in this area allocated to vessels participating in the BSAI trawl limited...

75 FR 69600 - Fisheries of the Exclusive Economic Zone Off Alaska; Pacific Ocean Perch in the Eastern Aleutian...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-15

.... 0910131363-0087-02] RIN 0648-XA034 Fisheries of the Exclusive Economic Zone Off Alaska; Pacific Ocean Perch.... ACTION: Temporary rule; closure. SUMMARY: NMFS is prohibiting directed fishing for Pacific ocean perch in... allocation of Pacific ocean perch in this area allocated to vessels participating in the BSAI trawl limited...

76 FR 43933 - Fisheries of the Exclusive Economic Zone Off Alaska; Pacific Ocean Perch in the Western Aleutian...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-07-22

.... 101126521-0640-02] RIN 0648-XA589 Fisheries of the Exclusive Economic Zone Off Alaska; Pacific Ocean Perch.... ACTION: Temporary rule; closure. SUMMARY: NMFS is prohibiting directed fishing for Pacific ocean perch in... allocation of Pacific ocean perch in this area allocated to vessels participating in the BSAI trawl limited...

76 FR 65972 - Fisheries of the Exclusive Economic Zone Off Alaska; Pacific Ocean Perch in the Eastern Aleutian...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-10-25

.... 101126521-0640-02] RIN 0648-XA782 Fisheries of the Exclusive Economic Zone Off Alaska; Pacific Ocean Perch.... ACTION: Temporary rule; closure. SUMMARY: NMFS is prohibiting directed fishing for Pacific ocean perch in... allocation of Pacific ocean perch in this area allocated to vessels participating in the BSAI trawl limited...

75 FR 69601 - Fisheries of the Exclusive Economic Zone Off Alaska; Pacific Ocean Perch in the Central Aleutian...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-15

.... 0910131363-0087-02] RIN 0648-XA035 Fisheries of the Exclusive Economic Zone Off Alaska; Pacific Ocean Perch.... ACTION: Temporary rule; closure. SUMMARY: NMFS is prohibiting directed fishing for Pacific ocean perch in... allocation of Pacific ocean perch in this area allocated to vessels participating in the BSAI trawl limited...

77 FR 39440 - Fisheries of the Exclusive Economic Zone Off Alaska; Pacific Ocean Perch in the Central Aleutian...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-07-03

.... 111213751-2102-02] RIN 0648-XC085 Fisheries of the Exclusive Economic Zone Off Alaska; Pacific Ocean Perch.... ACTION: Temporary rule; closure. SUMMARY: NMFS is prohibiting directed fishing for Pacific ocean perch in... allocation of Pacific ocean perch in this area allocated to vessels participating in the BSAI trawl limited...

75 FR 69601 - Fisheries of the Exclusive Economic Zone Off Alaska; Pacific Ocean Perch in the Western Aleutian...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-11-15

.... 0910131363-0087-02] RIN 0648-XA036 Fisheries of the Exclusive Economic Zone Off Alaska; Pacific Ocean Perch.... ACTION: Temporary rule; closure. SUMMARY: NMFS is prohibiting directed fishing for Pacific ocean perch in... allocation of Pacific ocean perch in this area allocated to vessels participating in the BSAI trawl limited...

Harnessing Scientific and Technological Advances to Improve Equity in Kidney Allocation Policies.

PubMed

Tambur, A R; Audry, B; Antoine, C; Suberbielle, C; Glotz, D; Jacquelinet, C

2017-12-01

We reported that current assignment of HLA-DQ is a barrier to organ allocation. Here we simulated the impact of incorporating HLA-DQ antigens and antibodies as A/B and αβ allelic variants, respectively, on calculated panel reactive antibody (cPRA) and probability of finding potential compatible donors (PCD). A cohort of 1224 donors and 2075 sensitized candidates was analyzed using HLA-DQαβ allelic (study) versus serologic (current practice) nomenclature. A significant (p < 10 -4 ) decrease in cPRA was observed with higher impact for male versus female, and first transplant versus retransplant (p < 10 -4 ), affecting mostly patients with moderate cPRA (30-80%). Consequently, the number of patients qualifying for 100% cPRA points according to the United Network for Organ Sharing-Kidney Allocation System decreased by 37%. More critically, by using allelic versus serologic nomenclature for HLA-DQ, the number of PCDs for all patients was increased, with male and first-transplant patients showing a higher expansion compared with female and retransplants. Patients of blood group O showed the highest benefit. The goal of reporting unacceptable antigens is to improve accuracy of virtual crossmatching and increase the likelihood of finding immunologically compatible donors. Our simulation provides strong support for the need to re-evaluate the use of allele typing and how HLA-DQ antigens and antibodies are incorporated into allocation policies to ensure equity. © 2017 The American Society of Transplantation and the American Society of Transplant Surgeons.

Access to kidney transplantation in European adults aged 75-84 years and related outcomes: an analysis of the European Renal Association-European Dialysis and Transplant Association Registry.

PubMed

Pippias, Maria; Stel, Vianda S; Kramer, Anneke; Abad Diez, Jose M; Aresté-Fosalba, Nuria; Ayav, Carole; Buturovic, Jadranka; Caskey, Fergus J; Collart, Frederic; Couchoud, Cécile; De Meester, Johan; Heaf, James G; Helanterä, Ilkka; Hemmelder, Marc H; Kostopoulou, Myrto; Noordzij, Marlies; Pascual, Julio; Palsson, Runolfur; Reisaeter, Anna Varberg; Traynor, Jamie P; Massy, Ziad; Jager, Kitty J

2018-05-01

To what extent access to, and allocation of kidney transplants and survival outcomes in patients aged ≥75 years have changed over time in Europe is unclear. We included patients aged ≥75-84 years (termed older adults) receiving renal replacement therapy in thirteen European countries between 2005 and 2014. Country differences and time trends in access to, and allocation of kidney transplants were examined. Survival outcomes were determined by Cox regression analyses. Between 2005 and 2014, 1392 older adult patients received 1406 transplants. Access to kidney transplantation varied from ~0% (Slovenia, Greece and Denmark) to ~4% (Norway and various Spanish regions) of all older adult dialysis patients, and overall increased from 0.3% (2005) to 0.9% (2014). Allocation of kidney transplants to older adults overall increased from 0.8% (2005) to 3.2% (2014). Seven-year unadjusted patient and graft survival probabilities were 49.1% (95% confidence interval, 95% CI: 43.6; 54.4) and 41.7% (95% CI: 36.5; 46.8), respectively, with a temporal trend towards improved survival outcomes. In conclusion, in the European dialysis population aged ≥75-84 years access to kidney transplantation is low, and allocation of kidney transplants remains a rare event. Though both are increasing with time and vary considerably between countries. The trend towards improved survival outcomes is encouraging. This information can aid informed decision-making regarding treatment options. © 2018 Steunstichting ESOT.

Resource allocation in public health practice: a national survey of local public health officials.

PubMed

Baum, Nancy M; DesRoches, Catherine; Campbell, Eric G; Goold, Susan Dorr

2011-01-01

The purpose of this study was to gain an empirical understanding of the types of allocation decisions local health officials (LHOs) make and the factors that influence those allocation decisions. We conducted a national survey of LHOs in the United States in 2008 to 2009. The sample was stratified by the size of the population served by the department. We merged our data with data from the 2008 National Association of County and City Health Officials Profile survey. Descriptive statistics were generated using weighted data. Our final sample size was 608 respondents, with an average of 10 years experience. The LHOs reported little shifting of resources among population groups but greater capacity to redirect staffing time. Less than half of LHOs reported using economic analyses or conducting needs assessments when setting priorities. Having sole provider status in a community strongly influenced LHOs' allocation decisions. In addition, the effectiveness of activities, previous budget allocations, and input from boards of health were influential factors in allocation decisions. Public expectations were moderately to very influential, but direct public input had a low impact on allocation decisions. Survey findings provide a clearer understanding of how LHOs fulfill their obligations as stewards of public health resources and ensure effective activities and access to needed services. It may be useful to assess the value of more structured allocation methods (eg, decision frameworks) in the allocation process. Expanding opportunities for public engagement in priority setting may also be valuable for difficult allocation decisions.

A pollutant load hierarchical allocation method integrated in an environmental capacity management system for Zhushan Bay, Taihu Lake.

PubMed

Liang, Shidong; Jia, Haifeng; Yang, Cong; Melching, Charles; Yuan, Yongping

2015-11-15

An environmental capacity management (ECM) system was developed to help practically implement a Total Maximum Daily Load (TMDL) for a key bay in a highly eutrophic lake in China. The ECM system consists of a simulation platform for pollutant load calculation and a pollutant load hierarchical allocation (PLHA) system. The simulation platform was developed by linking the Environmental Fluid Dynamics Code (EFDC) and Water Quality Analysis Simulation Program (WASP). In the PLHA, pollutant loads were allocated top-down in several levels based on characteristics of the pollutant sources. Different allocation methods could be used for the different levels with the advantages of each method combined over the entire allocation. Zhushan Bay of Taihu Lake, one of the most eutrophic lakes in China, was selected as a case study. The allowable loads of total nitrogen, total phosphorus, ammonia, and chemical oxygen demand were found to be 2122.2, 94.9, 1230.4, and 5260.0 t·yr(-1), respectively. The PLHA for the case study consists of 5 levels. At level 0, loads are allocated to those from the lakeshore direct drainage, atmospheric deposition, internal release, and tributary inflows. At level 1 the loads allocated to tributary inflows are allocated to the 3 tributaries. At level 2, the loads allocated to one inflow tributary are allocated to upstream areas and local sources along the tributary. At level 3, the loads allocated to local sources are allocated to the point and non-point sources from different towns. At level 4, the loads allocated to non-point sources in each town are allocated to different villages. Compared with traditional forms of pollutant load allocation methods, PLHA can combine the advantages of different methods which put different priority weights on equity and efficiency, and the PLHA is easy to understand for stakeholders and more flexible to adjust when applied in practical cases. Copyright © 2015 Elsevier B.V. All rights reserved.

Donor-estimated GFR as an appropriate criterion for allocation of ECD kidneys into single or dual kidney transplantation.

PubMed

Snanoudj, R; Rabant, M; Timsit, M O; Karras, A; Savoye, E; Tricot, L; Loupy, A; Hiesse, C; Zuber, J; Kreis, H; Martinez, F; Thervet, E; Méjean, A; Lebret, T; Legendre, C; Delahousse, M

2009-11-01

It has been suggested that dual kidney transplantation (DKT) improves outcomes for expanded criteria donor (ECD) kidneys. However, no criteria for allocation to single or dual transplantation have been assessed prospectively. The strategy of DKT remains underused and potentially eligible kidneys are frequently discarded. We prospectively compared 81 DKT and 70 single kidney transplant (SKT) receiving grafts from ECD donors aged >65 years, allocated according to donor estimated glomerular filtration rate (eGFR): DKT if eGFR between 30 and 60 mL/min, SKT if eGFR greater than 60 mL/min. Patient and graft survival were similar in the two groups. In the DKT group, 13/81 patients lost one of their two kidneys due to hemorrhage, arterial or venous thrombosis. Mean eGFR at month 12 was similar in the DKT and SKT groups (47.8 mL/min and 46.4 mL/min, respectively). Simulated allocation of kidneys according to criteria based on day 0 donor parameters such as those described by Remuzzi et al., Andres et al. and UNOS, did not indicate an improvement in 12-month eGFR compared to our allocation based on donor eGFR.

Criteria for site selection and frequency allocation (keynote paper), part 5

NASA Technical Reports Server (NTRS)

Rottger, J.

1985-01-01

Technical aspects of mesosphere-stratosphere-troposphere (MST) Radar on site and frequency selection were discussed. Recommendations on site selections are presented. Tests of interference will be conducted before selecting a site. A small directional antenna may be suitable to simulate sidelobe sensitivity of radars however, sophisticated data-processing methods make system sensitivity extremely good. The use of the complete data system to look for interference is recommended. There is the difficulty of allocation of frequencies -- almost continuous use by these radars will be made when the band 40 to 60 MHz is allocated to other services.

Nash Social Welfare in Multiagent Resource Allocation

NASA Astrophysics Data System (ADS)

Ramezani, Sara; Endriss, Ulle

We study different aspects of the multiagent resource allocation problem when the objective is to find an allocation that maximizes Nash social welfare, the product of the utilities of the individual agents. The Nash solution is an important welfare criterion that combines efficiency and fairness considerations. We show that the problem of finding an optimal outcome is NP-hard for a number of different languages for representing agent preferences; we establish new results regarding convergence to Nash-optimal outcomes in a distributed negotiation framework; and we design and test algorithms similar to those applied in combinatorial auctions for computing such an outcome directly.

Positron emission tomography/computed tomography with 18F-fluorocholine improve tumor staging and treatment allocation in patients with hepatocellular carcinoma.

PubMed

Chalaye, Julia; Costentin, Charlotte E; Luciani, Alain; Amaddeo, Giuliana; Ganne-Carrié, Nathalie; Baranes, Laurence; Allaire, Manon; Calderaro, Julien; Azoulay, Daniel; Nahon, Pierre; Seror, Olivier; Mallat, Ariane; Soussan, Michael; Duvoux, Christophe; Itti, Emmanuel; Nault, Jean Charles

2018-03-06

Hepatocellular carcinoma (HCC) staging according to the Barcelona Clinical Liver Cancer (BCLC) classification is based on conventional imaging. The aim of our study was to assess the impact of dual-tracer 18F-fluorocholine and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) on tumor staging and treatment allocation. A total of 192 dual-tracer PET/CT scans (18F-fluorocholine and 18F-fluorodeoxyglucose PET/CT) were performed in 177 patients with HCC. BCLC staging and treatment proposal were retrospectively collected based on conventional imaging, along with any new lesions detected, and changes in BCLC classification or treatment allocation based on dual-tracer PET/CT. Patients were primarily men (87.5%) with cirrhosis (71%) due to alcohol ± non-alcoholic steatohepatitis (26%), viral infection (62%) or unknown causes (12%). Among 122 patients with PET/CT performed for staging, BCLC stage based on conventional imaging was 0/A in 61 patients (50%), B in 32 patients (26%) and C in 29 patients (24%). Dual-tracer PET/CT detected new lesions in 26 patients (21%), upgraded BCLC staging in 14 (11%) and modified treatment strategy in 17 (14%). In addition, dual-tracer PET/CT modified the final treatment in 4/9 (44%) patients with unexplained elevation of alpha-fetoprotein (AFP), 10/25 patients (40%) with doubtful lesions on conventional imaging and 3/36 patients (8%) waiting for liver transplantation without active HCC after tumor response following bridging therapy. When used for HCC staging, dual-tracer PET/CT enabled BCLC upgrading and treatment modification in 11% and 14% of patients, respectively. Dual-tracer PET/CT might also be useful in specific situations (an unexplained rise in AFP, doubtful lesions or pre-transplant evaluation of patients without active HCC). Using a combination of tracers 18F-fluorocholine and 18F-fluorodeoxyglucose when performing positron emission tomography/computed tomography (PET/CT), often called a PET scan, helps to identify new tumor lesions in patients with hepatocellular carcinoma. This technique enabled staging modification of patients' tumors and led to changes in treatment allocation in certain patients. Copyright © 2018. Published by Elsevier B.V.

Transcutaneous tibial nerve stimulation in the treatment of lower urinary tract symptoms and its impact on health-related quality of life in patients with Parkinson disease: a randomized controlled trial.

PubMed

Perissinotto, Maria Carolina; DʼAncona, Carlos Arturo Levi; Lucio, Adélia; Campos, Renata Martins; Abreu, Anelyssa

2015-01-01

A randomized controlled trial study was performed to evaluate the efficacy of transcutaneous tibial nerve stimulation (TTNS) and sham TTNS, in patients with Parkinson disease (PD) with lower urinary tract symptoms (LUTS). Randomized controlled trial. Thirteen patients with a diagnosis of PD and bothersome LUTS were randomly allocated to one of the following groups: Group I: TTNS group (n = 8) and group II: Sham group (n = 5). Both groups attended twice a week during 5 weeks; each session lasted 30 minutes. Eight patients received TTNS treatment and 5 subjects allocated to group II were managed with sham surface electrodes that delivered no electrical stimulation. Assessments were performed before and after the treatment; they included a 3-day bladder diary, Overactive Bladder Questionnaire (OAB-V8), and the International Consultation on Incontinence Quality of Life Questionnaire Short Form (ICIQ-SF), and urodynamic evaluation. Following 5 weeks of treatment, patients allocated to TTNS demonstrated statistically significant reductions in the number of urgency episodes (P = .004) and reductions in nocturia episodes (P < .01). Participants allocated to active treatment also showed better results after treatment in the OAB-V8 and ICIQ-SF scores (P < .01, respectively). Urodynamic testing revealed that patients in the active treatment group showed improvements in intravesical volume at strong desire to void (P < .05) and volume at urgency (P < .01) when compared to subjects in the sham treatment group. These findings suggest that TTNS is effective in the treatment of LUTS in patients with PD, reducing urgency and nocturia episodes and improving urodynamic parameters as well as symptom scores measured by the OAB-V8 and health-related quality-of-life scores measured by the ICIQ-SF.

401(k) plan asset allocation, account balances, and loan activity.

PubMed

VanDerhei, J; Galer, R; Quick, C; Rea, J

1999-01-01

The Employee Benefit Research Institute (EBRI) and the Investment Company Institute (ICI) have been collaborating for the past two years to collect data on participants in 401(k) plans. This effort, known as the EBRI/ICI Participant-Directed Retirement Plan Data Collection Project, has obtained data for 401(k) plan participants from certain of EBRI and ICI sponsors and members serving as plan recordkeepers and administrators. The report includes 1996 information on 6.6 million active participants in 27,762 plans holding nearly $246 billion in assets. The data include demographic information, annual contributions, plan balances, asset allocation, and loans, and are currently the most comprehensive source of information on individual plan participants. In 1996, the first year for which data are ready for analysis, the EBRI/ICI database appears to be broadly representative of the universe of 401(k) plans. Key findings include: for all participants, 44.0 percent of the total plan balance is invested in equity funds, 19.1 percent in employer stock, 15.1 percent in guaranteed investment contracts (GICs), 7.8 percent in balanced funds, 6.8 percent in bond funds, 5.4 percent in money funds, 0.8 percent in other stable value funds, and 1.0 percent in other or unidentified investments. This allocation implies that over two-thirds of plan balances are invested directly or indirectly in equity securities. Asset allocation varies with age. For instance, on average, individuals in their twenties invested 76.8 percent of assets in equities and only 22.1 percent in fixed-income investments. By comparison, individuals in their sixties invested 53.2 percent of their assets in equities and 45.9 percent of assets in fixed-income investments. Investment options offered by 401(k) plans appear to influence asset allocation. For example, the addition of company stock substantially reduces the allocation to equity funds and the addition of GICs lowers allocations to bond and money funds. Employer contributions in the form of company stock affect participant allocation behavior. Participants in plans in which employer contributions are made in company stock appear to decrease allocations to equity funds and to increase the allocation of company stock in self-directed balances. The average account balance (net of plan loans) for all participants is $37,323. The balances, however, represent only amounts with current employers and do not include amounts remaining in the plans of prior employers. Nor do the balances indicate what savings would be in a "mature" 401(k) plan program. The average balances of older workers with long tenure at one employer indicate that a mature 401(k) plan program will produce substantial account balances. For example, individuals in their sixties with at least 30 years of tenure have average account balances in excess of $156,000; those in their fifties have balances in excess of $117,000.

Global trends and challenges in deceased donor kidney allocation.

PubMed

Wu, Diana A; Watson, Christopher J; Bradley, J Andrew; Johnson, Rachel J; Forsythe, John L; Oniscu, Gabriel C

2017-06-01

Worldwide, the number of patients able to benefit from kidney transplantation is greatly restricted by the severe shortage of deceased donor organs. Allocation of this scarce resource is increasingly challenging and complex. Striking an acceptable balance between efficient use of (utility) and fair access to (equity) the limited supply of donated kidneys raises controversial but important debates at ethical, medical, and social levels. There is no international consensus on the recipient and donor factors that should be considered in the kidney allocation process. There is a general trend toward a reduction in the influence of human leukocyte antigen mismatch and an increase in the importance of other factors shown to affect posttransplant outcomes, such as cold ischemia, duration of dialysis, donor and recipient age, and comorbidity. Increased consideration of equity has led to improved access to transplantation for disadvantaged patient groups. There has been an overall improvement in the transparency and accountability of allocation policies. Novel and contentious approaches in kidney allocation include the use of survival prediction scores as a criterion for accessing the waiting list and at the point of organ offering with matching of predicted graft and recipient survival. This review compares the diverse international approaches to deceased donor kidney allocation and their evolution over the last decade. Copyright © 2017 International Society of Nephrology. Published by Elsevier Inc. All rights reserved.

The organ transplantation act and recent trends in Korea.

PubMed

Joo, Ho No

2013-03-01

The Organ Transplantation Act, including transplantation of organs from brain-dead donors, entered into force in Korea on February 9, 2000. This article introduces the Organ Transplantation Act, focusing on scope of the Act, determination of brain death, removal of organs from brain-dead or deceased donors, removal from living donors, organ allocation, and prohibition of trade in human organs. Especially, some primary ethical dilemmas surrounding organ allocation arise from the shortage of available organs. The primary ethical problems surrounding organ allocation are as follows. A key purpose of the organ donation incentive system is to increase the number of organ transplants from brain-dead donors. In particular, the priority for kidney patient was allowed in consideration of doctor's strong desire to increase the brain-dead donors. Also, the organ allocation criteria based on the organ donation incentive system appear unfair, especially for the kidney patient, because the criteria do not fit the principles of distributive justice. In the future, the organ donation incentive system itself may need to be reexamined.

An educational intervention to reduce pain and improve pain management for Malawian people living with HIV/AIDS and their family carers: study protocol for a randomised controlled trial.

PubMed

Nkhoma, Kennedy; Seymour, Jane; Arthur, Antony

2013-07-13

Many HIV/AIDS patients experience pain often due to advanced HIV/AIDS infection and side effects of treatment. In sub-Saharan Africa, pain management for people with HIV/AIDS is suboptimal. With survival extended as a direct consequence of improved access to antiretroviral therapy, the prevalence of HIV/AIDS related pain is increasing. As most care is provided at home, the management of pain requires patient and family involvement. Pain education is an important aspect in the management of pain in HIV/AIDS patients. Studies of the effectiveness of pain education interventions for people with HIV/AIDS have been conducted almost exclusively in western countries. A randomised controlled trial is being conducted at the HIV and palliative care clinics of two public hospitals in Malawi. To be eligible, patient participants must have a diagnosis of HIV/AIDS (stage III or IV). Carer participants must be the individual most involved in the patient's unpaid care. Eligible participants are randomised to either: (1) a 30-minute face-to-face educational intervention covering pain assessment and management, augmented by a leaflet and follow-up telephone call at two weeks; or (2) usual care. Those allocated to the usual care group receive the educational intervention after follow-up assessments have been conducted (wait-list control group). The primary outcome is pain severity measured by the Brief Pain Inventory. Secondary outcomes are pain interference, patient knowledge of pain management, patient quality of life, carer knowledge of pain management, caregiver motivation and carer quality of life. Follow-up assessments are conducted eight weeks after randomisation by palliative care nurses blind to allocation. This randomised controlled trial conducted in sub-Saharan Africa among people living with HIV/AIDS and their carers will assess whether a pain education intervention is effective in reducing pain and improving pain management, quality of life and carer motivation. Current Controlled Trials ISRCTN72861423.

Share 35 Changes Center Level Liver Acceptance Practices

PubMed Central

Goldberg, David S.; Levine, Matthew; Karp, Seth; Gilroy, Richard; Peter, L

2017-01-01

Share 35 was implemented to provide improved access to organs for patients with MELD scores ≥35. However, little is known about the impact of Share 35 on organ offer acceptance rates. We evaluated all liver offers to adult patients that were ultimately transplanted between 1/1/2011–12/31/2015. The analyses focused on patients ranked in the top five positions of a given match run, and used multi-level mixed-effects models, clustering on individual waitlist candidate and transplant center. There was a significant interaction between Share 35 era and MELD category (p<0.001). Comparing offers to MELD score ≥35 patients, offers post-Share 35 were 36% less likely to be accepted compared to offers to MELD score ≥35 patients pre-Share 35 (adjusted OR: 0.64). There was no clinically meaningful difference in the DRI of livers that were declined for patients with an allocation MELD score ≥35 in the pre- vs post-Share 35 era. Organ offer acceptance rates for patients with an allocation MELD≥35 decreased in every region post-Share 35; the magnitude of these changes was bigger in regions 2, 3, 4, 5, 6, 7, and 11, compared to regions 8 and 9 that had regional sharing in place pre-Share 35. There were significant changes in organ offer acceptance rates at the center level pre- vs post-Share 35, and these changes varied across centers (p<0.001). Conclusions In liver transplant candidates achieving a MELD score ≥35, liver acceptance of offers declined significantly after implementation of Share 35. The alterations in behavior at the center level suggest that practice patterns changed as a direct result of Share 35. Changes in organ acceptance under even broader organ sharing (redistricting) would likely be even greater, posing major logistical and operational challenges, while potentially increasing discard rates, thus decreasing the total number of transplant nationally. PMID:28240804

Supportive and palliative care for metastatic breast cancer: resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement.

PubMed

Cleary, James; Ddungu, Henry; Distelhorst, Sandra R; Ripamonti, Carla; Rodin, Gary M; Bushnaq, Mohammad A; Clegg-Lamptey, Joe N; Connor, Stephen R; Diwani, Msemo B; Eniu, Alexandru; Harford, Joe B; Kumar, Suresh; Rajagopal, M R; Thompson, Beti; Gralow, Julie R; Anderson, Benjamin O

2013-10-01

Many women diagnosed with breast cancer in low- and middle-income countries (LMICs) present with advanced-stage disease. While cure is not a realistic outcome, site-specific interventions, supportive care, and palliative care can achieve meaningful outcomes and improve quality of life. As part of the 5th Breast Health Global Initiative (BHGI) Global Summit, an expert international panel identified thirteen key resource recommendations for supportive and palliative care for metastatic breast cancer. The recommendations are presented in three resource-stratified tables: health system resource allocations, resource allocations for organ-based metastatic breast cancer, and resource allocations for palliative care. These tables illustrate how health systems can provide supportive and palliative care services for patients at a basic level of available resources, and incrementally add services as more resources become available. The health systems table includes health professional education, patient and family education, palliative care models, and diagnostic testing. The metastatic disease management table provides recommendations for supportive care for bone, brain, liver, lung, and skin metastases as well as bowel obstruction. The third table includes the palliative care recommendations: pain management, and psychosocial and spiritual aspects of care. The panel considered pain management a priority at a basic level of resource allocation and emphasized the need for morphine to be easily available in LMICs. Regular pain assessments and the proper use of pharmacologic and non-pharmacologic interventions are recommended. Basic-level resources for psychosocial and spiritual aspects of care include health professional and patient and family education, as well as patient support, including community-based peer support. Copyright © 2013 The Authors. Published by Elsevier Ltd.. All rights reserved.

[Description of the severely injured in the DRG system: is treatment of the severely injured still affordable?].

PubMed

Mahlke, L; Lefering, R; Siebert, H; Windolf, J; Roeder, N; Franz, D

2013-11-01

Due to the heterogeneity of severely injured patients (multiple trauma) it is difficult to assign them to homogeneic diagnosis-related groups (DRG). In recent years this has led to a systematic underfunding in the German reimbursement system (G-DRG) for cases of multiply injured patients. This project aimed to improve the reimbursement by modifying the case allocation algorithms of multiply injured patients within the G-DRG system. A retrospective analysis of standardized G-DRG data according to §21 of the Hospital Reimbursement Act (§ 21 KHEntgG) including case-related cost data from 3,362 critically injured patients from 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals was carried out. For 1,241 cases complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of multiply injured patients within the G-DRG system. Analysis of coding and grouping, performance of case allocation and the homogeneity of costs in the G-DRG versions 2008-2012 was carried out. The results showed systematic underfunding of trauma patients in the G-DRG version 2008 but adequate cost covering in the majority of cases with the G-DRG versions 2011 and 2012. Cost coverage was foundfor multiply injured patients from the clinical viewpoint who were identified as multiple trauma by the G-DRG system. Some of the overfunded trauma patients had high intensive care costs. Also there was underfunding for multiple injured patients not identified as such in the G-DRG system. Specific modifications of the G-DRG allocation structures could increase the appropriateness of reimbursement of multiply injured patients. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical specialist societies.

Can self-care health books affect amount of contact with the primary health care team? A randomized controlled trial in general practice.

PubMed

Platts, Amanda; Mitton, Rosly; Boniface, David; Friedli, Karin

2005-09-01

To investigate the effects of two differently styled self-care health books in general practice on the frequency and duration of patients' consultations and their views of the books. Random allocation of patients to either a descriptive or a decision-tree based self-care health book, or a no-book control condition. Three- and 12-months follow-up by postal questionnaire and monitoring of consultations. A large general practice in the South East of England. A total of 1967 volunteer, adult patients who attended the practice in 2001 participated. Demographics; health problems; use of health services; use and perceptions of the trial book; frequency and duration of consultations. Response rates to postal questionnaires at 3 and 12 months were 80% and 74%. In all, 48% consulted their allocated book, compared with 25% who consulted any healthcare book in the Control group. Those reporting health problems were more likely to have consulted their allocated book; 60% reported that the allocated book made them more likely to deal with a problem themselves and 40% reported themselves less likely to consult the practice. However, there were no differences in consultation rates or durations of consultations between the three groups. Handing out of self-care health books may provide qualitative benefits for patients but is unlikely to reduce attendance at the GP practice.

[Web-based evidence of treatment capacity. An instrument for optimizing the interface between prehospital and hospital management].

PubMed

Schweigkofler, U; Reimertz, C; Auhuber, T C; Jung, H G; Gottschalk, R; Hoffmann, R

2011-10-01

The outcome of injured patients depends on intrastractural circumstances as well as on the time until clinical treatment begins. A rapid patient allocation can only be achieved occur if informations about the care capacity status of the medical centers are available. Considering this an improvement at the interface prehospital/clinical care seems possible. In 2010 in Frankfurt am Main the announcement of free capacity (positive proof) was converted to a web-based negative proof of interdisciplinary care capacities. So-called closings are indicated in a web portal, recorded centrally and registered at the local health authority and the management of participating hospitals. Analyses of the allocations to hospitals of all professional disciplines from the years 2009 and 2010 showed an optimized use of the resources. A decline of the allocations by the order from 261 to 0 could be reached by the introduction of the clear care capacity proof system. The health authorities as the regulating body rarely had to intervene (decline from 400 to 7 cases). Surgical care in Frankfurt was guaranteed at any time by one of the large medical centers. The web-based care capacity proof system introduced in 2010 does justice to the demand for optimum resource use on-line. Integration of this allocation system into the developing trauma networks can optimize the process for a quick and high quality care of severely injured patients. It opens new approaches to improve allocation of high numbers of casualties in disaster medicine.

High phenylalanine levels directly affect mood and sustained attention in adults with phenylketonuria: a randomised, double-blind, placebo-controlled, crossover trial.

PubMed

ten Hoedt, Amber E; de Sonneville, Leo M J; Francois, Baudouin; ter Horst, Nienke M; Janssen, Mirian C H; Rubio-Gozalbo, M Estela; Wijburg, Frits A; Hollak, Carla E M; Bosch, Annet M

2011-02-01

The main debate in the treatment of Phenylketonuria (PKU) is whether adult patients need the strict phenylalanine (Phe)-restricted diet. Physicians and patients lack evidence-based guidelines to help them make well-informed choices. We have carried out the first randomised double-blind placebo-controlled trial into the effects of short-term elevation of Phe levels on neuropsychological functions and mood of adults with PKU. Nine continuously treated adults with PKU underwent two 4-week supplementation periods: one with Phe, mimicking normal dietary intake, and one with placebo in randomly allocated order via a randomisation coding list in a double-blind cross-over design. A set of neuropsychological tests (Amsterdam Neuropsychological Tasks) was administered at the end of each study period. In addition, patients and for each patient a friend or relative, completed weekly Profile of Mood States (POMS) questionnaires, evaluating the patients' mood. Phe levels were measured twice weekly. Mean plasma Phe levels were significantly higher during Phe supplementation compared with placebo (p = 0.008). Neuropsychological tests demonstrated an impairment in sustained attention during Phe supplementation (p = 0.029). Both patients and their friend or relative reported lower scores on the POMS questionnaires during Phe supplementation (p = 0.017 and p = 0.040, respectively). High plasma Phe levels have a direct negative effect on both sustained attention and on mood in adult patients with PKU. A Phe-restricted "diet for life" might be an advisable option for many.

Survival Benefit of Lung Transplantation in the Modern Era of Lung Allocation.

PubMed

Vock, David M; Durheim, Michael T; Tsuang, Wayne M; Finlen Copeland, C Ashley; Tsiatis, Anastasios A; Davidian, Marie; Neely, Megan L; Lederer, David J; Palmer, Scott M

2017-02-01

Lung transplantation is an accepted and increasingly employed treatment for advanced lung diseases, but the anticipated survival benefit of lung transplantation is poorly understood. To determine whether and for which patients lung transplantation confers a survival benefit in the modern era of U.S. lung allocation. Data on 13,040 adults listed for lung transplantation between May 2005 and September 2011 were obtained from the United Network for Organ Sharing. A structural nested accelerated failure time model was used to model the survival benefit of lung transplantation over time. The effects of patient, donor, and transplant center characteristics on the relative survival benefit of transplantation were examined. Overall, 73.8% of transplant recipients were predicted to achieve a 2-year survival benefit with lung transplantation. The survival benefit of transplantation varied by native disease group (P = 0.062), with 2-year expected benefit in 39.2 and 98.9% of transplants occurring in those with obstructive lung disease and cystic fibrosis, respectively, and by lung allocation score at the time of transplantation (P < 0.001), with net 2-year benefit in only 6.8% of transplants occurring for lung allocation score less than 32.5 and in 99.9% of transplants for lung allocation score exceeding 40. A majority of adults undergoing transplantation experience a survival benefit, with the greatest potential benefit in those with higher lung allocation scores or restrictive native lung disease or cystic fibrosis. These results provide novel information to assess the expected benefit of lung transplantation at an individual level and to enhance lung allocation policy.

The dark side of the alpha rhythm: fMRI evidence for induced alpha modulation during complete darkness.

PubMed

Ben-Simon, Eti; Podlipsky, Ilana; Okon-Singer, Hadas; Gruberger, Michal; Cvetkovic, Dean; Intrator, Nathan; Hendler, Talma

2013-03-01

The unique role of the EEG alpha rhythm in different states of cortical activity is still debated. The main theories regarding alpha function posit either sensory processing or attention allocation as the main processes governing its modulation. Closing and opening eyes, a well-known manipulation of the alpha rhythm, could be regarded as attention allocation from inward to outward focus though during light is also accompanied by visual change. To disentangle the effects of attention allocation and sensory visual input on alpha modulation, 14 healthy subjects were asked to open and close their eyes during conditions of light and of complete darkness while simultaneous recordings of EEG and fMRI were acquired. Thus, during complete darkness the eyes-open condition is not related to visual input but only to attention allocation, allowing direct examination of its role in alpha modulation. A data-driven ridge regression classifier was applied to the EEG data in order to ascertain the contribution of the alpha rhythm to eyes-open/eyes-closed inference in both lighting conditions. Classifier results revealed significant alpha contribution during both light and dark conditions, suggesting that alpha rhythm modulation is closely linked to the change in the direction of attention regardless of the presence of visual sensory input. Furthermore, fMRI activation maps derived from an alpha modulation time-course during the complete darkness condition exhibited a right frontal cortical network associated with attention allocation. These findings support the importance of top-down processes such as attention allocation to alpha rhythm modulation, possibly as a prerequisite to its known bottom-up processing of sensory input. © 2012 Federation of European Neuroscience Societies and Blackwell Publishing Ltd.

77 FR 14994 - Fisheries of the Exclusive Economic Zone Off Alaska; Reallocation of Pollock in the Bering Sea...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-03-14

... error on page 12215 in row 16 of the third column. The 2012 A season directed fishing allowance for the... \\1\\ 2013 B season \\1\\ season \\1\\ Area and sector 2012 2013 Allocations A season SCA harvest B season... allocated as a DFA as follows: inshore sector--50 percent, catcher/processor sector (C/P)--40 percent, and...

The effects of Transcutaneous Electrical Nerve Stimulation on postural control in patients with chronic low back pain.

PubMed

Rojhani-Shirazi, Z; Rezaeian, T

2015-01-01

Objective: The effects of transcutaneous electrical nerve stimulation (TENS) on postural control in patients with low back pain which is not well known. This study aimed to evaluate the effects of TENS on postural control in chronic low back pain. Methods: This study was an experimental research design. Twenty-eight patients with chronic LBP (25-45 Y/ O) participated and by using a random allocation, were divided to samples who participated in this study. The mean center of pressure (COP) velocity and displacement were measured before, immediately and 30 min after the intervention. The tests were done with eyes open and closed on a force platform. Sensory electrical stimulation was applied through the TENS device. The descriptive statistics, independent sample T-test and ANOVA with repeated measurement on time were used for data analysis. Results: The results of the present study demonstrated that the application of the sensory electrical stimulation in chronic LBP patients showed a statistically significant improvement in postural control in Medio-lateral direction with no corresponding effect on the anterior-posterior direction immediately following the TENS application and 30 minutes after it in closed eyes conditions as compared to baseline. The application of TENS decreased the displacement and velocity of COP (p≤0.05), 30 minutes after the application of sensory electrical stimulation. The results showed that the mean displacement and velocity of COP decreased in eyes open position (p≤0.05). Also, immediately and 30 minutes after the application of sensory electrical stimulation, COP displacement and velocity in ML direction with eyes closed significantly decreased in the intervention group in comparison with control group (p≤0.05). Conclusion: The application of TENS in patients with chronic low back pain could improve postural control in these patients.

The effects of Transcutaneous Electrical Nerve Stimulation on postural control in patients with chronic low back pain

PubMed Central

Rojhani-Shirazi, Z; Rezaeian, T

2015-01-01

Objective: The effects of transcutaneous electrical nerve stimulation (TENS) on postural control in patients with low back pain which is not well known. This study aimed to evaluate the effects of TENS on postural control in chronic low back pain. Methods: This study was an experimental research design. Twenty-eight patients with chronic LBP (25-45 Y/ O) participated and by using a random allocation, were divided to samples who participated in this study. The mean center of pressure (COP) velocity and displacement were measured before, immediately and 30 min after the intervention. The tests were done with eyes open and closed on a force platform. Sensory electrical stimulation was applied through the TENS device. The descriptive statistics, independent sample T-test and ANOVA with repeated measurement on time were used for data analysis. Results: The results of the present study demonstrated that the application of the sensory electrical stimulation in chronic LBP patients showed a statistically significant improvement in postural control in Medio-lateral direction with no corresponding effect on the anterior-posterior direction immediately following the TENS application and 30 minutes after it in closed eyes conditions as compared to baseline. The application of TENS decreased the displacement and velocity of COP (p≤0.05), 30 minutes after the application of sensory electrical stimulation. The results showed that the mean displacement and velocity of COP decreased in eyes open position (p≤0.05). Also, immediately and 30 minutes after the application of sensory electrical stimulation, COP displacement and velocity in ML direction with eyes closed significantly decreased in the intervention group in comparison with control group (p≤0.05). Conclusion: The application of TENS in patients with chronic low back pain could improve postural control in these patients. PMID:28255392

Improvement of Upper Extremity Deficit after Constraint-Induced Movement Therapy Combined with and without Preconditioning Stimulation Using Dual-hemisphere Transcranial Direct Current Stimulation and Peripheral Neuromuscular Stimulation in Chronic Stroke Patients: A Pilot Randomized Controlled Trial.

PubMed

Takebayashi, Takashi; Takahashi, Kayoko; Moriwaki, Misa; Sakamoto, Tomosaburo; Domen, Kazuhisa

2017-01-01

In this study, we investigated the effects of dual-hemisphere transcranial direct current stimulation (dual-tDCS) of both the affected (anodal tDCS) and non-affected (cathodal tDCS) primary motor cortex, combined with peripheral neuromuscular electrical stimulation (PNMES), on the effectiveness of constraint-induced movement therapy (CIMT) as a neurorehabilitation intervention in chronic stroke. We conducted a randomized controlled trial of feasibility, with a single blind assessor, with patients recruited from three outpatient clinics. Twenty chronic stroke patients were randomly allocated to the control group, receiving conventional CIMT, or the intervention group receiving dual-tDCS combined with PNMES before CIMT. Patients in the treatment group first underwent a 20-min period of dual-tDCS, followed immediately by PNMES, and subsequent CIMT for 2 h. Patients in the control group only received CIMT (with no pretreatment stimulation). All patients underwent two CIMT sessions, one in the morning and one in the afternoon, each lasting 2 h, for a total of 4 h of CIMT per day. Upper extremity function was assessed using the Fugl-Meyer Assessment (primary outcome), as well as the amount of use (AOU) and quality of movement (QOM) scores, obtained via the Motor Activity Log (secondary outcome). Nineteen patients completed the study, with one patient withdrawing after allocation. Compared to the control group, the treatment improvement in upper extremity function and AOU was significantly greater in the treatment than control group (change in upper extremity score, 9.20 ± 4.64 versus 4.56 ± 2.60, respectively, P  < 0.01, η 2  = 0.43; change in AOU score, 1.10 ± 0.65 versus 0.62 ± 0.85, respectively, P  = 0.02, η 2  = 0.52). There was no significant effect of the intervention on the QOM between the intervention and control groups (change in QOM score, 1.00 ± 0.62 versus 0.71 ± 0.72, respectively, P  = 0.07, η 2  = 0.43; treatment versus control). Our findings suggest a novel pretreatment stimulation strategy based on dual-tDCS and PNMES may enhance the therapeutic benefit of CIMT.

Kidney allocation to liver transplant candidates with renal failure of undetermined etiology: role of percutaneous renal biopsy.

PubMed

Wadei, H M; Geiger, X J; Cortese, C; Mai, M L; Kramer, D J; Rosser, B G; Keaveny, A P; Willingham, D L; Ahsan, N; Gonwa, T A

2008-12-01

The feasibility, value and risk of percutaneous renal biopsy (PRB) in liver transplant candidates with renal failure are unknown. PRB was performed on 44 liver transplant candidates with renal failure of undetermined etiology and glomerular filtration rate (GFR) <40 mL/min/1.73 m(2) (n = 37) or on renal replacement therapy (RRT) (n = 7). Patients with >or=30% interstitial fibrosis (IF), >or=40% global glomerulosclerosis (gGS) and/or diffuse glomerulonephritis were approved for simultaneous-liver-kidney (SLK) transplantation. Prebiopsy GFR, urinary sodium indices, dependency on RRT and kidney size were comparable between 27 liver-transplant-alone (LTA) and 17 SLK candidates and did not relate to the biopsy diagnosis. The interobserver agreement for the degree of IF or gGS was moderate-to-excellent. After a mean of 78 +/- 67 days, 16 and 8 patients received LTA and SLK transplants. All five LTA recipients on RRT recovered kidney function after transplantation and serum creatinine was comparable between LTA and SLK recipients at last follow-up. Biopsy complications developed in 13, of these, five required intervention. PRB is feasible in liver transplant candidates with renal failure and provides reproducible histological information that does not relate to the pretransplant clinical data. Randomized studies are needed to determine if PRB can direct kidney allocation in this challenging group of liver transplant candidates.

Improving the Success of Strategic Management Using Big Data.

PubMed

Desai, Sapan S; Wilkerson, James; Roberts, Todd

2016-01-01

Strategic management involves determining organizational goals, implementing a strategic plan, and properly allocating resources. Poor access to pertinent and timely data misidentifies clinical goals, prevents effective resource allocation, and generates waste from inaccurate forecasting. Loss of operational efficiency diminishes the value stream, adversely impacts the quality of patient care, and hampers effective strategic management. We have pioneered an approach using big data to create competitive advantage by identifying trends in clinical practice, accurately anticipating future needs, and strategically allocating resources for maximum impact.

[Hand surgery in the German DRG System 2007].

PubMed

Franz, D; Windolf, J; Kaufmann, M; Siebert, C H; Roeder, N

2007-05-01

Hand surgery often needs only a short length of stay in hospital. Patients' comorbidity is low. Many hand surgery procedures do not need inpatient structures. Up until 2006 special procedures of hand surgery could not be coded. The DRG structure did not separate very complex and less complex operations. Specialized hospitals needed a proper case allocation of their patients within the G-DRG system. The DRG structure concerning hand surgery increased in version 2007 of the G-DRG system. The main parameter of DRG splitting is the complexity of the operation. Furthermore additional criteria such as more than one significant OR procedure, the patients' age, or special diagnoses influence case allocation. A special OPS code for complex cases treated with hand surgery was implemented. The changes in the DRG structure and the implementation of the new OPS code for complex cases establish a strong basis for the identification of different patient costs. Different case allocation leads to different economic impacts on departments of hand surgery. Whether the new OPS code becomes a DRG splitting parameter has to be calculated by the German DRG Institute for further DRG versions.

The economic burden of schizophrenia in Malaysia

PubMed Central

Teoh, Siew Li; Chong, Huey Yi; Abdul Aziz, Salina; Chemi, Norliza; Othman, Abdul Razak; Md Zaki, Nurzuriana; Vanichkulpitak, Possatorn; Chaiyakunapruk, Nathorn

2017-01-01

Introduction Schizophrenia (SCZ) is a highly debilitating disease despite its low prevalence. The economic burden associated with SCZ is substantial and mainly attributed to productivity loss. To improve the understanding of economic burden of SCZ in the low- and middle-income country regions, we aimed to determine the economic burden of SCZ in Malaysia. Methods A retrospective study was conducted using a prevalence-based approach from a societal perspective in Malaysia with a 1 year period from 2013. We used micro-costing technique with bottom-up method and included direct medical cost, direct non-medical cost, and indirect cost. The main data source was medical chart review which was conducted in Hospital Kuala Lumpur (HKL). The medical charts were identified electronically by matching the unique patient’s identification number registered under the National Mental Health Schizophrenia Registry and the list of patients in HKL in 2013. Other data sources were government documents, literatures, and local websites. To ensure robustness of result, probabilistic sensitivity analysis was conducted. Results The total estimated number of treated SCZ cases in Malaysia in 2015 was 15,104 with the total economic burden of USD 100 million (M) which was equivalent to 0.04% of the national gross domestic product. On average, the mean cost per patient was USD 6,594. Of the total economic burden of SCZ, 72% was attributed to indirect cost, costing at USD 72M, followed by direct medical cost (26%), costing at USD 26M, and direct non-medical cost (2%), costing at USD 1.7M. Conclusion This study highlights the magnitude of economic burden of SCZ and informs the policy-makers that there is an inadequate support for SCZ patients. More resources should be allocated to improve the condition of SCZ patients and to reduce the economic burden. PMID:28814869

Direct Pulp Capping with Calcium Hydroxide, Mineral Trioxide Aggregate, and Biodentine in Permanent Young Teeth with Caries: A Randomized Clinical Trial.

PubMed

Brizuela, Claudia; Ormeño, Andrea; Cabrera, Carolina; Cabezas, Roxana; Silva, Carolina Inostroza; Ramírez, Valeria; Mercade, Montse

2017-11-01

Direct pulp capping treatment is intended to preserve pulp vitality, to avoid or retard root canal treatment, and, in cases with an open apex, to allow continued root development. Historically, calcium hydroxide (CH) was the gold standard material, but nowadays calcium silicate materials (CSMs) are displacing CH because of their high bioactivity, biocompatibility, sealing ability, and mechanical properties. However, more randomized clinical trials are needed to confirm the appropriateness of CSMs as replacement materials for CH in direct pulp capping procedures. A randomized clinical trial was conducted that included 169 patients (mean age, 11.3 years) from the Maipo district (Chile). The inclusion criterion was patients with 1 carious permanent tooth with pulpal exposure, a candidate for a direct pulp capping procedure. The patients were randomly allocated to one of the experimental groups (CH, Biodentine, or mineral trioxide aggregate [MTA]). Clinical follow-up examinations were performed at 1 week, 3 months, 6 months, and 1 year. The Fisher exact test was performed. At the follow-up examination at 1 week, the patients showed 100% clinical success. At 3 months, there was 1 failure in the CH group. At 6 months, there were 4 new failures (1 in the CH group and 3 in the MTA group). At 1 year, there was another failure in the CH group. There were no statistically significant differences among the experimental groups. CSMs appear to be suitable materials to replace CH. Although no significant differences were found among the materials studied, Biodentine and MTA offered some advantages over CH. Copyright © 2017 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.

Virtual colonoscopy, optical colonoscopy, or fecal occult blood testing for colorectal cancer screening: results of a pilot randomized controlled trial.

PubMed

You, John J; Liu, Yudong; Kirby, John; Vora, Parag; Moayyedi, Paul

2015-07-09

No head-to-head randomized controlled trials have demonstrated the superiority of one colorectal screening modality over another in reducing colorectal cancer mortality. We conducted a pilot randomized controlled trial of fecal occult blood testing (FOBT), optical colonoscopy (OC), and virtual colonoscopy (VC), to inform the planning of a larger evaluative trial. Eligible patients (aged 50 to 70) were recruited from five primary care practices in Hamilton, ON, Canada, between March 23, 2010 and August 11, 2010, and randomized 1:1:1 in a parallel design using an automated, centralized telephone service to either FOBT, OC, or VC. To reflect conventional practice, patients received no additional reminders to complete their allocated screening test beyond those received in usual practice. The primary outcome was completion of the assigned screening procedure. Results of the index test and any follow-up investigations were ascertained at 6 months. Participants, caregivers, and outcome assessors were not blinded to group assignment. The trial was stopped early due to lack of ongoing funding. A total of 198 participants were enrolled, of whom 67 were allocated to FOBT, 66 to OC, and 65 to VC. The allocated screening procedure was completed by 43 (64%) subjects allocated to FOBT (95% confidence interval [CI], 52-75%), 53 (80%) subjects allocated to OC (95% CI, 69-88%), and 50 (77%) subjects allocated to VC (95% CI, 65-85%); because the trial stopped early, we had insufficient statistical power to detect clinically relevant differences in completion rates. During 6 months follow-up, colorectal adenomas were detected in 0 (0%) subjects allocated to FOBT, 12 (18%) subjects allocated to OC, and 2 (3%) subjects allocated to VC. One subject in the OC arm had histological evidence of high-grade dysplasia. No subjects were diagnosed with colorectal cancer. In this pilot randomized controlled trial of colorectal cancer screening in a primary care setting, 64-80% of subjects completed their allocated screening test. These findings may be of value to investigators planning clinical trials to evaluate the effectiveness of colorectal cancer screening. ClinicalTrials.gov NCT00865527. https://clinicaltrials.gov/ct2/show/NCT00865527.

Public Health Nutrition: The Accord of Dietitian Providers in Managing Medicare Chronic Care Outpatients in Australia

PubMed Central

Cant, Robyn P.

2010-01-01

Medicare Australia: Chronic Disease Management program subsidizes allied health consultations for eligible outpatients with chronic disease or complex needs. In an evaluation study, private practice dietitians (n = 9) were interviewed to explore their patient management strategies including consultation time-allocation and fees. Time allocation was fee-based. Short first consultations were seen as meeting patients’ needs for low-cost services but were regarded by dietitians as ineffective, however longer initial consultations increased cost to patients. No strategy in use was optimal. There is a need for change in Medicare policy to meet the needs of both dietitians and patients in achieving the behaviour change goals of patients. PMID:20617063

A prospective study of primary care patients with musculoskeletal pain: the identification of predictive factors for chronicity.

PubMed Central

Potter, R G; Jones, J M; Boardman, A P

2000-01-01

Primary care faces the challenge of reducing the proportion of patients continuing with musculoskeletal pain beyond the acute phase. This study assessed patients presenting in general practice with a four- to 12-week history of pain and re-assessed them 12 weeks later. Patients whose pain was described as 'none' or 'slight' were allocated to the 'acute group', and those whose pain continued to be 'moderate' or 'severe' were allocated to the 'chronic group'. Comparative analysis of the two groups' responses at initial assessment identified pain intensity, active coping score, and previous pain episode to be factors independently predictive of chronicity. PMID:10750237

Zinc allocation and re-allocation in rice.

PubMed

Stomph, Tjeerd Jan; Jiang, Wen; Van Der Putten, Peter E L; Struik, Paul C

2014-01-01

Agronomy and breeding actively search for options to enhance cereal grain Zn density. Quantifying internal (re-)allocation of Zn as affected by soil and crop management or genotype is crucial. We present experiments supporting the development of a conceptual model of whole plant Zn allocation and re-allocation in rice. Two solution culture experiments using (70)Zn applications at different times during crop development and an experiment on within-grain distribution of Zn are reported. In addition, results from two earlier published experiments are re-analyzed and re-interpreted. A budget analysis showed that plant zinc accumulation during grain filling was larger than zinc allocation to the grains. Isotope data showed that zinc taken up during grain filling was only partly transported directly to the grains and partly allocated to the leaves. Zinc taken up during grain filling and allocated to the leaves replaced zinc re-allocated from leaves to grains. Within the grains, no major transport barrier was observed between vascular tissue and endosperm. At low tissue Zn concentrations, rice plants maintained concentrations of about 20 mg Zn kg(-1) dry matter in leaf blades and reproductive tissues, but let Zn concentrations in stems, sheath, and roots drop below this level. When plant zinc concentrations increased, Zn levels in leaf blades and reproductive tissues only showed a moderate increase while Zn levels in stems, roots, and sheaths increased much more and in that order. In rice, the major barrier to enhanced zinc allocation towards grains is between stem and reproductive tissues. Enhancing root to shoot transfer will not contribute proportionally to grain zinc enhancement.

Zinc allocation and re-allocation in rice

PubMed Central

Stomph, Tjeerd Jan; Jiang, Wen; Van Der Putten, Peter E. L.; Struik, Paul C.

2014-01-01

Aims: Agronomy and breeding actively search for options to enhance cereal grain Zn density. Quantifying internal (re-)allocation of Zn as affected by soil and crop management or genotype is crucial. We present experiments supporting the development of a conceptual model of whole plant Zn allocation and re-allocation in rice. Methods: Two solution culture experiments using 70Zn applications at different times during crop development and an experiment on within-grain distribution of Zn are reported. In addition, results from two earlier published experiments are re-analyzed and re-interpreted. Results: A budget analysis showed that plant zinc accumulation during grain filling was larger than zinc allocation to the grains. Isotope data showed that zinc taken up during grain filling was only partly transported directly to the grains and partly allocated to the leaves. Zinc taken up during grain filling and allocated to the leaves replaced zinc re-allocated from leaves to grains. Within the grains, no major transport barrier was observed between vascular tissue and endosperm. At low tissue Zn concentrations, rice plants maintained concentrations of about 20 mg Zn kg−1 dry matter in leaf blades and reproductive tissues, but let Zn concentrations in stems, sheath, and roots drop below this level. When plant zinc concentrations increased, Zn levels in leaf blades and reproductive tissues only showed a moderate increase while Zn levels in stems, roots, and sheaths increased much more and in that order. Conclusions: In rice, the major barrier to enhanced zinc allocation towards grains is between stem and reproductive tissues. Enhancing root to shoot transfer will not contribute proportionally to grain zinc enhancement. PMID:24478788

Epirubicin, oxaliplatin, and capecitabine with or without panitumumab for patients with previously untreated advanced oesophagogastric cancer (REAL3): a randomised, open-label phase 3 trial.

PubMed

Waddell, Tom; Chau, Ian; Cunningham, David; Gonzalez, David; Okines, Alicia Frances Clare; Frances, Alicia; Okines, Clare; Wotherspoon, Andrew; Saffery, Claire; Middleton, Gary; Wadsley, Jonathan; Ferry, David; Mansoor, Wasat; Crosby, Tom; Coxon, Fareeda; Smith, David; Waters, Justin; Iveson, Timothy; Falk, Stephen; Slater, Sarah; Peckitt, Clare; Barbachano, Yolanda

2013-05-01

EGFR overexpression occurs in 27-55% of oesophagogastric adenocarcinomas, and correlates with poor prognosis. We aimed to assess addition of the anti-EGFR antibody panitumumab to epirubicin, oxaliplatin, and capecitabine (EOC) in patients with advanced oesophagogastric adenocarcinoma. In this randomised, open-label phase 3 trial (REAL3), we enrolled patients with untreated, metastatic, or locally advanced oesophagogastric adenocarcinoma at 63 centres (tertiary referral centres, teaching hospitals, and district general hospitals) in the UK. Eligible patients were randomly allocated (1:1) to receive up to eight 21-day cycles of open-label EOC (epirubicin 50 mg/m(2) and oxaliplatin 130 mg/m(2) on day 1 and capecitabine 1250 mg/m(2) per day on days 1-21) or modified-dose EOC plus panitumumab (mEOC+P; epirubicin 50 mg/m(2) and oxaliplatin 100 mg/m(2) on day 1, capecitabine 1000 mg/m(2) per day on days 1-21, and panitumumab 9 mg/kg on day 1). Randomisation was blocked and stratified for centre region, extent of disease, and performance status. The primary endpoint was overall survival in the intention-to-treat population. We assessed safety in all patients who received at least one dose of study drug. After a preplanned independent data monitoring committee review in October, 2011, trial recruitment was halted and panitumumab withdrawn. Data for patients on treatment were censored at this timepoint. This study is registered with ClinicalTrials.gov, number NCT00824785. Between June 2, 2008, and Oct 17, 2011, we enrolled 553 eligible patients. Median overall survival in 275 patients allocated EOC was 11.3 months (95% CI 9.6-13.0) compared with 8.8 months (7.7-9.8) in 278 patients allocated mEOC+P (hazard ratio [HR] 1.37, 95% CI 1.07-1.76; p=0.013). mEOC+P was associated with increased incidence of grade 3-4 diarrhoea (48 [17%] of 276 patients allocated mEOC+P vs 29 [11%] of 266 patients allocated EOC), rash (29 [11%] vs two [1%]), mucositis (14 [5%] vs none), and hypomagnesaemia (13 [5%] vs none) but reduced incidence of haematological toxicity (grade ≥ 3 neutropenia 35 [13%] vs 74 [28%]). Addition of panitumumab to EOC chemotherapy does not increase overall survival and cannot be recommended for use in an unselected population with advanced oesophagogastric adenocarcinoma. Amgen, UK National Institute for Health Research Biomedical Research Centre. Copyright © 2013 Elsevier Ltd. All rights reserved.

An agent-based simulation combined with group decision-making technique for improving the performance of an emergency department.

PubMed

Yousefi, M; Ferreira, R P M

2017-03-30

This study presents an agent-based simulation modeling in an emergency department. In a traditional approach, a supervisor (or a manager) allocates the resources (receptionist, nurses, doctors, etc.) to different sections based on personal experience or by using decision-support tools. In this study, each staff agent took part in the process of allocating resources based on their observation in their respective sections, which gave the system the advantage of utilizing all the available human resources during the workday by being allocated to a different section. In this simulation, unlike previous studies, all staff agents took part in the decision-making process to re-allocate the resources in the emergency department. The simulation modeled the behavior of patients, receptionists, triage nurses, emergency room nurses and doctors. Patients were able to decide whether to stay in the system or leave the department at any stage of treatment. In order to evaluate the performance of this approach, 6 different scenarios were introduced. In each scenario, various key performance indicators were investigated before and after applying the group decision-making. The outputs of each simulation were number of deaths, number of patients who leave the emergency department without being attended, length of stay, waiting time and total number of discharged patients from the emergency department. Applying the self-organizing approach in the simulation showed an average of 12.7 and 14.4% decrease in total waiting time and number of patients who left without being seen, respectively. The results showed an average increase of 11.5% in total number of discharged patients from emergency department.

An agent-based simulation combined with group decision-making technique for improving the performance of an emergency department

PubMed Central

Yousefi, M.; Ferreira, R.P.M.

2017-01-01

This study presents an agent-based simulation modeling in an emergency department. In a traditional approach, a supervisor (or a manager) allocates the resources (receptionist, nurses, doctors, etc.) to different sections based on personal experience or by using decision-support tools. In this study, each staff agent took part in the process of allocating resources based on their observation in their respective sections, which gave the system the advantage of utilizing all the available human resources during the workday by being allocated to a different section. In this simulation, unlike previous studies, all staff agents took part in the decision-making process to re-allocate the resources in the emergency department. The simulation modeled the behavior of patients, receptionists, triage nurses, emergency room nurses and doctors. Patients were able to decide whether to stay in the system or leave the department at any stage of treatment. In order to evaluate the performance of this approach, 6 different scenarios were introduced. In each scenario, various key performance indicators were investigated before and after applying the group decision-making. The outputs of each simulation were number of deaths, number of patients who leave the emergency department without being attended, length of stay, waiting time and total number of discharged patients from the emergency department. Applying the self-organizing approach in the simulation showed an average of 12.7 and 14.4% decrease in total waiting time and number of patients who left without being seen, respectively. The results showed an average increase of 11.5% in total number of discharged patients from emergency department. PMID:28380196

Evaluation as institution: a contractarian argument for needs-based economic evaluation.

PubMed

Rogowski, Wolf H

2018-06-13

There is a gap between health economic evaluation methods and the value judgments of coverage decision makers, at least in Germany. Measuring preference satisfaction has been claimed to be inappropriate for allocating health care resources, e.g. because it disregards medical need. The existing methods oriented at medical need have been claimed to disregard non-consequentialist fairness concerns. The aim of this article is to propose a new, contractarian argument for justifying needs-based economic evaluation. It is based on consent rather than maximization of some impersonal unit of value to accommodate the fairness concerns. This conceptual paper draws upon contractarian ethics and constitution economics to show how economic evaluation can be viewed as an institution to overcome societal conflicts in the allocation of scarce health care resources. For this, the problem of allocating scarce health care resources in a society is reconstructed as a social dilemma. Both disadvantaged patients and affluent healthy individuals can be argued to share interests in a societal contract to provide technologies which ameliorate medical need, based on progressive funding. The use of needs-based economic evaluation methods for coverage determination can be interpreted as institutions for conflict resolution as far as they use consented criteria to ensure the social contract's sustainability and avoid implicit rationing or unaffordable contribution rates. This justifies the use of needs-based evaluation methods by Pareto-superiority and consent (rather than by some needs-based value function per se). The view of economic evaluation presented here may help account for fairness concerns in the further development of evaluation methods. This is because it directs the attention away from determining some unit of value to be maximized towards determining those persons who are most likely not to consent and meeting their concerns. Following this direction in methods development is likely to increase the acceptability of health economic evaluation by decision makers.

Allocating application to group of consecutive processors in fault-tolerant deadlock-free routing path defined by routers obeying same rules for path selection

DOEpatents

Leung, Vitus J [Albuquerque, NM; Phillips, Cynthia A [Albuquerque, NM; Bender, Michael A [East Northport, NY; Bunde, David P [Urbana, IL

2009-07-21

In a multiple processor computing apparatus, directional routing restrictions and a logical channel construct permit fault tolerant, deadlock-free routing. Processor allocation can be performed by creating a linear ordering of the processors based on routing rules used for routing communications between the processors. The linear ordering can assume a loop configuration, and bin-packing is applied to this loop configuration. The interconnection of the processors can be conceptualized as a generally rectangular 3-dimensional grid, and the MC allocation algorithm is applied with respect to the 3-dimensional grid.

Evaluating and improving a model of nursing care delivery: a process of partnership.

PubMed

Hall, Catherine; McCutcheon, Helen; Deuter, Kate; Matricciani, Lisa

2012-01-01

Evaluating and improving a model of nursing care is a fundamental part of clinical practice improvement. While Australian nurses are showing increasing interest in improving models of care delivery, more research is needed that addresses and articulates the processes attendant upon evaluating, re-designing and implementing improvements to the provision of nursing care. Providing nurses with an open opportunity to plan, act, observe and reflect on their practice promotes successful partnerships between academics and clinicians. The aim of this study was to evaluate and improve the model of nursing care delivery to patients in a general surgical ward using participatory action research. Researchers conducted non-participant observations (n = 9) of two hours duration across the 24 h period. Focus groups (n = 3) were used to share non-participant observation data with staff, providing them with an opportunity to reflect on their practice and explore possible solutions. Data was collected in 2008-2009. Two main problem areas were identified as impeding the nurses' ability to provide care to patients: (i) practices and behaviours of nurses and (ii) infrastructure and physical layout of the ward. An overview of issues within each problem area is presented. Shifting the focus of task-centred care towards a more patient-centred care approach, results directly in improvements in resource utilisation, improved cost-effectiveness and job satisfaction for nursing staff. New ways of thinking about nursing processes and systems, workflow design and skill allocation will guide hospital administrators and managers in the effective and efficient allocation of nursing work in similar settings.

Antibiotic treatment to prevent postextraction complications: a monocentric, randomized clinical trial. Preliminary outcomes.

PubMed

Barone, Antonio; Marchionni, Francesco S; Cinquini, Chiara; Cipolli Panattoni, Andrea; Toti, Paolo; Marconcini, Simone; Covani, Ugo; Gabriele, Mario

2017-08-01

Tooth extraction is a very common procedure in oral surgery. Despite this, very little information is available in the literature as to the antibiotic management of the patient. The aim of this study is to evaluate whether the antibiotic prophylaxis could be beneficial in preventing postextraction local complications and whether the use of a probiotic could help reduce the antibiotic gastro-intestinal side effects. One hundred eleven patients meeting the inclusion criteria were initially included in this randomized clinical trial and randomly allocated to one of the three experimental groups according to a computer-generated randomization list. Patients allocated to the group 1 were given amoxicillin+clavulanic acid (2 g/day for 6 days), patients allocated to the group 2 received antibiotic + probiotic (Bifidobacterium longum+lactoferrin) and patients allocated to the group 3 received no antibiotic therapy after the extraction. To evaluate post-extractive complications, controls were performed at days 7, 14 and 21 after the extraction. At T1 pain at the surgical site was present in the 48%, 30% and 71.4% of the patients belonging respectively to the antibiotic alone group, to the antibiotic+probiotic group and to the control group. The mean Numeric Rating Score (NRS) score was 1.56±1.91, 1.08±1.93, 2.02±2.27 respectively (P=0.0498). Two patients belonging to the control group experienced dry socket. In addition, 9 patients (33.3%) in the antibiotic-alone group and 1 patient (2.7%) in the antibiotic+probiotic group reported intestinal distension (P=0.0012), 7 days after surgery. Finally, diarrhea was recorded in 5 patients of the antibiotic alone group (18.5%), on the other hand, no patients of the antibiotic+probiotic group and the control group reported diarrhea. Postextractive complications observed in each group have been mild and fast to resolve. The antibiotic administration showed a decrease in pain suffered by patients but a higher incidence of gastrointestinal side effects, such as abdominal distension and diarrhea, which seemed to be relieved by the concomitant use of the probiotic.

Long-term effectiveness of dopamine agonists and monoamine oxidase B inhibitors compared with levodopa as initial treatment for Parkinson's disease (PD MED): a large, open-label, pragmatic randomised trial.

PubMed

Gray, Richard; Ives, Natalie; Rick, Caroline; Patel, Smitaa; Gray, Alastair; Jenkinson, Crispin; McIntosh, Emma; Wheatley, Keith; Williams, Adrian; Clarke, Carl E

2014-09-27

Whether initial treatment for Parkinson's disease should consist of levodopa, dopamine agonists, or monoamine oxidase type B inhibitors (MAOBI) is uncertain. We aimed to establish which of these three classes of drug, as initial treatment, provides the most effective long-term control of symptoms and best quality of life for people with early Parkinson's disease. In this pragmatic, open-label randomised trial, patients newly diagnosed with Parkinson's disease were randomly assigned (by telephone call to a central office; 1:1:1) between levodopa-sparing therapy (dopamine agonists or MAOBI) and levodopa alone. Patients and investigators were not masked to group assignment. Primary outcomes were the mobility dimension on the 39-item patient-rated Parkinson's disease questionnaire (PDQ-39) quality-of-life scale (range 0-100 with six points defined as the minimally important difference) and cost-effectiveness. Analysis was intention to treat. This trial is registered, number ISRCTN69812316. Between Nov 9, 2000, and Dec 22, 2009, 1620 patients were assigned to study groups (528 to levodopa, 632 to dopamine agonist, 460 to MAOBI). With 3-year median follow-up, PDQ-39 mobility scores averaged 1·8 points (95% CI 0·5-3·0, p=0·005) better in patients randomly assigned to levodopa than those assigned to levodopa-sparing therapy, with no increase or attrition of benefit during 7 years' observation. PDQ-39 mobility scores were 1·4 points (95% CI 0·0-2·9, p=0·05) better in patients allocated MAOBI than in those allocated dopamine agonists. EQ-5D utility scores averaged 0·03 (95% CI 0·01-0·05; p=0·0002) better with levodopa than with levodopa-sparing therapy; rates of dementia (hazard ratio [HR] 0·81, 95% CI 0·61-1·08, p=0·14), admissions to institutions (0·86, 0·63-1·18; p=0·4), and death (0·85, 0·69-1·06, p=0·17) were not significantly different, but the upper CIs precluded any substantial increase with levodopa compared with levodopa-sparing therapy. 179 (28%) of 632 patients allocated dopamine agonists and 104 (23%) of 460 patients allocated MAOBI discontinued allocated treatment because of side-effects compared with 11 (2%) of 528 patients allocated levodopa (p<0·0001). Very small but persistent benefits are shown for patient-rated mobility scores when treatment is initiated with levodopa compared with levodopa-sparing therapy. MAOBI as initial levodopa-sparing therapy was at least as effective as dopamine agonists. UK National Institute for Health Research Health Technology Assessment Programme and UK Department of Health. Copyright © 2014 Elsevier Ltd. All rights reserved.

Application of case mix index in the allocation of nursing human resources.

PubMed

Han, Binru; Chen, Xi; Li, Qiuping

2018-02-23

To investigate the feasibility of the case mix index and compare the allocation of nursing human resources between two departments of a hospital with different case mix indexes in China. The case mix index is used to assess the resource allocation of all cases in two departments of a hospital. Its values can determine the resource allocation required to diagnose and treat the patients. Clinical data were obtained from 23 different departments in 2015 and analysed retrospectively from October to November, 2016. Factors influencing the allocation of registered nurses were identified, and balanced quantities of patients with different case mix indexes were chosen from two departments. Spearman correlation analysis was performed. The per capita nursing workload was significant (r = .669, p = .000). The length of hospital stay, quantity of nurses, and department case mix index were correlated with the nursing workload (t = 4.211, p = .000; t = 2.962, p = .008; t = 2.266, p = .035). Education levels (Z = -1.391, p = .164) and the professional titles (Z = -1.832, p = .067) of the nurses were not statistically significant, whereas the registered nurse level differed between two departments (Z = -2.125, p = .034). The case management index provides references for the efficient allocation of registered nurses in clinical practice. © 2018 John Wiley & Sons Ltd.

Method for spatially distributing a population

DOEpatents

Bright, Edward A [Knoxville, TN; Bhaduri, Budhendra L [Knoxville, TN; Coleman, Phillip R [Knoxville, TN; Dobson, Jerome E [Lawrence, KS

2007-07-24

A process for spatially distributing a population count within a geographically defined area can include the steps of logically correlating land usages apparent from a geographically defined area to geospatial features in the geographically defined area and allocating portions of the population count to regions of the geographically defined area having the land usages, according to the logical correlation. The process can also include weighing the logical correlation for determining the allocation of portions of the population count and storing the allocated portions within a searchable data store. The logically correlating step can include the step of logically correlating time-based land usages to geospatial features of the geographically defined area. The process can also include obtaining a population count for the geographically defined area, organizing the geographically defined area into a plurality of sectors, and verifying the allocated portions according to direct observation.

7 CFR 1940.588 - Business and Industry Guaranteed and Direct Loans.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 7 Agriculture 13 2012-01-01 2012-01-01 false Business and Industry Guaranteed and Direct Loans. 1940.588 Section 1940.588 Agriculture Regulations of the Department of Agriculture (Continued) RURAL... Allocation of Loan and Grant Program Funds § 1940.588 Business and Industry Guaranteed and Direct Loans. (a...

7 CFR 1940.588 - Business and Industry Guaranteed and Direct Loans.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 7 Agriculture 13 2014-01-01 2013-01-01 true Business and Industry Guaranteed and Direct Loans. 1940.588 Section 1940.588 Agriculture Regulations of the Department of Agriculture (Continued) RURAL... Allocation of Loan and Grant Program Funds § 1940.588 Business and Industry Guaranteed and Direct Loans. (a...

7 CFR 1940.588 - Business and Industry Guaranteed and Direct Loans.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 7 Agriculture 13 2013-01-01 2013-01-01 false Business and Industry Guaranteed and Direct Loans. 1940.588 Section 1940.588 Agriculture Regulations of the Department of Agriculture (Continued) RURAL... Allocation of Loan and Grant Program Funds § 1940.588 Business and Industry Guaranteed and Direct Loans. (a...

7 CFR 1940.588 - Business and Industry Guaranteed and Direct Loans.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 7 Agriculture 13 2010-01-01 2009-01-01 true Business and Industry Guaranteed and Direct Loans. 1940.588 Section 1940.588 Agriculture Regulations of the Department of Agriculture (Continued) RURAL... Allocation of Loan and Grant Program Funds § 1940.588 Business and Industry Guaranteed and Direct Loans. (a...

7 CFR 1940.588 - Business and Industry Guaranteed and Direct Loans.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 7 Agriculture 13 2011-01-01 2009-01-01 true Business and Industry Guaranteed and Direct Loans. 1940.588 Section 1940.588 Agriculture Regulations of the Department of Agriculture (Continued) RURAL... Allocation of Loan and Grant Program Funds § 1940.588 Business and Industry Guaranteed and Direct Loans. (a...

77 FR 53951 - Self-Regulatory Organizations; EDGA Exchange, Inc.; Notice of Filing and Immediate Effectiveness...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-09-04

... DIRECT Logical Ports from ten sessions to five sessions represents an equitable allocation of reasonable... data (collectively, ``DIRECT Logical Ports'').\\4\\ The Exchange proposes to reduce the quantity of free DIRECT Logical Ports from ten (10) sessions to five (5) sessions. Therefore, the Exchange will assess a...

Developments in pediatric liver transplantation since implementation of the new allocation rules in Eurotransplant.

PubMed

Herden, Uta; Grabhorn, Enke; Briem-Richter, Andrea; Ganschow, Rainer; Nashan, Björn; Fischer, Lutz

2014-09-01

Liver allocation in the Eurotransplant (ET) region has changed from a waiting time to an urgency-based system using the model of end-stage liver disease (MELD) score in 2006. To allow timely transplantation, pediatric recipients are allocated by an assigned pediatric MELD independent of severity of illness. Consequences for children listed at our center were evaluated by retrospective analysis of all primary pediatric liver transplantation (LTX) from deceased donors between 2002 and 2010 (110 LTX before/50 LTX after new allocation). Of 50 children transplanted in the MELD era, 17 (34%) underwent LTX with a high-urgent status that was real in five patients (median lab MELD 22, waiting time five d) and assigned in 12 patients (lab MELD 7, waiting time 35 d). Thirty-three children received a liver by their assigned pediatric MELD (lab MELD 15, waiting time 255 d). Waiting time in the two periods was similar, whereas the wait-list mortality decreased (from about four children/yr to about one child/yr). One- and three-yr patient survival showed no significant difference (94.5/97.7%; p = 0.385) as did one- and three-yr graft survival (80.7/75.2%; and 86.5/82%; p = 0.436 before/after). Introduction of a MELD-based allocation system in ET with assignment of a granted score for pediatric recipients has led to a clear priorization of children resulting in a low wait-list mortality and good clinical outcome. © 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

High emergency organ allocation rule in lung transplantation: a simulation study

PubMed Central

Boëlle, Pierre-Yves; Christie, Jason D.; Thabut, Gabriel

2017-01-01

The scarcity of suitable organ donors leads to protracted waiting times and mortality in patients awaiting lung transplantation. This study aims to assess the short- and long-term effects of a high emergency organ allocation policy on the outcome of lung transplantation. We developed a simulation model of lung transplantation waiting queues under two allocation strategies, based either on waiting time only or on additional criteria to prioritise the sickest patients. The model was informed by data from the United Network for Organ Sharing. We compared the impact of these strategies on waiting time, waiting list mortality and overall survival in various situations of organ scarcity. The impact of a high emergency allocation strategy depends largely on the organ supply. When organ supply is sufficient (>95 organs per 100 patients), it may prevent a small number of early deaths (1 year survival: 93.7% against 92.4% for waiting time only) without significant impact on waiting times or long-term survival. When the organ/recipient ratio is lower, the benefits in early mortality are larger but are counterbalanced by a dramatic increase of the size of the waiting list. Consequently, we observed a progressive increase of mortality on the waiting list (although still lower than with waiting time only), a deterioration of patients’ condition at transplant and a decrease of post-transplant survival times. High emergency organ allocation is an effective strategy to reduce mortality on the waiting list, but causes a disruption of the list equilibrium that may have detrimental long-term effects in situations of significant organ scarcity. PMID:29181383

29 CFR 4206.7 - Amount of credit in plans using the direct attribution method.

Code of Federal Regulations, 2010 CFR

2010-07-01

... TO A PARTIAL WITHDRAWAL § 4206.7 Amount of credit in plans using the direct attribution method. In a plan that uses the direct attribution allocation method described in section 4211(c)(4) of ERISA, the... 29 Labor 9 2010-07-01 2010-07-01 false Amount of credit in plans using the direct attribution...

The influence of naturalistic, directionally non-specific motion on the spatial deployment of visual attention in right-hemispheric stroke.

PubMed

Cazzoli, Dario; Hopfner, Simone; Preisig, Basil; Zito, Giuseppe; Vanbellingen, Tim; Jäger, Michael; Nef, Tobias; Mosimann, Urs; Bohlhalter, Stephan; Müri, René M; Nyffeler, Thomas

2016-11-01

An impairment of the spatial deployment of visual attention during exploration of static (i.e., motionless) stimuli is a common finding after an acute, right-hemispheric stroke. However, less is known about how these deficits: (a) are modulated through naturalistic motion (i.e., without directional, specific spatial features); and, (b) evolve in the subacute/chronic post-stroke phase. In the present study, we investigated free visual exploration in three patient groups with subacute/chronic right-hemispheric stroke and in healthy subjects. The first group included patients with left visual neglect and a left visual field defect (VFD), the second patients with a left VFD but no neglect, and the third patients without neglect or VFD. Eye movements were measured in all participants while they freely explored a traffic scene without (static condition) and with (dynamic condition) naturalistic motion, i.e., cars moving from the right or left. In the static condition, all patient groups showed similar deployment of visual exploration (i.e., as measured by the cumulative fixation duration) as compared to healthy subjects, suggesting that recovery processes took place, with normal spatial allocation of attention. However, the more demanding dynamic condition with moving cars elicited different re-distribution patterns of visual attention, quite similar to those typically observed in acute stroke. Neglect patients with VFD showed a significant decrease of visual exploration in the contralesional space, whereas patients with VFD but no neglect showed a significant increase of visual exploration in the contralesional space. No differences, as compared to healthy subjects, were found in patients without neglect or VFD. These results suggest that naturalistic motion, without directional, specific spatial features, may critically influence the spatial distribution of visual attention in subacute/chronic stroke patients. Copyright © 2016 Elsevier Ltd. All rights reserved.

Survival Benefit of Lung Transplantation in the Modern Era of Lung Allocation

PubMed Central

Tsuang, Wayne M.; Copeland, C. Ashley Finlen; Tsiatis, Anastasios A.; Davidian, Marie; Neely, Megan L.; Lederer, David J.; Palmer, Scott M.

2017-01-01

Rationale: Lung transplantation is an accepted and increasingly employed treatment for advanced lung diseases, but the anticipated survival benefit of lung transplantation is poorly understood. Objectives: To determine whether and for which patients lung transplantation confers a survival benefit in the modern era of U.S. lung allocation. Methods: Data on 13,040 adults listed for lung transplantation between May 2005 and September 2011 were obtained from the United Network for Organ Sharing. A structural nested accelerated failure time model was used to model the survival benefit of lung transplantation over time. The effects of patient, donor, and transplant center characteristics on the relative survival benefit of transplantation were examined. Measurements and Main Results: Overall, 73.8% of transplant recipients were predicted to achieve a 2-year survival benefit with lung transplantation. The survival benefit of transplantation varied by native disease group (P = 0.062), with 2-year expected benefit in 39.2 and 98.9% of transplants occurring in those with obstructive lung disease and cystic fibrosis, respectively, and by lung allocation score at the time of transplantation (P < 0.001), with net 2-year benefit in only 6.8% of transplants occurring for lung allocation score less than 32.5 and in 99.9% of transplants for lung allocation score exceeding 40. Conclusions: A majority of adults undergoing transplantation experience a survival benefit, with the greatest potential benefit in those with higher lung allocation scores or restrictive native lung disease or cystic fibrosis. These results provide novel information to assess the expected benefit of lung transplantation at an individual level and to enhance lung allocation policy. PMID:27779905

Estimation of Direct Melanoma-related Costs by Disease Stage and by Phase of Diagnosis and Treatment According to Clinical Guidelines.

PubMed

Buja, Alessandra; Sartor, Gino; Scioni, Manuela; Vecchiato, Antonella; Bolzan, Mario; Rebba, Vincenzo; Sileni, Vanna Chiarion; Palozzo, Angelo Claudio; Montesco, Maria; Del Fiore, Paolo; Baldo, Vincenzo; Rossi, Carlo Riccardo

2018-02-07

Cutaneous melanoma is a major concern in terms of healthcare systems and economics. The aim of this study was to estimate the direct costs of melanoma by disease stage, phase of diagnosis, and treatment according to the pre-set clinical guidelines drafted by the AIOM (Italian Medical Oncological Association). Based on the AIOM guidelines for malignant cutaneous melanoma, a highly detailed decision-making model was developed describing the patient's pathway from diagnosis through the subsequent phases of disease staging, surgical and medical treatment, and follow-up. The model associates each phase potentially involving medical procedures with a likelihood measure and a cost, thus enabling an estimation of the expected costs by disease stage and clinical phase of melanoma diagnosis and treatment according to the clinical guidelines. The mean per-patient cost of the whole melanoma pathway (including one year of follow-up) ranged from €149 for stage 0 disease to €66,950 for stage IV disease. The costs relating to each phase of the disease's diagnosis and treatment depended on disease stage. It is essential to calculate the direct costs of managing malignant cutaneous melanoma according to clinical guidelines in order to estimate the economic burden of this disease and to enable policy-makers to allocate appropriate resources.

The Determinants of Productivity in Medical Testing: Intensity and Allocation of Care*

PubMed Central

Abaluck, Jason; Agha, Leila; Kabrhel, Chris; Raja, Ali; Venkatesh, Arjun

2017-01-01

A large body of research has investigated whether physicians overuse care. There is less evidence on whether, for a fixed level of spending, doctors allocate resources to patients with the highest expected returns. We assess both sources of inefficiency exploiting variation in rates of negative imaging tests for pulmonary embolism. We document enormous across-doctor heterogeneity in testing conditional on patient population, which explains the negative relationship between physicians’ testing rates and test yields. Furthermore, doctors do not target testing to the highest risk patients, reducing test yields by one third. Our calibration suggests misallocation is more costly than overuse. PMID:29104293

Predictors of Post-discharge Mortality Among Patients Hospitalized for Acute Heart Failure

PubMed Central

Collins, Sean P; Greene, Stephen J; Pang, Peter S; Ambrosy, Andrew P; Antohi, Elena-Laura; Vaduganathan, Muthiah; Butler, Javed; Gheorghiade, Mihai

2017-01-01

Acute Heart Failure (AHF) is a “ multi-event disease” and hospitalisation is a critical event in the clinical course of HF. Despite relatively rapid relief of symptoms, hospitalisation for AHF is followed by an increased risk of death and re-hospitalisation. In AHF, risk stratification from clinically available data is increasingly important in evaluating long-term prognosis. From the perspective of patients, information on the risk of mortality and re-hospitalisation would be helpful in providing patients with insight into their disease. From the perspective of care providers, it may facilitate management decisions, such as who needs to be admitted and to what level of care (i.e. floor, step-down, ICU). Furthermore, risk-stratification may help identify patients who need to be evaluated for advanced HF therapies (i.e. left-ventricle assistance device or transplant or palliative care), and patients who need early a post-discharge follow-up plan. Finally, risk stratification will allow for more robust efforts to identify among risk markers the true targets for therapies that may direct treatment strategies to selected high-risk patients. Further clinical research will be needed to evaluate if appropriate risk stratification of patients could improve clinical outcome and resources allocation. PMID:29387465

A critical assessment on kidney allocation systems.

PubMed

Formica, Richard N

2017-01-01

The kidney allocation system that took effect on December 4, 2014 represents a significant improvement over the prior approach. It seeks to improve outcomes by longevity matching - pairing kidneys expected to function the longest with recipients expected to live the longest. It addresses the biological barriers faced by highly sensitized patients in an evidence based fashion and it begins to introduce the concept of medical need into kidney allocation by crediting time from the starting dialysis to a patient's waiting time. Additionally, it adds a more granular and continuous approach to classifying deceased donor kidneys through the kidney donor profile index and moves away from the dichotomous and flawed, standard criteria/extended criteria approach to allocating kidneys. Despite these changes, access to kidney transplantation across the age spectrum has remained intact and equitable. However even with these numerous positive improvements the system is not without its flaws. The increased sharing and by extension shipping of kidneys have created logistical challenges for organ procurement organizations and transplant centers. Early results seem to indicate that there have been an increase in cold ischemic time, an increase in delayed graft function and an increase in organ discard rate. There is also a reduced offer rate for children and while not a statistically significant decline in the number of transplants, it is a trend that requires close monitoring. Finally, the new kidney allocation system has done nothing to address the glaring deficiencies in the multi-organ allocation practices, all of which include a kidney, in the United States. Therefore despite the improvements made in kidney allocation, there is work yet to be done to ensure that the allocation of life saving and life prolonging organs for transplantation is done in a fashion consistent with ethical principles, based on science and free from local self interest so that this national resource is used for the betterment of the population it is meant to serve. Copyright © 2016. Published by Elsevier Inc.

Optimal allocation model of construction land based on two-level system optimization theory

NASA Astrophysics Data System (ADS)

Liu, Min; Liu, Yanfang; Xia, Yuping; Lei, Qihong

2007-06-01

The allocation of construction land is an important task in land-use planning. Whether implementation of planning decisions is a success or not, usually depends on a reasonable and scientific distribution method. Considering the constitution of land-use planning system and planning process in China, multiple levels and multiple objective decision problems is its essence. Also, planning quantity decomposition is a two-level system optimization problem and an optimal resource allocation decision problem between a decision-maker in the topper and a number of parallel decision-makers in the lower. According the characteristics of the decision-making process of two-level decision-making system, this paper develops an optimal allocation model of construction land based on two-level linear planning. In order to verify the rationality and the validity of our model, Baoan district of Shenzhen City has been taken as a test case. Under the assistance of the allocation model, construction land is allocated to ten townships of Baoan district. The result obtained from our model is compared to that of traditional method, and results show that our model is reasonable and usable. In the end, the paper points out the shortcomings of the model and further research directions.

How to get the most bang for your buck: the evolution and physiology of nutrition-dependent resource allocation strategies.

PubMed

Ng'oma, Enoch; Perinchery, Anna M; King, Elizabeth G

2017-06-28

All organisms use resources to grow, survive and reproduce. The supply of these resources varies widely across landscapes and time, imposing ultimate constraints on the maximal trait values for allocation-related traits. In this review, we address three key questions fundamental to our understanding of the evolution of allocation strategies and their underlying mechanisms. First, we ask: how diverse are flexible resource allocation strategies among different organisms? We find there are many, varied, examples of flexible strategies that depend on nutrition. However, this diversity is often ignored in some of the best-known cases of resource allocation shifts, such as the commonly observed pattern of lifespan extension under nutrient limitation. A greater appreciation of the wide variety of flexible allocation strategies leads directly to our second major question: what conditions select for different plastic allocation strategies? Here, we highlight the need for additional models that explicitly consider the evolution of phenotypically plastic allocation strategies and empirical tests of the predictions of those models in natural populations. Finally, we consider the question: what are the underlying mechanisms determining resource allocation strategies? Although evolutionary biologists assume differential allocation of resources is a major factor limiting trait evolution, few proximate mechanisms are known that specifically support the model. We argue that an integrated framework can reconcile evolutionary models with proximate mechanisms that appear at first glance to be in conflict with these models. Overall, we encourage future studies to: (i) mimic ecological conditions in which those patterns evolve, and (ii) take advantage of the 'omic' opportunities to produce multi-level data and analytical models that effectively integrate across physiological and evolutionary theory. © 2017 The Author(s).

Advantageous Inequity Aversion Does Not Always Exist: The Role of Determining Allocations Modulates Preferences for Advantageous Inequity.

PubMed

Li, Ou; Xu, Fuming; Wang, Lei

2018-01-01

Previous studies have shown that people would like to sacrifice benefits to themselves in order to avoid inequitable outcomes, not only when they receive less than others (disadvantageous inequity aversion) but also when they receive more (advantageous inequity aversion). This feature is captured by the theory of inequity aversion. The present study was inspired by what appears to be asymmetry in the research paradigm toward advantageous inequity aversion. Specifically, studies that supported the existence of advantageous inequity aversion always relied on the paradigm in which participants can determine allocations. Thus, it is interesting to know what would occur if participants could not determine allocations or simply passed judgment on predetermined allocations. To address this, a behavioral experiment ( N = 118) and a skin conductance response (SCR) experiment ( N = 29) were adopted to compare participants' preferences for advantageous inequity directly when allocations were determined and when allocations were predetermined in an allocating task. In the determined condition, participants could divide by themselves a sum of money between themselves and a matched person, whereas in the predetermined condition, they could simply indicate their satisfaction with an equivalent program-generated allocation. It was found that, compared with those in the determined condition, participants in the predetermined condition behaved as if they liked the advantageous inequity and equity to the same degree (Experiment One) and that the SCRs elicited by advantageous inequity had no differences from those elicited by equity, suggesting that participants did not feel negatively toward advantageous inequity in this situation (Experiment Two). The present study provided mutual corroboration (behavioral and electrophysiological data) to document that advantageous inequity aversion may differ as a function of the individual's role in determining allocations, and it would disappear if individual cannot determine allocations.

How to get the most bang for your buck: the evolution and physiology of nutrition-dependent resource allocation strategies

PubMed Central

2017-01-01

All organisms use resources to grow, survive and reproduce. The supply of these resources varies widely across landscapes and time, imposing ultimate constraints on the maximal trait values for allocation-related traits. In this review, we address three key questions fundamental to our understanding of the evolution of allocation strategies and their underlying mechanisms. First, we ask: how diverse are flexible resource allocation strategies among different organisms? We find there are many, varied, examples of flexible strategies that depend on nutrition. However, this diversity is often ignored in some of the best-known cases of resource allocation shifts, such as the commonly observed pattern of lifespan extension under nutrient limitation. A greater appreciation of the wide variety of flexible allocation strategies leads directly to our second major question: what conditions select for different plastic allocation strategies? Here, we highlight the need for additional models that explicitly consider the evolution of phenotypically plastic allocation strategies and empirical tests of the predictions of those models in natural populations. Finally, we consider the question: what are the underlying mechanisms determining resource allocation strategies? Although evolutionary biologists assume differential allocation of resources is a major factor limiting trait evolution, few proximate mechanisms are known that specifically support the model. We argue that an integrated framework can reconcile evolutionary models with proximate mechanisms that appear at first glance to be in conflict with these models. Overall, we encourage future studies to: (i) mimic ecological conditions in which those patterns evolve, and (ii) take advantage of the ‘omic’ opportunities to produce multi-level data and analytical models that effectively integrate across physiological and evolutionary theory. PMID:28637856

Energy-saving EPON Bandwidth Allocation Algorithm Supporting ONU's Sleep Mode

NASA Astrophysics Data System (ADS)

Zhang, Yinfa; Ren, Shuai; Liao, Xiaomin; Fang, Yuanyuan

2014-09-01

A new bandwidth allocation algorithm was presented by combining merits of the IPACT algorithm and the cyclic DBA algorithm based on the DBA algorithm for ONU's sleep mode. Simulation results indicate that compared with the normal mode ONU, the ONU's sleep mode can save about 74% of energy. The new algorithm has a smaller average packet delay and queue length in the upstream direction. While in the downstream direction, the average packet delay of the new algorithm is less than polling cycle Tcycle and the average queue length is less than the product of Tcycle and the maximum link rate. The new algorithm achieves a better compromise between energy-saving and ensuring quality of service.

Auctions with Dynamic Populations: Efficiency and Revenue Maximization

NASA Astrophysics Data System (ADS)

Said, Maher

We study a stochastic sequential allocation problem with a dynamic population of privately-informed buyers. We characterize the set of efficient allocation rules and show that a dynamic VCG mechanism is both efficient and periodic ex post incentive compatible; we also show that the revenue-maximizing direct mechanism is a pivot mechanism with a reserve price. We then consider sequential ascending auctions in this setting, both with and without a reserve price. We construct equilibrium bidding strategies in this indirect mechanism where bidders reveal their private information in every period, yielding the same outcomes as the direct mechanisms. Thus, the sequential ascending auction is a natural institution for achieving either efficient or optimal outcomes.

10 CFR 1009.2 - Definitions.

Code of Federal Regulations, 2010 CFR

2010-01-01

... allocable to a particular cost objective (i.e., a specific function, project, process, or organization) if...) Direct materials. (4) Other direct costs. (5) Processing materials and chemicals. (6) Power and other... equipment. (10) Added factor includes general and administrative costs and other support costs that are...

19 CFR 10.710 - Value-content requirement.

Code of Federal Regulations, 2011 CFR

2011-04-01

... allocable to the specific goods; (iii) Research, development, design, engineering, and blueprint costs... or value of the materials produced in Jordan, plus the direct costs of processing operations... disposal. (d) Direct costs of processing operations—(1) Items included. For purposes of paragraph (a) of...

STEMS pilot trial: a pilot cluster randomised controlled trial to investigate the addition of patient direct access to physiotherapy to usual GP-led primary care for adults with musculoskeletal pain.

PubMed

Bishop, Annette; Ogollah, Reuben O; Jowett, Sue; Kigozi, Jesse; Tooth, Stephanie; Protheroe, Joanne; Hay, Elaine M; Salisbury, Chris; Foster, Nadine E

2017-03-12

Around 17% of general practitioner (GP) consultations are for musculoskeletal conditions, which will rise as the population ages. Patient direct access to physiotherapy provides one solution, yet adoption in the National Health Service (NHS) has been slow. A pilot, pragmatic, non-inferiority, cluster randomised controlled trial (RCT) in general practice and physiotherapy services in the UK. Investigate feasibility of a main RCT. Adult patients registered in participating practices and consulting with a musculoskeletal problem. 4 general practices (clusters) randomised to provide GP-led care as usual or the addition of a patient direct access to physiotherapy pathway. Process outcomes and exploratory analyses of clinical and cost outcomes. Participant-level data were collected via questionnaires at identification, 2, 6 and 12 months and through medical records. The study statistician and research nurses were blinded to practice allocation. Of 2696 patients invited to complete study questionnaires, 978 participated (intervention group n=425, control arm n=553) and were analysed. Participant recruitment was completed in 6 months. Follow-up rates were 78% (6 months) and 71% (12 months). No evidence of selection bias was observed. The direct access pathway was used by 90% of patients in intervention practices needing physiotherapy. Some increase in referrals to physiotherapy occurred from one practice, although waiting times for physiotherapy did not increase (28 days before, 26 days after introduction of direct access). No safety issues were identified. Clinical and cost outcomes were similar in both groups. Exploratory estimates of between group effect (using 36-item Short Form Health Survey (SF-36) Physical Component Summary (PCS)) at 6 months was -0.28 (95% CI -1.35 to 0.79) and at 12 months 0.12 (95% CI -1.27 to 1.51). A full RCT is feasible and will provide trial evidence about the clinical and cost-effectiveness of patient direct access to physiotherapy. ISRCTN23378642. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Physician allocation of Medicare resources for patients with advanced cancer.

PubMed

Rocke, Daniel J; Lee, Walter T; Beumer, Halton W; Taylor, Donald H; Schulz, Kristine; Thomas, Steven; Puscas, Liana

2013-08-01

Little is known about what patients and physicians value in end-of-life care, or how these groups would craft a health plan for those with advanced cancer. The study objective was to assess how otolaryngology, head and neck surgery (OHNS) physicians would structure a Medicare benefit plan for patients with advanced cancer, and to compare this with cancer patient and cancer patient caregiver preferences. OHNS physicians used an online version of a validated tool for assessing preferences for health plans in the setting of limited resources. These data were compared to cancer patient and caregiver preferences. OHNS physicians nationwide were assessed with comparison to similar data obtained in a separate study of cancer patients and their caregivers treated at Duke University Medical Center. Otolaryngology physicians (n=767) completed the online assessment and this was compared with data from 146 patients and 114 caregivers. OHNS physician allocations differed significantly in 14 of the 15 benefit categories when compared with patients and caregivers. Physicians elected more coverage in the Advice, Emotional Care, Palliative Care, and Treatment for Cancer benefit categories. Patients and their caregivers elected more coverage in the Cash, Complementary Care, Cosmetic Care, Dental and Vision, Drug Coverage, Home Improvement, House Calls, Nursing Facility, Other Medical Care, and Primary Care benefit categories. Otolaryngology physicians have significantly different values in end-of-life care than cancer patients and their caregivers. This information is important for efficient allocation of scarce Medicare resources and for effective end-of-life discussions, both of which are key for developing appropriate health policy.

The effects of Pilates exercise training on static and dynamic balance in chronic stroke patients: a randomized controlled trial

PubMed Central

Lim, Hee Sung; Kim, You Lim; Lee, Suk Min

2016-01-01

[Purpose] The purpose of this study was to analyze the effects of Pilates exercise on static and dynamic balance in chronic stroke patients. [Subjects and Methods] Nineteen individuals with unilateral chronic hemiparetic stroke (age, 64.7 ± 6.9 years; height, 161.7 ± 7.9 cm; weight, 67.0 ± 11.1 kg) were randomly allocated to either a Pilates exercise group (PG, n=10) or a control group (CG, n=9). The PG attended 24 exercise sessions conducted over an 8-week period (3 sessions/week). Center of pressure (COP) sway and COP velocity were measured one week before and after the exercise program and compared to assess training effects. [Results] Pilates exercise positively affected both static and dynamic balance in patients with chronic stroke. For static balance, COP sway and velocity in the medial-lateral (M-L) and anterior-posterior (A-P) directions were significantly decreased in the PG after training while no significant differences were found in the CG. For dynamic balance, measured during treadmill walking, the PG showed significantly reduced COP sway and velocity in the M-L and A-P directions for both the paretic and non-paretic leg. [Conclusions] The findings provide initial evidence that Pilates exercise can enhance static and dynamic balance in patients with chronic stroke. PMID:27390424

Reproductive Allocation of Biomass and Nitrogen in Annual and Perennial Lesquerella Crops

PubMed Central

PLOSCHUK, E. L.; SLAFER, G. A.; RAVETTA, D. A.

2005-01-01

• Background and Aims The use of perennial crops could contribute to increase agricultural sustainability. However, almost all of the major grain crops are herbaceous annuals and opportunities to replace them with more long-lived perennials have been poorly explored. This follows the presumption that the perennial life cycle is associated with a lower potential yield, due to a reduced allocation of biomass to grains. The hypothesis was tested that allocation to perpetuation organs in the perennial L. mendocina would not be directly related to a lower allocation to seeds. • Methods Two field experiments were carried on with the annual Lesquerella fendleri and the iteroparous perennial L. mendocina, two promising oil-seed crops for low-productivity environments, subjected to different water and nitrogen availability. • Key Results Seed biomass allocation was similar for both species, and unresponsive to water and nitrogen availability. Greater root and vegetative shoot allocation in the perennial was counterbalanced by a lower allocation to other reproductive structures compared with the annual Lesquerella. Allometric relationships revealed that allocation differences between the annual and the perennial increased linearly with plant size. The general allocation patterns for nitrogen did not differ from those of biomass. However, nitrogen concentrations were higher in the vegetative shoot and root of L. mendocina than of L. fendleri but remained stable in seeds of both species. • Conclusions It is concluded that vegetative organs are more hierarchically important sinks in L. mendocina than in the annual L. fendleri, but without disadvantages in seed hierarchy. PMID:15863469

Lung transplantation in the most critically-III: forging ahead.

PubMed

Mulvihill, Michael S; Hartwig, Matthew G; Daneshmand, Mani A

2017-09-01

Lung transplantation is the gold standard therapy for patients with end-stage lung disease. The use of the lung allocation score (LAS) has permitted improved allocation of scarce pulmonary allografts. Recently, Crawford et al. examined the experience in the United States in lung transplantation in candidates with the highest LAS, demonstrating that outcomes for candidates with the highest LAS scores have improved significantly. This editorial places these data in the broader context of thoracic transplantation, and highlights the critical need for ongoing examination of this critically-ill patient population.

A strategic endeavor in business planning--an oncology perspective.

PubMed

Eck, C

2000-06-01

Planning is imperative to provide direction for future growth. The purpose of writing a business plan is to cultivate, analyze, and refine ideas. Planning for academic health centers has become increasingly important because of the changes in financing and delivery of health care. Gathering data related to the current patients population as well as the projected future trends is necessary to establish a framework. Identifying the market and financial data and formulating the strategies needed to move forward are key elements of a business plan. The ultimate outcome of the process is to convince others that the vision is achievable and to ensure allocation of resources to carry out the plan.

Impact of centralized diagnostic review on quality of initial staging in Hodgkin lymphoma: experience of the German Hodgkin Study Group.

PubMed

Bröckelmann, Paul J; Goergen, Helen; Fuchs, Michael; Kriz, Jan; Semrau, Robert; Baues, Christian; Kobe, Carsten; Behringer, Karolin; Eichenauer, Dennis A; von Tresckow, Bastian; Klimm, Beate; Halbsguth, Teresa; Wongso, Diana; Plütschow, Annette; Haverkamp, Heinz; Dietlein, Markus; Eich, Hans T; Stein, Harald; Diehl, Volker; Borchmann, Peter; Engert, Andreas

2015-11-01

Accurate clinical staging is crucial for adequate risk-adapted treatment in Hodgkin lymphoma (HL) to prevent patients from under- or over-treatment. Within the latest German Hodgkin Study Group trial generation, diagnostic findings such as histopathology, computerized tomography imaging and clinical risk factors were re-evaluated by expert panels. Here, we retrospectively analysed 5965 patients and identified 399 in who major discordant findings changed their first-line treatment allocation. Histopathology review did not confirm the initial diagnosis of HL in 87 patients. Treatment allocation was revised in 312 of the remaining 5878 patients: 176 were assigned to a higher and 128 to a lower risk group, respectively; the correct treatment group remained unclear in 8 patients. Cases of revised treatment allocation accounted for 9·8%, 6·0%, 0·8%, and 14·8% of patients initially assigned to the HD13, HD14, HD15 trials and stage IA lymphocyte-predominant HL project, respectively. Most revisions were due to wrong application of clinical stage (20·5% of 312 patients with revised treatment group), histological subtype (9·0%) or the risk factors ≥3 involved areas (46·8%) or large mediastinal mass (9·3%). In conclusion, centralized review by experienced experts changed risk-adapted first-line treatment in a relevant proportion of HL patients. Quality control measures clearly improve the accuracy of treatment and should be implemented in clinical practice. © 2015 John Wiley & Sons Ltd.

Effect of social influence on effort-allocation for monetary rewards.

PubMed

Gilman, Jodi M; Treadway, Michael T; Curran, Max T; Calderon, Vanessa; Evins, A Eden

2015-01-01

Though decades of research have shown that people are highly influenced by peers, few studies have directly assessed how the value of social conformity is weighed against other types of costs and benefits. Using an effort-based decision-making paradigm with a novel social influence manipulation, we measured how social influence affected individuals' decisions to allocate effort for monetary rewards during trials with either high or low probability of receiving a reward. We found that information about the effort-allocation of peers modulated participant choices, specifically during conditions of low probability of obtaining a reward. This suggests that peer influence affects effort-based choices to obtain rewards especially under conditions of risk. This study provides evidence that people value social conformity in addition to other costs and benefits when allocating effort, and suggests that neuroeconomic studies that assess trade-offs between effort and reward should consider social environment as a factor that can influence decision-making.

Allocation of Resources to Communication of Research Result Summaries.

PubMed

Richards, Julie E; Bane, Emmi; Fullerton, Stephanie M; Ludman, Evette J; Jarvik, Gail

2016-10-01

Researchers and policymakers recommend communicating summary research results to biobank participants when feasible. To date, however, there have been few explorations of participant preferences for dedicating resources to this activity. Fifteen semi-structured interviews were conducted with participants of a genetic medicine biobank. Participants were interviewed by phone about their motivation for participation, and opinions about the allocation of resources to communicating summary results. De-identified transcripts were used for a directed content analysis. Most biobank participation was altruistic. All participants were not only interested in receiving summary results but also expressed a clear preference for allocating limited funds to conducting additional genetic research. The results suggest that participants have a nuanced view about the allocation of biobank resources to returning summary results, and asking their opinion is a valuable exercise. Researchers may benefit from transparency about research goals and involving biobank participants in decisions about return of summary results.

The role of intrinsic motivations in attention allocation and shifting

PubMed Central

Di Nocera, Dario; Finzi, Alberto; Rossi, Silvia; Staffa, Mariacarla

2014-01-01

The concepts of attention and intrinsic motivations are of great interest within adaptive robotic systems, and can be exploited in order to guide, activate, and coordinate multiple concurrent behaviors. Attention allocation strategies represent key capabilities of human beings, which are strictly connected with action selection and execution mechanisms, while intrinsic motivations directly affect the allocation of attentional resources. In this paper we propose a model of Reinforcement Learning (RL), where both these capabilities are involved. RL is deployed to learn how to allocate attentional resources in a behavior-based robotic system, while action selection is obtained as a side effect of the resulting motivated attentional behaviors. Moreover, the influence of intrinsic motivations in attention orientation is obtained by introducing rewards associated with curiosity drives. In this way, the learning process is affected not only by goal-specific rewards, but also by intrinsic motivations. PMID:24744746

19 CFR 10.178 - Direct costs of processing operations performed in the beneficiary developing country.

Code of Federal Regulations, 2013 CFR

2013-04-01

..., design, engineering, and blueprint costs insofar as they are allocable to the specific merchandise; and... 19 Customs Duties 1 2013-04-01 2013-04-01 false Direct costs of processing operations performed in... TO A REDUCED RATE, ETC. General Provisions Generalized System of Preferences § 10.178 Direct costs of...

19 CFR 10.178 - Direct costs of processing operations performed in the beneficiary developing country.

Code of Federal Regulations, 2014 CFR

2014-04-01

..., design, engineering, and blueprint costs insofar as they are allocable to the specific merchandise; and... 19 Customs Duties 1 2014-04-01 2014-04-01 false Direct costs of processing operations performed in... TO A REDUCED RATE, ETC. General Provisions Generalized System of Preferences § 10.178 Direct costs of...

19 CFR 10.178 - Direct costs of processing operations performed in the beneficiary developing country.

Code of Federal Regulations, 2012 CFR

2012-04-01

..., design, engineering, and blueprint costs insofar as they are allocable to the specific merchandise; and... 19 Customs Duties 1 2012-04-01 2012-04-01 false Direct costs of processing operations performed in... TO A REDUCED RATE, ETC. General Provisions Generalized System of Preferences § 10.178 Direct costs of...

Habit training versus habit training with direct visual biofeedback in adults with chronic constipation: study protocol for a randomised controlled trial.

PubMed

Norton, Christine; Emmanuel, Anton; Stevens, Natasha; Scott, S Mark; Grossi, Ugo; Bannister, Sybil; Eldridge, Sandra; Mason, James M; Knowles, Charles H

2017-03-24

Constipation affects up to 20% of adults. Chronic constipation (CC) affects 1-2% of adults. Patient dissatisfaction is high; nearly 80% feel that laxative therapy is unsatisfactory and symptoms have significant impact on quality of life. There is uncertainty about the value of specialist investigations and whether equipment-intensive therapies using biofeedback confer additional benefit when compared with specialist conservative advice. A three-arm, parallel-group, multicentre randomised controlled trial. to determine whether standardised specialist-led habit training plus pelvic floor retraining using computerised biofeedback is more clinically effective than standardised specialist-led habit training alone; to determine whether outcomes are improved by stratification based on prior investigation of anorectal and colonic pathophysiology. Primary outcome measure is response to treatment, defined as a 0.4-point (10% of scale) or greater reduction in Patient Assessment of Constipation-Quality of Life (PAC-QOL) score 6 months after the end of treatment. Other outcomes up to 12 months include symptoms, quality of life, health economics, psychological health and qualitative experience. (1) habit training (HT) with computer-assisted direct visual biofeedback (HTBF) results in an average reduction in PAC-QOL score of 0.4 points at 6 months compared to HT alone in unselected adults with CC, (2) stratification to either HT or HTBF informed by pathophysiological investigation (INVEST) results in an average 0.4-point reduction in PAC-QOL score at 6 months compared with treatment not directed by investigations (No-INVEST). Inclusion: chronic constipation in adults (aged 18-70 years) defined by self-reported symptom duration of more than 6 months; failure of previous laxatives or prokinetics and diet and lifestyle modifications. Consenting participants (n = 394) will be randomised to one of three arms in an allocation ratio of 3:3:2: [1] habit training, [2] habit training and biofeedback or [3] investigation-led allocation to one of these arms. Analysis will be on an intention-to-treat basis. This trial has the potential to answer some of the major outstanding questions in the management of chronic constipation, including whether costly invasive tests are warranted and whether computer-assisted direct visual biofeedback confers additional benefit to well-managed specialist advice alone. International Standard Randomised Controlled Trial Number: ISRCTN11791740. Registered on 16 July 2015.

Elevated C-reactive protein and hypoalbuminemia measured before resection of colorectal liver metastases predict postoperative survival.

PubMed

Kobayashi, Takashi; Teruya, Masanori; Kishiki, Tomokazu; Endo, Daisuke; Takenaka, Yoshiharu; Miki, Kenji; Kobayashi, Kaoru; Morita, Koji

2010-01-01

Few studies have investigated whether the Glasgow Prognostic Score (GPS), an inflammation-based prognostic score measured before resection of colorectal liver metastasis (CRLM), can predict postoperative survival. Sixty-three consecutive patients who underwent curative resection for CRLM were investigated. GPS was calculated on the basis of admission data as follows: patients with both an elevated C-reactive protein (>10 mg/l) and hypoalbuminemia (<35 g/l) were allocated a GPS score of 2. Patients in whom only one of these biochemical abnormalities was present were allocated a GPS score of 1, and patients with a normal C-reactive protein and albumin were allocated a score of 0. Significant factors concerning survival were the number of liver metastases (p = 0.0044), carcinoembryonic antigen level (p = 0.0191), GPS (p = 0.0029), grade of liver metastasis (p = 0.0033), and the number of lymph node metastases around the primary cancer (p = 0.0087). Multivariate analysis showed the two independent prognostic variables: liver metastases > or =3 (relative risk 2.83) and GPS1/2 (relative risk 3.07). GPS measured before operation and the number of liver metastases may be used as novel predictors of postoperative outcomes in patients who underwent curative resection for CRLM. Copyright 2010 S. Karger AG, Basel.

Electronic Health Record Logs Indicate That Physicians Split Time Evenly Between Seeing Patients And Desktop Medicine.

PubMed

Tai-Seale, Ming; Olson, Cliff W; Li, Jinnan; Chan, Albert S; Morikawa, Criss; Durbin, Meg; Wang, Wei; Luft, Harold S

2017-04-01

Time spent by physicians is a key resource in health care delivery. This study used data captured by the access time stamp functionality of an electronic health record (EHR) to examine physician work effort. This is a potentially powerful, yet unobtrusive, way to study physicians' use of time. We used data on physicians' time allocation patterns captured by over thirty-one million EHR transactions in the period 2011-14 recorded by 471 primary care physicians, who collectively worked on 765,129 patients' EHRs. Our results suggest that the physicians logged an average of 3.08 hours on office visits and 3.17 hours on desktop medicine each day. Desktop medicine consists of activities such as communicating with patients through a secure patient portal, responding to patients' online requests for prescription refills or medical advice, ordering tests, sending staff messages, and reviewing test results. Over time, log records from physicians showed a decline in the time allocated to face-to-face visits, accompanied by an increase in time allocated to desktop medicine. Staffing and scheduling in the physician's office, as well as provider payment models for primary care practice, should account for these desktop medicine efforts. Project HOPE—The People-to-People Health Foundation, Inc.

Optimal resource allocation for novelty detection in a human auditory memory.

PubMed

Sinkkonen, J; Kaski, S; Huotilainen, M; Ilmoniemi, R J; Näätänen, R; Kaila, K

1996-11-04

A theory of resource allocation for neuronal low-level filtering is presented, based on an analysis of optimal resource allocation in simple environments. A quantitative prediction of the theory was verified in measurements of the magnetic mismatch response (MMR), an auditory event-related magnetic response of the human brain. The amplitude of the MMR was found to be directly proportional to the information conveyed by the stimulus. To the extent that the amplitude of the MMR can be used to measure resource usage by the auditory cortex, this finding supports our theory that, at least for early auditory processing, energy resources are used in proportion to the information content of incoming stimulus flow.

Case-mix groups for VA hospital-based home care.

PubMed

Smith, M E; Baker, C R; Branch, L G; Walls, R C; Grimes, R M; Karklins, J M; Kashner, M; Burrage, R; Parks, A; Rogers, P

1992-01-01

The purpose of this study is to group hospital-based home care (HBHC) patients homogeneously by their characteristics with respect to cost of care to develop alternative case mix methods for management and reimbursement (allocation) purposes. Six Veterans Affairs (VA) HBHC programs in Fiscal Year (FY) 1986 that maximized patient, program, and regional variation were selected, all of which agreed to participate. All HBHC patients active in each program on October 1, 1987, in addition to all new admissions through September 30, 1988 (FY88), comprised the sample of 874 unique patients. Statistical methods include the use of classification and regression trees (CART software: Statistical Software; Lafayette, CA), analysis of variance, and multiple linear regression techniques. The resulting algorithm is a three-factor model that explains 20% of the cost variance (R2 = 20%, with a cross validation R2 of 12%). Similar classifications such as the RUG-II, which is utilized for VA nursing home and intermediate care, the VA outpatient resource allocation model, and the RUG-HHC, utilized in some states for reimbursing home health care in the private sector, explained less of the cost variance and, therefore, are less adequate for VA home care resource allocation.

Patient allocations in general practice in case of patients' preferences for gender of doctor and their unavailability.

PubMed

Lillestøl, Jostein; Ubøe, Jan; Rønsen, Yngve; Hjortdahl, Per

2011-04-08

In some countries every citizen has the right to obtain a designated general practitioner. However, each individual may have preferences that cannot be fulfilled due to shortages of some kind. The questions raised in this paper are: To what extent can we expect that preferences are fulfilled when the patients "compete" for entry on the lists of practitioners? What changes can we expect under changing conditions? A particular issue explored in the paper is when the majority of women prefer a female doctor and there is a shortage of female doctors. The analysis is done on the macro level by the so called gravity model and on the micro level by recent theories of benefit efficient population behaviour, partly developed by two of the authors. A major finding is that the number of patients wanting a doctor of the underrepresented gender is less important than the strength of their preferences as determining factor for the benefit efficient allocation. We were able to generate valuable insights to the questions asked and to the dynamics of benefit efficient allocations. The approach is quite general and can be applied in a variety of contexts.

Patient allocations in general practice in case of patients' preferences for gender of doctor and their unavailability

PubMed Central

2011-01-01

Background In some countries every citizen has the right to obtain a designated general practitioner. However, each individual may have preferences that cannot be fulfilled due to shortages of some kind. The questions raised in this paper are: To what extent can we expect that preferences are fulfilled when the patients "compete" for entry on the lists of practitioners? What changes can we expect under changing conditions? A particular issue explored in the paper is when the majority of women prefer a female doctor and there is a shortage of female doctors. Findings The analysis is done on the macro level by the so called gravity model and on the micro level by recent theories of benefit efficient population behaviour, partly developed by two of the authors. A major finding is that the number of patients wanting a doctor of the underrepresented gender is less important than the strength of their preferences as determining factor for the benefit efficient allocation. Conclusions We were able to generate valuable insights to the questions asked and to the dynamics of benefit efficient allocations. The approach is quite general and can be applied in a variety of contexts. PMID:21477281

Evaluation of the McGrath MAC and Macintosh laryngoscope for tracheal intubation in 2000 patients undergoing general anaesthesia: the randomised multicentre EMMA trial study protocol

PubMed Central

Kriege, Marc; Alflen, Christian; Tzanova, Irene; Schmidtmann, Irene; Piepho, Tim; Noppens, Ruediger R

2017-01-01

Introduction The direct laryngoscopy technique using a Macintosh blade is the first choice globally for most anaesthetists. In case of an unanticipated difficult airway, the complication rate increases with the number of intubation attempts. Recently, McGrath MAC (McGrath) video laryngoscopy has become a widely accepted method for securing an airway by tracheal intubation because it allows the visualisation of the glottis without a direct line of sight. Several studies and case reports have highlighted the benefit of the video laryngoscope in the visualisation of the glottis and found it to be superior in difficult intubation situations. The aim of this study was to compare the first-pass intubation success rate using the (McGrath) video laryngoscope compared with conventional direct laryngoscopy in surgical patients. Methods and analysis The EMMA trial is a multicentre, open-label, patient-blinded, randomised controlled trial. Consecutive patients requiring tracheal intubation are randomly allocated to either the McGrath video laryngoscope or direct laryngoscopy using the Macintosh laryngoscope. The expected rate of successful first-pass intubation is 95% in the McGrath group and 90% in the Macintosh group. Each group must include a total of 1000 patients to achieve 96% power for detecting a difference at the 5% significance level. Successful intubation with the first attempt is the primary endpoint. The secondary endpoints are the time to intubation, attempts for successful intubation, the necessity of alternatives, visualisation of the glottis using the Cormack & Lehane score and percentage of glottic opening score and definite complications. Ethics and dissemination The project was approved by the local ethics committee of the Medical Association of the Rhineland Palatine state and Westphalia-Lippe. The results of this study will be made available in the form of manuscripts for publication and presentations at national and international meetings. Trial registration number ClinicalTrials.gov NCT 02611986; pre-results. PMID:28827261

Practice parameters and financial factors impacting developmental-behavioral pediatrics.

PubMed

Adair, Robin; Perrin, Ellen; Hubbard, Carol; Savageau, Judith A

2010-01-01

Little has been published about the professional activities of developmental-behavioral (DB) pediatricians. To better understand the settings in which DB pediatricians work, allocation of their professional time, and how financial considerations impact their practice, the Society for Developmental and Behavioral Pediatrics surveyed its membership. An extensive on-line three-part survey was conducted in 2006-2007 assessing sociodemographic characteristics, practice descriptors, coding and billing practices, productivity goals and perceived pressures among Society for Developmental and Behavioral Pediatric's 438 physician members. Of the pediatricians responding, representing all regions of the United States, 93% were DB pediatrics subspecialty board certified or eligible. The majority was practicing DB pediatrics full-time (73%); and 67% were exclusively in academic settings. All reported seeing patients, 84% reported teaching, 76% reported having administrative responsibilities, and 46% reported conducting research. Despite having non-clinical responsibilities, full-time equivalent positions included an average of 25 hours per week in direct patient care and 14.5 hours per week (37% of clinical time) in indirect patient care. Only 42% reported working with multidisciplinary teams. Salaries varied widely within and across regions. Deficits in billing/coding practices, awareness of personal clinical productivity, and familiarity with national productivity benchmarks were identified. DB pediatricians work in diverse settings nationwide. They provide considerable time in indirect patient care, which is poorly reimbursed in general and relative to direct patient care. The results of this survey offer opportunities for provider, institutional and payer education.

Integrated collaborative care for major depression comorbid with a poor prognosis cancer (SMaRT Oncology-3): a multicentre randomised controlled trial in patients with lung cancer.

PubMed

Walker, Jane; Hansen, Christian Holm; Martin, Paul; Symeonides, Stefan; Gourley, Charlie; Wall, Lucy; Weller, David; Murray, Gordon; Sharpe, Michael

2014-09-01

The management of depression in patients with poor prognosis cancers, such as lung cancer, creates specific challenges. We aimed to assess the efficacy of an integrated treatment programme for major depression in patients with lung cancer compared with usual care. Symptom Management Research Trials (SMaRT) Oncology-3 is a parallel-group, multicentre, randomised controlled trial. We enrolled patients with lung cancer and major depression from three cancer centres and their associated clinics in Scotland, UK. Participants were randomly assigned in a 1:1 ratio to the depression care for people with lung cancer treatment programme or usual care by a database software algorithm that used stratification (by trial centre) and minimisation (by age, sex, and cancer type) with allocation concealment. Depression care for people with lung cancer is a manualised, multicomponent collaborative care treatment that is systematically delivered by a team of cancer nurses and psychiatrists in collaboration with primary care physicians. Usual care is provided by primary care physicians. The primary outcome was depression severity (on the Symptom Checklist Depression Scale [SCL-20], range 0-4) averaged over the patient's time in the trial (up to a maximum of 32 weeks). Trial statisticians and data collection staff were masked to treatment allocation, but patients and clinicians could not be masked to the allocations. Analyses were by intention to treat. This trial is registered with Current Controlled Trials, number ISRCTN75905964. 142 participants were recruited between Jan 5, 2009, and Sept 9, 2011; 68 were randomly allocated to depression care for people with lung cancer and 74 to usual care. 43 (30%) of 142 patients had died by 32 weeks, all of which were cancer-related deaths. No intervention-related serious adverse events occurred. 131 (92%) of 142 patients provided outcome data (59 in the depression care for people with lung cancer group and 72 in the usual care group) and were included in the intention-to-treat primary analysis. Average depression severity was significantly lower in patients allocated to depression care for people with lung cancer (mean score on the SCL-20 1·24 [SD 0·64]) than in those allocated to usual care (mean score 1·61 [SD 0·58]); difference -0·38 (95% CI -0·58 to -0·18); standardised mean difference -0·62 (95% CI -0·94 to -0·29). Self-rated depression improvement, anxiety, quality of life, role functioning, perceived quality of care, and proportion of patients achieving a 12-week treatment response were also significantly better in the depression care for people with lung cancer group than in the usual care group. Our findings suggest that major depression can be treated effectively in patients with a poor prognosis cancer; integrated depression care for people with lung cancer was substantially more efficacious than was usual care. Larger trials are now needed to estimate the effectiveness and cost-effectiveness of this care programme in this patient population, and further adaptation of the treatment will be necessary to address the unmet needs of patients with major depression and even shorter life expectancy. Cancer Research UK and Chief Scientist Office of the Scottish Government. Copyright © 2014 Elsevier Ltd. All rights reserved.

Cost-effectiveness of health research study participant recruitment strategies: a systematic review.

PubMed

Huynh, Lynn; Johns, Benjamin; Liu, Su-Hsun; Vedula, S Swaroop; Li, Tianjing; Puhan, Milo A

2014-10-01

A large fraction of the cost of conducting clinical trials is allocated to recruitment of participants. A synthesis of findings from studies that evaluate the cost and effectiveness of different recruitment strategies will inform investigators in designing cost-efficient clinical trials. To systematically identify, assess, and synthesize evidence from published comparisons of the cost and yield of strategies for recruitment of participants to health research studies. We included randomized studies in which two or more strategies for recruitment of participants had been compared. We focused our economic evaluation on studies that randomized participants to different recruitment strategies. We identified 10 randomized studies that compared recruitment strategies, including monetary incentives (cash or prize), direct contact (letters or telephone call), and medical referral strategies. Only two of the 10 studies compared strategies for recruiting participants to clinical trials. We found that allocating additional resources to recruit participants using monetary incentives or direct contact yielded between 4% and 23% additional participants compared to using neither strategy. For medical referral, recruitment of prostate cancer patients by nurses was cost-saving compared to recruitment by consultant urologists. For all underlying study designs, monetary incentives cost more than direct contact with potential participants, with a median incremental cost per recruitment ratio of Int$72 (Int$-International dollar, a theoretical unit of currency) for monetary incentive strategy compared to Int$28 for direct contact strategy. Only monetary incentives and source of referral were evaluated for recruiting participants into clinical trials. We did not review studies that presented non-monetary cost or lost opportunity cost. We did not adjust for the number of study recruitment sites or the study duration in our economic evaluation analysis. Systematic and explicit reporting of cost and effectiveness of recruitment strategies from randomized comparisons is required to aid investigators to select cost-efficient strategies for recruiting participants to health research studies including clinical trials. © The Author(s) 2014.

Comparison between the efficacy of ginger and sumatriptan in the ablative treatment of the common migraine.

PubMed

Maghbooli, Mehdi; Golipour, Farhad; Moghimi Esfandabadi, Alireza; Yousefi, Mehran

2014-03-01

Frequency and torment caused by migraines direct patients toward a variety of remedies. Few studies to date have proposed ginger derivates for migraine relief. This study aims to evaluate the efficacy of ginger in the ablation of common migraine attack in comparison to sumatriptan therapy. In this double-blinded randomized clinical trial, 100 patients who had acute migraine without aura were randomly allocated to receive either ginger powder or sumatriptan. Time of headache onset, its severity, time interval from headache beginning to taking drug and patient self-estimation about response for five subsequent migraine attacks were recorded by patients. Patients(,) satisfaction from treatment efficacy and their willingness to continue it was also evaluated after 1 month following intervention. Two hours after using either drug, mean headaches severity decreased significantly. Efficacy of ginger powder and sumatriptan was similar. Clinical adverse effects of ginger powder were less than sumatriptan. Patients' satisfaction and willingness to continue did not differ. The effectiveness of ginger powder in the treatment of common migraine attacks is statistically comparable to sumatriptan. Ginger also poses a better side effect profile than sumatriptan. Copyright © 2013 John Wiley & Sons, Ltd.

An observational study showed that explaining randomization using gambling-related metaphors and computer-agency descriptions impeded randomized clinical trial recruitment.

PubMed

Jepson, Marcus; Elliott, Daisy; Conefrey, Carmel; Wade, Julia; Rooshenas, Leila; Wilson, Caroline; Beard, David; Blazeby, Jane M; Birtle, Alison; Halliday, Alison; Stein, Rob; Donovan, Jenny L

2018-07-01

To explore how the concept of randomization is described by clinicians and understood by patients in randomized controlled trials (RCTs) and how it contributes to patient understanding and recruitment. Qualitative analysis of 73 audio recordings of recruitment consultations from five, multicenter, UK-based RCTs with identified or anticipated recruitment difficulties. One in 10 appointments did not include any mention of randomization. Most included a description of the method or process of allocation. Descriptions often made reference to gambling-related metaphors or similes, or referred to allocation by a computer. Where reference was made to a computer, some patients assumed that they would receive the treatment that was "best for them". Descriptions of the rationale for randomization were rarely present and often only came about as a consequence of patients questioning the reason for a random allocation. The methods and processes of randomization were usually described by recruiters, but often without clarity, which could lead to patient misunderstanding. The rationale for randomization was rarely mentioned. Recruiters should avoid problematic gambling metaphors and illusions of agency in their explanations and instead focus on clearer descriptions of the rationale and method of randomization to ensure patients are better informed about randomization and RCT participation. Copyright © 2018 University of Bristol. Published by Elsevier Inc. All rights reserved.

Direct-acting antivirals combination for elderly patients with chronic hepatitis C: A cost-effectiveness analysis.

PubMed

Ciaccio, Antonio; Cortesi, Paolo A; Bellelli, Giuseppe; Rota, Matteo; Conti, Sara; Okolicsanyi, Stefano; Rota, Monica; Cesana, Giancarlo; Mantovani, Lorenzo G; Annoni, Giorgio; Strazzabosco, Mario

2017-07-01

Chronic hepatitis C (CHC) has been undertreated among elderly patients. Interferon-free treatment represents an opportunity for these patients. The aim of this study was to assess the cost-effectiveness of directly acting antivirals (DAAs) in CHC elderly patients. A Markov model of CHC natural history was built. This study focuses on CHC patients older than 65 years, stratified according to genotype (1/4, 2 and 3), liver fibrosis (METAVIR F1 to F4), age and frailty phenotype (robust, pre-frail and frail). DAAs combination vs no treatment was simulated for each theoretical population, assessing life years, quality-adjusted life years (QALYs), costs, incremental cost-effectiveness ratios (ICERs) in a lifetime time horizon and by the Healthcare System perspective. Incremental cost-effectiveness ratio increased with age and frailty status in all fibrosis stages. For robust F3 and F4 patients ICERs remained below the willingness-to-pay threshold (WTP) of 40 000€/QALY up to age 75 and 86 years, respectively, depending on drug price and sustained virological response probability (sensitivity analysis). Notably, in F4 and frail subjects older than 75 years, ICER was more sensitive to non-liver-related mortality rate. In elderly F1 and F2 patients, ICERs were below WTP only up to 77 years old, with wide variability among frailty phenotypes. Cost-effectiveness of DAAs treatment of elderly CHC patients is solid in those with advanced fibrosis, but it depends strongly on frailty status and age, particularly in patients with milder fibrosis stages. Accurate assessment of clinical variables, including frailty, is necessary to allocate limited resources to this special population. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

Verification of Heart Disease: Implications for a New Heart Transplantation Allocation System.

PubMed

Raeisi-Giglou, Pejman; Rodriguez, E Rene; Blackstone, Eugene H; Tan, Carmela D; Hsich, Eileen M

2017-12-01

This study sought to determine the accuracy of the pre-transplantation clinical diagnosis of heart disease in the United Network for Organ Sharing (UNOS) database. Because survival on the heart transplantation waitlist depends on underlying heart disease, a new allocation system will include the type of heart disease. Accuracy of the pre-transplantation clinical diagnosis and the effect of misclassification are unknown. We included all adults who received transplants at our center between January 2009 to December 2015. We compared the pre-transplantation clinical diagnosis at listing with pathology of the explanted heart and determined the potential effect of misclassification with the proposed allocation system. A total of 334 patients had the following clinical cardiac diagnoses at listing: 148 had dilated cardiomyopathy, 19 had restrictive cardiomyopathy, 103 had ischemic cardiomyopathy, 24 had hypertrophic cardiomyopathy, 11 had valvular disease, 16 had congenital heart disease (CHD), and 13 patients had a diagnosis of "other." Pathology of the explanted hearts revealed 82% concordance and 18% discordance (10% coding errors and 8% incorrect diagnosis). The most common incorrect diagnoses were sarcoidosis (66%), arrhythmogenic right ventricular dysplasia (60%), and other causes of predominately right-sided heart failure (33%). Among the misclassified diagnoses, 40% were listed as UNOS status 2, 8% remained at status 2 at transplantation, and only sarcoidosis and CHD were potentially at a disadvantage with the new allocation. There is high concordance between clinical and pathologic diagnosis, except for sarcoidosis and genetic diseases. Few misclassifications result in disadvantages to patients based on the new allocation system, but rare diseases like sarcoidosis remain problematic. To improve the UNOS database and enhance outcome research, pathology of the explanted hearts should be required post-transplantation. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Assessing DRG cost accounting with respect to resource allocation and tariff calculation: the case of Germany

PubMed Central

2012-01-01

The purpose of this paper is to analyze the German diagnosis related groups (G-DRG) cost accounting scheme by assessing its resource allocation at hospital level and its tariff calculation at national level. First, the paper reviews and assesses the three steps in the G-DRG resource allocation scheme at hospital level: (1) the groundwork; (2) cost-center accounting; and (3) patient-level costing. Second, the paper reviews and assesses the three steps in G-DRG national tariff calculation: (1) plausibility checks; (2) inlier calculation; and (3) the “one hospital” approach. The assessment is based on the two main goals of G-DRG introduction: improving transparency and efficiency. A further empirical assessment attests high costing quality. The G-DRG cost accounting scheme shows high system quality in resource allocation at hospital level, with limitations concerning a managerially relevant full cost approach and limitations in terms of advanced activity-based costing at patient-level. However, the scheme has serious flaws in national tariff calculation: inlier calculation is normative, and the “one hospital” model causes cost bias, adjustment and representativeness issues. The G-DRG system was designed for reimbursement calculation, but developed to a standard with strategic management implications, generalized by the idea of adapting a hospital’s cost structures to DRG revenues. This combination causes problems in actual hospital financing, although resource allocation is advanced at hospital level. PMID:22935314

Assessing DRG cost accounting with respect to resource allocation and tariff calculation: the case of Germany.

PubMed

Vogl, Matthias

2012-08-30

The purpose of this paper is to analyze the German diagnosis related groups (G-DRG) cost accounting scheme by assessing its resource allocation at hospital level and its tariff calculation at national level. First, the paper reviews and assesses the three steps in the G-DRG resource allocation scheme at hospital level: (1) the groundwork; (2) cost-center accounting; and (3) patient-level costing. Second, the paper reviews and assesses the three steps in G-DRG national tariff calculation: (1) plausibility checks; (2) inlier calculation; and (3) the "one hospital" approach. The assessment is based on the two main goals of G-DRG introduction: improving transparency and efficiency. A further empirical assessment attests high costing quality. The G-DRG cost accounting scheme shows high system quality in resource allocation at hospital level, with limitations concerning a managerially relevant full cost approach and limitations in terms of advanced activity-based costing at patient-level. However, the scheme has serious flaws in national tariff calculation: inlier calculation is normative, and the "one hospital" model causes cost bias, adjustment and representativeness issues. The G-DRG system was designed for reimbursement calculation, but developed to a standard with strategic management implications, generalized by the idea of adapting a hospital's cost structures to DRG revenues. This combination causes problems in actual hospital financing, although resource allocation is advanced at hospital level.

Automation trust and attention allocation in multitasking workspace.

PubMed

Karpinsky, Nicole D; Chancey, Eric T; Palmer, Dakota B; Yamani, Yusuke

2018-07-01

Previous research suggests that operators with high workload can distrust and then poorly monitor automation, which has been generally inferred from automation dependence behaviors. To test automation monitoring more directly, the current study measured operators' visual attention allocation, workload, and trust toward imperfect automation in a dynamic multitasking environment. Participants concurrently performed a manual tracking task with two levels of difficulty and a system monitoring task assisted by an unreliable signaling system. Eye movement data indicate that operators allocate less visual attention to monitor automation when the tracking task is more difficult. Participants reported reduced levels of trust toward the signaling system when the tracking task demanded more focused visual attention. Analyses revealed that trust mediated the relationship between the load of the tracking task and attention allocation in Experiment 1, an effect that was not replicated in Experiment 2. Results imply a complex process underlying task load, visual attention allocation, and automation trust during multitasking. Automation designers should consider operators' task load in multitasking workspaces to avoid reduced automation monitoring and distrust toward imperfect signaling systems. Copyright © 2018. Published by Elsevier Ltd.

Needle Tip Position and Bevel Direction Have No Effect in the Fluoroscopic Epidural Spreading Pattern in Caudal Epidural Injections: A Randomized Trial

PubMed Central

Kwon, Won Kyoung; Kim, Ah Na; Lee, Pil Moo; Park, Cheol Hwan; Kim, Jae Hun

2016-01-01

Background. Caudal epidural steroid injections (CESIs) are an effective treatment for pain. If the injection spreads in a specific pattern depending on the needle position or bevel direction, it would be possible to inject the agent into a specific and desired area. Objectives. We conducted a prospective randomized trial to determine if the needle position and bevel direction have any effect on the epidural spreading pattern in CESI. Methods. Demographic data of the patient were collected. During CESI, the needle position (middle or lateral) and direction (ventral or dorsal) were randomly allocated. Following fluoroscope-guided injection of 4 mL contrast media and 10 mL of injectates, the epidural spreading patterns (ventral or dorsal, bilateral or lateral) were imaged. Results. In the 210 CESIs performed, the needle tip position and bevel direction did not influence the epidural spreading patterns at L4-5 and L5-S1 disc levels. A history of Lumbar spine surgery was associated with a significantly limited spread to each disc level. A midline needle tip position was more effective than the lateral position in spreading to the distant disc levels. Conclusions. Neither the needle tip position nor the bevel direction affected the epidural drug spreading pattern during CESI. PMID:27445609

Prioritizing registered donors in organ allocation: an ethical appraisal of the Israeli organ transplant law.

PubMed

Lavee, Jacob; Brock, Dan W

2012-12-01

A new organ transplant law in Israel, which gives priority in organ allocation to candidates who in various ways support organ donation, has resulted in a significant increase in organ donation in 2011. We provide an ethical analysis of the new law. We note that by continuing to require opt-in consent, the Israeli law has an ethical advantage over opt-out laws, which may result in some use of organs from donors who have not consented. We discuss the fair response to 'free-riding' candidates who, usually for religious reasons, are opposed to donation, but nevertheless seek a transplant, who will not receive any priority over candidates who have been registered donors for at least 3 years before listing. We spell out several reasons why it is potentially unfair to prioritize patients whose first-degree relatives are registered donors, whereas it is fair to prioritize candidates who have been living directed or nondirected donors. Finally, we note the difficulty of ensuring public awareness of the priority system, which is necessary for its fairness. Athough needing some modifications, the new Israeli law is based on sound ethical approach that seems to begin already to bear fruits.

Patient-care time allocation by nurse practitioners and physician assistants in the intensive care unit.

PubMed

Carpenter, David L; Gregg, Sara R; Owens, Daniel S; Buchman, Timothy G; Coopersmith, Craig M

2012-02-15

Use of nurse practitioners and physician assistants ("affiliates") is increasing significantly in the intensive care unit (ICU). Despite this, few data exist on how affiliates allocate their time in the ICU. The purpose of this study was to understand the allocation of affiliate time into patient-care and non-patient-care activity, further dividing the time devoted to patient care into billable service and equally important but nonbillable care. We conducted a quasi experimental study in seven ICUs in an academic hospital and a hybrid academic/community hospital. After a period of self-reporting, a one-time monetary incentive of $2,500 was offered to 39 affiliates in each ICU in which every affiliate documented greater than 75% of their time devoted to patient care over a 6-month period in an effort to understand how affiliates allocated their time throughout a shift. Documentation included billable time (critical care, evaluation and management, procedures) and a new category ("zero charge time"), which facilitated record keeping of other patient-care activities. At baseline, no ICUs had documentation of 75% patient-care time by all of its affiliates. In the 6 months in which reporting was tied to a group incentive, six of seven ICUs had every affiliate document greater than 75% of their time. Individual time documentation increased from 53% to 84%. Zero-charge time accounted for an average of 21% of each shift. The most common reason was rounding, which accounted for nearly half of all zero-charge time. Sign out, chart review, and teaching were the next most common zero-charge activities. Documentation of time spent on billable activities also increased from 53% of an affiliate's shift to 63%. Time documentation was similar regardless of during which shift an affiliate worked. Approximately two thirds of an affiliate's shift is spent providing billable services to patients. Greater than 20% of each shift is spent providing equally important but not reimbursable patient care. Understanding how affiliates spend their time and what proportion of time is spent in billable activities can be used to plan the financial impact of staffing ICUs with affiliates.

The Effect of IV Amino Acid Supplementation on Mortality in ICU Patients May Be Dependent on Kidney Function: Post Hoc Subgroup Analyses of a Multicenter Randomized Trial.

PubMed

Zhu, Ran; Allingstrup, Matilde J; Perner, Anders; Doig, Gordon S

2018-05-15

We investigated whether preexisting kidney function determines if ICU patients may benefit from increased (2.0 g/kg/d) protein intake. Post hoc, hypothesis-generating, subgroup analysis of a multicenter, phase 2, randomized clinical trial. All analyses were conducted by intention to treat and maintained group allocation. Ninety-day mortality was the primary outcome. ICUs of 16 hospitals throughout Australia and New Zealand. Adult critically ill patients expected to remain in the study ICU for longer than 2 days. Random allocation to receive a daily supplement of up to 100 g of IV amino acids to achieve a total protein intake of 2.0 g/kg/d or standard nutrition care. A total of 474 patients were randomized: 235 to standard care and 239 to IV amino acid supplementation. There was a statistically significant interaction between baseline kidney function and supplementation with study amino acids (p value for interaction = 0.026). Within the subgroup of patients with normal kidney function at randomization, patients who were allocated to receive the study amino acid supplement were less likely to die before study day 90 (covariate-adjusted risk difference, -7.9%; 95% CI, -15.1 to -0.7; p = 0.034). Furthermore, amino acid supplementation significantly increased estimated glomerular filtration rate in these patients (repeated-measures treatment × time interaction p = 0.009). Within the subgroup of patients with baseline kidney dysfunction and/or risk of progression of acute kidney injury, a significant effect of the study intervention on mortality was not found (covariate-adjusted risk difference, -0.6%; 95% CI, -16.2 to 15.2; p = 0.95). In this post hoc, hypothesis-generating, subgroup analysis, we observed reduced mortality and improved estimated glomerular filtration rate in ICU patients with normal kidney function who were randomly allocated to receive increased protein intake (up to 2.0 g/kg/d). We strongly recommend confirmation of these results in trials with low risk of bias before this treatment is recommended for routine care.

Multidonor intensive faecal microbiota transplantation for active ulcerative colitis: a randomised placebo-controlled trial.

PubMed

Paramsothy, Sudarshan; Kamm, Michael A; Kaakoush, Nadeem O; Walsh, Alissa J; van den Bogaerde, Johan; Samuel, Douglas; Leong, Rupert W L; Connor, Susan; Ng, Watson; Paramsothy, Ramesh; Xuan, Wei; Lin, Enmoore; Mitchell, Hazel M; Borody, Thomas J

2017-03-25

The intestinal microbiota is implicated in the pathogenesis of ulcerative colitis. Faecal microbiota transplantation is a novel form of therapeutic microbial manipulation, but its efficacy in ulcerative colitis is uncertain. We aimed to establish the efficacy of intensive-dosing, multidonor, faecal microbiota transplantation in active ulcerative colitis. We conducted a multicentre, double-blind, randomised, placebo-controlled trial at three hospitals in Australia. We randomly allocated patients with active ulcerative colitis (Mayo score 4-10) in a 1:1 ratio, using a pre-established randomisation list, to either faecal microbiota transplantation or placebo colonoscopic infusion, followed by enemas 5 days per week for 8 weeks. Patients, treating clinicians, and other study staff were unaware of the assigned treatment. Faecal microbiota transplantation enemas were each derived from between three and seven unrelated donors. The primary outcome was steroid-free clinical remission with endoscopic remission or response (Mayo score ≤2, all subscores ≤1, and ≥1 point reduction in endoscopy subscore) at week 8. Analysis was by modified intention-to-treat and included all patients receiving one study dose. We performed 16S rRNA stool analysis to assess associated microbial changes. This trial is registered with ClinicalTrials.gov, number NCT01896635. The trial has ended; this report presents the final analysis. From November, 2013, to May, 2015, 85 patients were enrolled to our trial, of whom 42 were randomly assigned faecal microbiota transplantation and 43 were allocated placebo. One patient assigned faecal microbiota transplantation and three allocated placebo did not receive study treatment and were excluded from the analysis. The primary outcome was achieved in 11 (27%) of 41 patients allocated faecal microbiota transplantation versus three (8%) of 40 who were assigned placebo (risk ratio 3·6, 95% CI 1·1-11·9; p=0·021). Adverse events were reported by 32 (78%) of 41 patients allocated faecal microbiota transplantation and 33 (83%) of 40 who were assigned placebo; most were self-limiting gastrointestinal complaints, with no significant difference in number or type of adverse events between treatment groups. Serious adverse events occurred in two patients assigned faecal microbiota transplantation and in one allocated placebo. Microbial diversity increased with and persisted after faecal microbiota transplantation. Several bacterial taxa were associated with clinical outcome; in particular, the presence of Fusobacterium spp was associated with lack of remission. Intensive-dosing, multidonor, faecal microbiota transplantation induces clinical remission and endoscopic improvement in active ulcerative colitis and is associated with distinct microbial changes that relate to outcome. Faecal microbiota transplantation is, thus, a promising new therapeutic option for ulcerative colitis. Future work should focus on precisely defining the optimum treatment intensity and the role of donor-recipient matching based on microbial profiles. Broad Medical Research Program, Gastroenterological Society of Australia, Mount Sinai (New York) SUCCESS fund, University of New South Wales. Copyright © 2017 Elsevier Ltd. All rights reserved.

Racial and socioeconomic disparities in access to mechanical revascularization procedures for acute ischemic stroke.

PubMed

Attenello, Frank J; Adamczyk, Peter; Wen, Ge; He, Shuhan; Zhang, Katie; Russin, Jonathan J; Sanossian, Nerses; Amar, Arun P; Mack, William J

2014-02-01

Mechanical revascularization procedures performed for treatment of acute ischemic stroke have increased in recent years. Data suggest association between operative volume and mortality rates. Understanding procedural allocation and patient access patterns is critical. Few studies have examined these demographics. Data were collected from the 2008 Nationwide Inpatient Sample database. Patients hospitalized with ischemic stroke and the subset of individuals who underwent mechanical thrombectomy were characterized by race, payer source, population density, and median wealth of the patient's zip code. Demographic data among patients undergoing mechanical thrombectomy procedures were examined. Stroke admission demographics were analyzed according to thrombectomy volume at admitting centers and patient demographics assessed according to the thrombectomy volume at treating centers. Significant allocation differences with respect to frequency of mechanical thrombectomy procedures among stroke patients existed according to race, expected payer, population density, and wealth of the patient's zip code (P < .0001). White, Hispanic, and Asian/Pacific Islander patients received endovascular treatment at higher rates than black and Native American patients. Compared with the white stroke patients, black (P < .001), Hispanic (P < .001), Asian/Pacific Islander (P < .001), and Native American stroke patients (P < .001) all demonstrated decreased frequency of admission to hospitals performing mechanical thrombectomy procedures at high volumes. Among treated patients, blacks (P = .0876), Hispanics (P = .0335), and Asian/Pacific Islanders (P < .001) demonstrated decreased frequency in mechanical thrombectomy procedures performed at high-volume centers when compared with whites. While present, socioeconomic disparities were not as consistent or pronounced as racial differences. We demonstrate variances in endovascular acute stroke treatment allocation according to racial and socioeconomic factors in 2008. Efforts should be made to monitor and address potential disparities in treatment utilization. Published by Elsevier Inc.

National survey focusing on the crucial information needs of intensive care charge nurses and intensivists: same goal, different demands.

PubMed

Lundgrén-Laine, Heljä; Kontio, Elina; Kauko, Tommi; Korvenranta, Heikki; Forsström, Jari; Salanterä, Sanna

2013-01-29

Although information technology adequately supports clinical care in many intensive care units (ICUs), it provides much poorer support for the managerial information needed to coordinate multi-professional care. To gain a general view of the most crucial multi-professional information needs of ICU shift leaders a national survey was conducted, focusing on the information needs of charge nurses and intensivists. Based on our previous observation study an online survey was developed, containing 122 information need statements related to the decision-making of ICU shift leaders. Information need statements were divided into six dimensions: patient admission, organisation and management of work, allocation of staff and material resources, special treatments, and patient discharge. This survey involved all ICU shift leaders (n = 738) who worked in any of the 17 highest level ICUs for adults in university hospitals in Finland during the autumn of 2009. Both charge nurses' and intensivists' crucial information needs for care coordination were evaluated. Two hundred and fifty-seven (50%) charge nurses and 96 (43%) intensivists responded to the survey. The consistency of the survey was found to be good (Cronbach's α scores between .87-.97, with a total explanatory power of 64.53%). Altogether, 57 crucial information needs for care coordination were found; 22 of which were shared between shift leaders. The most crucial of these information needs were related to organisation and management, patient admission, and allocation of staff resources. The associations between working experience, or shift leader acting frequencies, and crucial information needs were not statistically significant. However, a statistically significant difference was found between the number of ICU beds and the ICU experience of charge nurses with information needs, under the dimension of organisation and management of work. The information needs of charge nurses and intensivists differed. Charge nurses' information needs related to care coordination, were more varied, and concerned issues at a unit level, whereas intensivists focused on direct patient care. The reliability and validity of our survey was found to be good. Our study findings show that care coordination at an ICU is a collaborative process among ICU shift leaders with multiprofessional information needs related to organisation and management, patient admission, and allocation of staff resources. Study findings can be used to identify the most crucial information needs of ICU shift leaders when new information technology is developed to support managerial decision-making during care coordination.

Lay public's understanding of equipoise and randomisation in randomised controlled trials.

PubMed

Robinson, E J; Kerr, C E P; Stevens, A J; Lilford, R J; Braunholtz, D A; Edwards, S J; Beck, S R; Rowley, M G

2005-03-01

To research the lay public's understanding of equipoise and randomisation in randomised controlled trials (RCTs) and to look at why information on this may not be not taken in or remembered, as well as the effects of providing information designed to overcome barriers. Investigations were informed by an update of systematic review on patients' understanding of consent information in clinical trials, and by relevant theory and evidence from experimental psychology. Nine investigations were conducted with nine participants. Access (return to education), leisure and vocational courses at Further Education Colleges in the Midlands, UK. Healthy adults with a wide range of educational backgrounds and ages. Participants read hypothetical scenarios and wrote brief answers to subsequent questions. Sub-samples of participants were interviewed individually to elaborate on their written answers. Participants' background assumptions concerning equipoise and randomisation were examined and ways of helping participants recognise the scientific benefits of randomisation were explored. Judgments on allocation methods; treatment preferences; the acceptability of random allocation; whether or not individual doctors could be completely unsure about the best treatment; whether or not doctors should reveal treatment preferences under conditions of collective equipoise; and how sure experts would be about the best treatment following random allocation vs doctor/patient choice. Assessments of understanding hypothetical trial information. Recent literature continues to report trial participants' failure to understand or remember information about randomisation and equipoise, despite the provision of clear and readable trial information leaflets. In current best practice, written trial information describes what will happen without offering accessible explanations. As a consequence, patients may create their own incorrect interpretations and consent or refusal may be inadequately informed. In six investigations, most participants identified which methods of allocation were random, but judged the random allocation methods to be unacceptable in a trial context; the mere description of a treatment as new was insufficient to engender a preference for it over a standard treatment; around half of the participants denied that a doctor could be completely unsure about the best treatment. A majority of participants judged it unacceptable for a doctor to suggest letting chance decide when uncertain of the best treatment, and, in the absence of a justification for random allocation, participants did not recognise scientific benefits of random allocation over normal treatment allocation methods. The pattern of results across three intervention studies suggests that merely supplementing written trial information with an explanation is unlikely to be helpful. However, when people manage to focus on the trial's aim of increasing knowledge (as opposed to making treatment decisions about individuals), and process an explanation actively, they may be helped to understand the scientific reasons for random allocation. This research was not carried out in real healthcare settings. However, participants who could correctly identify random allocation methods, yet judged random allocation unacceptable, doubted the possibility of individual equipoise and saw no scientific benefits of random allocation over doctor/patient choice, are unlikely to draw upon contrasting views if invited to enter a real clinical trial. This suggests that many potential trial participants may have difficulty understanding and remembering trial information that conforms to current best practice in its descriptions of randomisation and equipoise. Given the extent of the disparity between the assumptions underlying trial design and the assumptions held by the lay public, the solution is unlikely to be simple. Nevertheless, the results suggest that including an accessible explanation of the scientific benefits of randomisation may be beneficial provided potential participants are also enabled to reflect on the trial's aim of advancing knowledge, and to think actively about the information presented. Further areas for consideration include: the identification of effective combinations of written and oral information; helping participants to reflect on the aim of advancing knowledge; and an evidence-based approach to leaflet construction.

Nutrition sensitivity of the 2014 budget statement of Republic of Ghana.

PubMed

Laar, Amos; Aryeetey, Richmond N O; Akparibo, Robert; Zotor, Francis

2015-11-01

Ghana's Constitution and several international treaties she has ratified demonstrate support for fundamental human rights to nutrition and freedom from hunger. However, it is unknown how this support is being translated into investment in nutrition. National budgets are important vehicles through which governments communicate intent to address pertinent national challenges. The present paper assesses the nutrition sensitivity of Ghana's budget statement for the year ending 31 December 2014. We perused the budget in its entirety, examining allocations to various sectors with the goal of identifying support for direct nutrition interventions. We examined allocations to various sectors as per cent of gross domestic product (GDP). The review shows that the total revenue and grants for the 2014 fiscal year is Ghana Cedis (GH¢) 26 001·9 million (25 % of GDP). The total expenditure for the same period is estimated at GH¢34 956·8 million (33·1 % of GDP). The health sector is allocated GH¢3 353 707 814 (3·8 % of GDP). As of 28 October 2014, the Bank of Ghana's Official Exchange Rate was US$1 = GH¢3·20. It is one of the key sectors whose interventions directly or indirectly impact on nutrition. However, the proportion of the national budget that goes to direct nutrition interventions is not evident in the budget. Nutrition is embedded in other budget lines. Allocations to relevant nutrition-sensitive sectors are very low (<0·5 % of GDP). We conclude that Ghana's 2014 budget statement pays scant attention to nutrition. By embedding nutrition in other budget lines, Ghana runs the risk of perpetually rolling out national spending actions insensitive to nutrition.

Bezafibrate for the treatment of dyslipidemia in patients with coronary artery disease: 20-year mortality follow-up of the BIP randomized control trial.

PubMed

Arbel, Yaron; Klempfner, Robert; Erez, Aharon; Goldenberg, Ilan; Benzekry, Sagit; Shlomo, Nir; Fisman, Enrique Z; Tenenbaum, Alexander

2016-01-22

Recent data support the renewed interest in hypertriglyceridemia as a possible important therapeutic target for cardiovascular risk reduction. This study was designed to address the question of all-cause mortality during extended follow-up of the BIP trial in patients stratified by baseline triglyceride levels. In the BIP trial 3090 patients with proven coronary artery disease were randomized to bezafibrate 400 mg/day or placebo. All-cause mortality data after 20 years of follow-up, were obtained from the National Israeli Population Registry. Patients with hypertriglyceridemia (triglycerides ≥200 mg/dL, n = 458) were equally distributed among the study groups (15 % in both placebo and bezafibrate groups). During follow-up 1869 patients died (952 in placebo vs. 917 in bezafibrate group). Following multivariate adjustment allocation to bezafibrate was associated with small but significant 10 % mortality risk reduction (HR 0.90; 95 % CI 0.82-0.98, p = 0.026). Variables associated with significantly increased mortality risk were history of a past MI, NYHA class, diabetes, age, higher BMI and glucose level. In patients with hypertriglyceridemia multivariate analysis demonstrated a 25 % all-cause mortality risk reduction associated with allocation to bezafibrate (HR 0.75, CI 95 % 0.60-0.94; p = 0.012). In patients without hypertriglyceridemia bezafibrate had no significant effect on long-term mortality. During long-term follow-up bezafibrate-allocated patients experienced a modest but significant 10 % reduction in the adjusted risk of mortality. This effect of bezafibrate was more prominent among patients with baseline hypertriglyceridemia (25 % mortality risk reduction).

Combined anatomical and functional imaging using coronary CT angiography and myocardial perfusion SPECT in symptomatic adults with abnormal origin of a coronary artery.

PubMed

Uebleis, C; Groebner, M; von Ziegler, F; Becker, A; Rischpler, C; Tegtmeyer, R; Becker, C; Lehner, S; Haug, A R; Cumming, P; Bartenstein, P; Franz, W M; Hacker, M

2012-10-01

There has been a lack of standardized workup guidelines for patients with congenital abnormal origin of a coronary artery from the opposite sinus (ACAOS). We aimed to evaluate the use of cardiac hybrid imaging using multi-detector row CT (MDCT) for coronary CT angiography (Coronary CTA) and stress-rest myocardial perfusion SPECT (MPS) for comprehensive diagnosis of symptomatic adult patients with ACAOS. Seventeen symptomatic patients (12 men; 54 ± 13 years) presenting with ACAOS underwent coronary CTA and MPS. Imaging data were analyzed by conventional means, and with additional use of 3D image fusion to allocate stress induced perfusion defects (PD) to their supplying coronary arteries. An anomalous RCA arose from the left anterior sinus in eight patients, an abnormal origin from the right sinus was detected in nine patients (5 left coronary arteries, LCA and 4 LCx). Five of the 17 patients (29%) demonstrated a reversible PD in MPS. There was no correlation between the anatomical variants of ACAOS and the presence of myocardial ischemia. Image fusion enabled the allocation of reversible PD to the anomalous vessel in three patients (two cases in the RCA and the other in the LCA territory); PD in two patients were allocated to the territory of artery giving rise to the anomalies, rather than the anomalies themselves. In a small cohort of adult symptomatic patients with ACAOS anomaly there was no relation found between the specific anatomical variant and the appearance of stress induced myocardial ischemia using cardiac hybrid imaging.

New Organ Allocation System for Combined Liver-Kidney Transplants and the Availability of Kidneys for Transplant to Patients with Stage 4-5 CKD.

PubMed

Asch, William S; Bia, Margaret J

2017-05-08

A new proposal has been created for establishing medical criteria for organ allocation in recipients receiving simultaneous liver-kidney transplants. In this article, we describe the new policy, elaborate on the points of greatest controversy, and offer a perspective on the policy going forward. Although we applaud the fact that simultaneous liver-kidney transplant activity will now be monitored and appreciate the creation of medical criteria for allocation in simultaneous liver-kidney transplants, we argue that some of the criteria proposed, especially those for allocating a kidney to a liver recipient with AKI, are too liberal. We call on the nephrology community to follow the consequences of this new policy and push for a re-examination of the longstanding policy of allocating kidneys to multiorgan transplant recipients before all other candidates. The charge to protect our system of equitable organ allocation is very challenging, but it is a challenge that we must embrace. Copyright © 2017 by the American Society of Nephrology.

The relationship between annual survival rate and migration distance in mallards: an examination of the time-allocation hypothesis for the evolution of migration

USGS Publications Warehouse

Hestbeck, J.B.; Nichols, J.D.; Hines, J.E.

1992-01-01

Predictions of the time-allocation hypothesis were tested with several a posteriori analyses of banding data for the mallard (Anas platyrhynchos). The time-allocation hypothesis states that the critical difference between resident and migrant birds is their allocation of time to reproduction on the breeding grounds and survival on the nonbreeding grounds. Residents have higher reproduction and migrants have higher survival. Survival and recovery rates were estimated by standard band-recovery methods for banding reference areas in the central United States and central Canada. A production-rate index was computed for each reference area with data from the U.S. Fish and Wildlife Service May Breeding Population Survey and July Production Survey. An analysis of covariance was used to test for the effects of migration distance and time period (decade) on survival, recovery, and production rates. Differences in migration chronology were tested by comparing direct-recovery distributions for different populations during the fall migration. Differences in winter locations were tested by comparing distributions of direct recoveries reported during December and January. A strong positive relationship was found between survival rate, and migration distance for 3 of the 4 age and sex classes. A weak negative relationship was found between recovery rate and migration distance. No relationship was found between production rate and migration distance. During the fall migration, birds from the northern breeding populations were located north of birds from the southern breeding populations. No pattern could be found in the relative locations of breeding and wintering areas. Although our finding that survival rate increased with migration distance was consistent with the time-allocation hypothesis, our results on migration chronology and location of wintering areas were not consistent with the mechanism underlying the time-allocation hypothesis. Neither this analysis nor other recent studies of life-history characteristics of migratory and resident birds supported the timeallocation hypothesis.

Impact of socioeconomic factors on in-patient length of stay and their consequences in per case hospital payment systems.

PubMed

Perelman, Julian; Closon, Marie-Christine

2011-10-01

The number of countries adopting per case hospital payment systems has been continuously increasing in recent years. Nonetheless, debates persist regarding their consequences for equity of access to services. This concern relates to the failure of diagnostic classifications properly to take into account patients' care requirements, raising the threat of case selection ('cream skimming'). We examine the heterogeneity of costs within diagnostic categories related to socioeconomic (SE) factors using length of stay (LOS) as a proxy measure of care needs and costs. We evaluate its consequences in terms of fairness in resource allocation between hospitals. We employ data on all discharges in 2002-03 from a sample of 60 Belgian hospitals (617,275 observations), measuring the association between LOS and SE factors using generalized linear models. We design a resource allocation formula based on the Belgian financing scheme, where non-medical activity is paid based on a normative number of in-patient days, and measure financial penalties and rewards according to whether payment is adjusted for the SE characteristics of patients or not. Both patients' SE status and hospitals' area SE profile have a significant impact on LOS, which persists after controlling for detailed diagnostic and hospital characteristics. Hospitals treating low income patients are financially penalized as a result. SE factors are a predictor of in-patient LOS and should be taken into account in per case resource allocation among hospitals.

Evaluation of an inflammation-based prognostic score (GPS) in patients with metastatic breast cancer.

PubMed

Al Murri, A M; Bartlett, J M S; Canney, P A; Doughty, J C; Wilson, C; McMillan, D C

2006-01-30

Prediction of outcome in patients with metastatic breast cancer remains problematical. The present study evaluated the value of an inflammation-based score (Glasgow Prognostic Score, GPS) in patients with metastatic breast cancer. The GPS was constructed as follows: patients with both an elevated C-reactive protein (>10 mg l(-1)) and hypoalbuminaemia (<35 g l(-1)) were allocated a score of 2. Patients in whom only one or none of these biochemical abnormalities was present were allocated a score of 1 or 0, respectively. In total, 96 patients were studied. During follow-up 51 patients died of their cancer. On multivariate analysis of the GPS and treatment received, only the GPS (HR 2.26, 95% CI 1.45-3.52, P<0.001) remained significantly associated with cancer-specific survival. The presence of a systemic inflammatory response (the GPS) appears to be a useful indicator of poor outcome independent of treatment in patients with metastatic breast cancer.

Carbon allocation patterns in boreal and hemiboreal forest ecosystems along the gradient of soil fertility

NASA Astrophysics Data System (ADS)

Kriiska, Kaie; Uri, Veiko; Frey, Jane; Napa, Ülle; Kabral, Naima; Soosaar, Kaido; Rannik, Kaire; Ostonen, Ivika

2017-04-01

Carbon (C) allocation plays a critical role in forest ecosystem carbon cycling. Changes in C allocation alter ecosystems carbon sequestration and plant-soil-atmosphere gas exchange, hence having an impact on the climate. Currently, there is lack of reliable indicators that show the direction of C accumulation patterns in forest ecosystems on regional scale. The first objective of our study was to determine the variability of carbon allocation in hemiboreal coniferous forests along the gradient of soil fertility in Estonia. We measured C stocks and fluxes, such as litter, fine root biomass and production, soil respiration etc. in 8 stands of different site types - Scots pine (Cladonia, Vaccinium, Myrtillus, Fragaria) and Norway spruce (Polytrichum, Myrtillus, Oxalis, Calamagrostis alvar). The suitability of above- and belowground litter production (AG/BG) ratio was analysed as a carbon allocation indicator. The second aim of the study was to analyse forest C allocation patterns along the north-south gradient from northern boreal Finland to hemiboreal Estonia. Finally, C sequestration in silver birch and grey alder stands were compared with coniferous stands in order to determine the impact of tree species on carbon allocation. Preliminary results indicate that estimated AG/BG ratio (0.5 ... 3.0) tends to decrease with increasing soil organic horizon C/N ratio, indicating that in less fertile sites more carbon is allocated into belowground through fine root growth and in consequence the soil organic carbon stock increases. Similar trends were found on the north-south forest gradient. However, there was a significant difference between coniferous and broadleaf stands in C allocation patterns. Net ecosystem exchange in Estonian coniferous stands varied from -1.64 ... 3.95 t C ha-1 yr-1, whereas older stands tended to be net carbon sources.

Portfolio evaluation of health programs: a reply to Sendi et al.

PubMed

Bridges, John F P; Terris, Darcey D

2004-05-01

Sendi et al. (Soc. Sci. Med. 57 (2003) 2207) extend previous research on cost-effectiveness analysis to the evaluation of a portfolio of interventions with risky outcomes using a "second best" approach that can identify improvements in efficiency in the allocation of resources. This method, however, cannot be used to directly identify the optimal solution to the resource allocation problem. Theoretically, a stricter adherence to the foundations of portfolio theory would permit direct optimization in portfolio selection, however, when we include uncertainty in our analysis in addition to the traditional concept of risk (which is often mislabelled uncertainty) complexities are introduced that create significant hurdles in the development of practical applications of portfolio theory for health care policy decision making.

"In the Driver's Seat": Parent Perceptions of Choice in a Participant-Directed Medicaid Waiver Program for Young Children with Autism

ERIC Educational Resources Information Center

Timberlake, Maria T.; Leutz, Walter N.; Warfield, Marji Erickson; Chiri, Giuseppina

2014-01-01

This study investigated families' experience of choice within a participant-directed Medicaid waiver program for young children with autism. Fourteen parents or grandparents participated in in-depth interviews about their experience of choosing personnel, directing in-home services, and managing the $25,000 annual allocation. Key findings…

Delayed versus immediate treatment for patients with acute hepatitis C: a randomised controlled non-inferiority trial.

PubMed

Deterding, Katja; Grüner, Norbert; Buggisch, Peter; Wiegand, Johannes; Galle, Peter R; Spengler, Ulrich; Hinrichsen, Holger; Berg, Thomas; Potthoff, Andrej; Malek, Nisar; Großhennig, Anika; Koch, Armin; Diepolder, Helmut; Lüth, Stefan; Feyerabend, Sandra; Jung, Maria Christina; Rogalska-Taranta, Magdalena; Schlaphoff, Verena; Cornberg, Markus; Manns, Michael P; Wedemeyer, Heiner

2013-06-01

Early treatment of acute hepatitis C virus (HCV) infection with interferon alfa monotherapy is very effective, with cure rates of greater than 85%. However, spontaneous clearance of HCV occurs in 10-50% of cases. We aimed to assess an alternative treatment strategy of delayed antiviral therapy in patients who do not eliminate the virus spontaneously compared with immediate treatment. In our open-label phase 3 non-inferiority trial, we enrolled adults (≥18 years) with acute hepatitis C but no HIV or hepatitis B co-infection at 72 centres in Germany. We randomly allocated patients with symptomatic acute hepatitis C (1:1) to receive immediate pegylated interferon alfa-2b treatment for 24 weeks or delayed treatment with pegylated interferon alfa-2b plus ribavirin (for 24 weeks) starting 12 weeks after randomisation if HCV RNA remained positive. We used a computer-generated randomisation sequence and block sizes of eight, stratified by bilirubin concentration. We assigned all asymptomatic patients to immediate treatment with pegylated interferon alfa-2b for 24 weeks. The primary endpoint was sustained HCV RNA negativity in all randomly allocated participants who completed screening (intention-to-treat analysis), with a non-inferiority margin of 10%. For the primary analysis, we calculated the virological response of patients in the immediate and delayed treatment groups and an absolute risk difference stratified by bilirubin status. The trial was stopped early on advice from the study advisory committee because of slow recruitment of participants. This study is registered, number ISRCTN88729946. Between April, 2004, and February, 2010, we recruited 107 symptomatic and 25 asymptomatic patients. 37 (67%) of 55 symptomatic patients randomly allocated to receive immediate treatment and 28 (54%) of 52 symptomatic patients randomly allocated to receive delayed treatment had a sustained virological response (difference 13·7%, 95% CI -4·6 to 32·0; p=0·071). 18 (72%) of 25 asymptomatic patients had a sustained virological response. 22 (42%) of 52 symptomatic patients allocated to receive delayed treatment did not complete follow-up compared with 20 (25%) of 80 symptomatic or asymptomatic patients assigned immediate treatment (p=0·037). 11 symptomatic patients (21%) assigned delayed treatment had spontaneous HCV clearance. 14 patients who received delayed pegylated interferon alfa-2b plus ribavirin treatment and completed follow-up achieved sustained virological response. Delayed treatment is effective although not of equal efficacy to immediate treatment; coupled with the rate of spontaneous clearance it can reduce unnecessary treatment in closely monitored populations. Immediate treatment seems preferable in populations where loss to follow-up is great. German Network of Competence on Viral Hepatitis (HepNet, funded by the German Federal Ministry of Education and Research, grants 01KI0102, 01KI0401, and 01KI0601), MSD, Schering-Plough. Copyright © 2013 Elsevier Ltd. All rights reserved.

Reducing Operating Room Turnover Time for Robotic Surgery Using a Motor Racing Pit Stop Model.

PubMed

Souders, Colby P; Catchpole, Ken R; Wood, Lauren N; Solnik, Jonathon M; Avenido, Raymund M; Strauss, Paul L; Eilber, Karyn S; Anger, Jennifer T

2017-08-01

Operating room (OR) turnover time, time taken between one patient leaving the OR and the next entering, is an important determinant of OR utilization, a key value metric for hospital administrators. Surgical robots have increased the complexity and number of tasks required during an OR turnover, resulting in highly variable OR turnover times. We sought to streamline the turnover process and decrease robotic OR turnover times and increase efficiency. Direct observation of 45 pre-intervention robotic OR turnovers was performed. Following a previously successful model for handoffs, we employed concepts from motor racing pit stops, including briefings, leadership, role definition, task allocation and task sequencing. Turnover task cards for staff were developed, and card assignments were distributed for each turnover. Forty-one cases were observed post-intervention. Average total OR turnover time was 99.2 min (95% CI 88.0-110.3) pre-intervention and 53.2 min (95% CI 48.0-58.5) at 3 months post-intervention. Average room ready time from when the patient exited the OR until the surgical technician was ready to receive the next patient was 42.2 min (95% CI 36.7-47.7) before the intervention, which reduced to 27.2 min at 3 months (95% CI 24.7-29.7) post-intervention (p < 0.0001). Role definition, task allocation and sequencing, combined with a visual cue for ease-of-use, create efficient, and sustainable approaches to decreasing robotic OR turnover times. Broader system changes are needed to capitalize on that result. Pit stop and other high-risk industry models may inform approaches to the management of tasks and teams.

Ethical triage and scarce resource allocation during public health emergencies: tenets and procedures.

PubMed

Kuschner, Ware G; Pollard, John B; Ezeji-Okoye, Stephen C

2007-01-01

Public health emergencies may result in mass casualties and a surge in demand for hospital-based care. Healthcare standards may need to be altered to respond to an imbalance between demands for care and resources. Clinical decisions that involve triage and scarce resource allocation may present unique ethical challenges. To address these challenges, the authors detailed tenets and procedures to guide triage and scarce resource allocation during public health emergencies. The authors propose health care organizations deploy a Triage and Scarce Resource Allocation Team to over-see and guide ethically challenging clinical decision-making during a crisis period. The authors' goal is to help healthcare organizations and clinicians balance public health responsibilities and their duty to individual patients during emergencies in as equitable and humane a manner as possible.

Impact of Different Creatinine Measurement Methods on Liver Transplant Allocation

PubMed Central

Kaiser, Thorsten; Kinny-Köster, Benedict; Bartels, Michael; Parthaune, Tanja; Schmidt, Michael; Thiery, Joachim

2014-01-01

Introduction The model for end-stage liver disease (MELD) score is used in many countries to prioritize organ allocation for the majority of patients who require orthotopic liver transplantation. This score is calculated based on the following laboratory parameters: creatinine, bilirubin and the international normalized ratio (INR). Consequently, high measurement accuracy is essential for equitable and fair organ allocation. For serum creatinine measurements, the Jaffé method and enzymatic detection are well-established routine diagnostic tests. Methods A total of 1,013 samples from 445 patients on the waiting list or in evaluation for liver transplantation were measured using both creatinine methods from November 2012 to September 2013 at the university hospital Leipzig, Germany. The measurements were performed in parallel according to the manufacturer’s instructions after the samples arrived at the institute of laboratory medicine. Patients who had required renal replacement therapy twice in the previous week were excluded from analyses. Results Despite the good correlation between the results of both creatinine quantification methods, relevant differences were observed, which led to different MELD scores. The Jaffé measurement led to greater MELD score in 163/1,013 (16.1%) samples with differences of up to 4 points in one patient, whereas differences of up to 2 points were identified in 15/1,013 (1.5%) samples using the enzymatic assay. Overall, 50/152 (32.9%) patients with MELD scores >20 had higher scores when the Jaffé method was used. Discussion Using the Jaffé method to measure creatinine levels in samples from patients who require liver transplantation may lead to a systematic preference in organ allocation. In this study, the differences were particularly pronounced in samples with MELD scores >20, which has clinical relevance in the context of urgency of transplantation. These data suggest that official recommendations are needed to determine which laboratory diagnostic methods should be used when calculating MELD scores. PMID:24587188

76 FR 6957 - FTA Fiscal Year 2011 Apportionments, Allocations, and Program Information

Federal Register 2010, 2011, 2012, 2013, 2014

2011-02-08

.... 5336(b), FTA used 60 percent of the directional route miles attributable to the Alaska Railroad... to 49 U.S.C. 5336(b), FTA uses 60 percent of the directional route miles attributable to the Alaska...: notifying eligible local entities of funding availability; developing project selection criteria...

Direct Broadcast Satellites: An Interview with Hartford Gunn.

ERIC Educational Resources Information Center

Library Hi Tech, 1984

1984-01-01

In this interview with Hartford Gunn, Vice-President of Program Development for Satellite Television Corporation (STC), the concept of direct broadcast by satellite (DBS) is explored. Allocation of radio frequencies, services provided by DBS network, home installation and purchase of dish antenna, and comparison of DBS with cable television are…

Alaska Department of Natural Resources

Science.gov Websites

/ Coastal Impact Assistance Program Alaska CIAP Plan December 2010 Amendment - APPROVED FEBRUARY 4, 2011 On state and its eligible Coastal Political Subdivisions (CPSs) will use and manage their CIAP allocation : Project Lists A-1: Direct to State Funding A-2: Direct to Coastal Political Subdivisions Appendix B-1

30 CFR 1220.011 - Schedule of allowable direct and allocable joint costs and credits.

Code of Federal Regulations, 2014 CFR

2014-07-01

... engineering design problems related to equipment or facilities required for NPSL operations. (4) The cost of any contract service related to research and development is specifically excluded, as are contract services calling for feasibility studies not directly related to specific engineering design problems or...

48 CFR 52.216-15 - Predetermined Indirect Cost Rates.

Code of Federal Regulations, 2010 CFR

2010-10-01

.... (c) Allowability of costs and acceptability of cost allocation methods shall be determined in...) the period for which the rates apply, and (4) the specific items treated as direct costs or any changes in the items previously agreed to be direct costs. The indirect cost rate agreement shall not...

48 CFR 3452.216-71 - Negotiated overhead rates-fixed.

Code of Federal Regulations, 2010 CFR

2010-10-01

... acceptability of cost allocation methods shall be determined in accordance with part 31 of the Federal... different period, for which the rates apply, and (4) the specific items treated as direct costs or any changes in the items previously agreed to be direct costs. (e) Pending establishment of fixed overhead...

Third degree waiting time discrimination: optimal allocation of a public sector healthcare treatment under rationing by waiting.

PubMed

Gravelle, Hugh; Siciliani, Luigi

2009-08-01

In many public healthcare systems treatments are rationed by waiting time. We examine the optimal allocation of a fixed supply of a given treatment between different groups of patients. Even in the absence of any distributional aims, welfare is increased by third degree waiting time discrimination: setting different waiting times for different groups waiting for the same treatment. Because waiting time imposes dead weight losses on patients, lower waiting times should be offered to groups with higher marginal waiting time costs and with less elastic demand for the treatment.

Predisposing Factors for Any and Major Hypoglycemia With Saxagliptin Versus Placebo and Overall: Analysis From the SAVOR-TIMI 53 Trial.

PubMed

Cahn, Avivit; Raz, Itamar; Mosenzon, Ofri; Leibowitz, Gil; Yanuv, Ilan; Rozenberg, Aliza; Iqbal, Nayyar; Hirshberg, Boaz; Sjostrand, Mikaela; Stahre, Christina; Im, KyungAh; Kanevsky, Estella; Scirica, Benjamin M; Bhatt, Deepak L; Braunwald, Eugene

2016-08-01

To analyze the impact of adding saxagliptin versus placebo on the risk for hypoglycemia and to identify predictors of any and major hypoglycemia in patients with type 2 diabetes included in the Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus-Thrombolysis in Myocardial Infarction 53 (SAVOR-TIMI 53) study. Patients with type 2 diabetes (n = 16,492) were randomized to saxagliptin or placebo and followed for a median of 2.1 years. Associations between any hypoglycemia (symptomatic or glucose measurement <54 mg/dL) or major hypoglycemia (requiring extended assistance) and patient characteristics overall and by treatment allocation were studied. At least one hypoglycemic event was reported in 16.6% of patients, and 1.9% reported at least one major event. Patients allocated to saxagliptin versus placebo experienced higher rates of any (hazard ratio [HR] 1.16 [95% CI 1.08, 1.25]; P < 0.001) or major (HR 1.26 [1.01, 1.58]; P = 0.038) hypoglycemia. Hypoglycemia rates (any or major) were increased with saxagliptin in patients taking sulfonylureas (SURs) but not in those taking insulin. Rates were increased with saxagliptin in those with baseline HbA1c ≤7.0% and not in those with baseline HbA1c >7.0%. Multivariate analysis of the overall population revealed that independent predictors of any hypoglycemia were as follows: allocation to saxagliptin, long duration of diabetes, increased updated HbA1c, macroalbuminuria, moderate renal failure, SUR use, and insulin use. Predictors of major hypoglycemia were allocation to saxagliptin, advanced age, black race, reduced BMI, long duration of diabetes, declining renal function, microalbuminuria, and use of short-acting insulin. Among SURs, glibenclamide was associated with increased risk of major but not any hypoglycemia. The identification of patients at risk for hypoglycemia can guide physicians to better tailor antidiabetic therapy. © 2016 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.

A randomized controlled trial of fresh frozen plasma for coagulopathy in Russell's viper (Daboia russelii) envenoming.

PubMed

Isbister, G K; Jayamanne, S; Mohamed, F; Dawson, A H; Maduwage, K; Gawarammana, I; Lalloo, D G; de Silva, H J; Scorgie, F E; Lincz, L F; Buckley, N A

2017-04-01

Essentials Russell's viper envenoming is a major health issue in South Asia and causes coagulopathy. We studied the effect of fresh frozen plasma and two antivenom doses on correcting coagulopathy. Fresh frozen plasma did not hasten recovery of coagulopathy. Low-dose antivenom did not worsen coagulopathy. Background Russell's viper (Daboia russelii) envenoming is a major health issue in South Asia and causes venom-induced consumption coagulopathy (VICC). Objectives To investigate the effects of fresh frozen plasma (FFP) and two antivenom doses in correcting VICC. Methods We undertook an open-label randomized controlled trial in patients with VICC at two Sri Lankan hospitals. Patients with suspected Russell's viper bites and coagulopathy were randomly allocated (1 : 1) to high-dose antivenom (20 vials) or low-dose antivenom (10 vials) plus 4 U of FFP. The primary outcome was the proportion of patients with an International Normalized Ratio (INR) of < 2 at 6 h after antivenom administration. Secondary outcomes included anaphylaxis, major hemorrhage, death, and clotting factor recovery. Results From 214 eligible patients, 141 were randomized: 71 to high-dose antivenom, and 70 to low-dose antivenom/FFP; five had no post-antivenom blood tests. The groups were similar except for a delay of 1 h in antivenom administration for FFP patients. Six hours after antivenom administration, 23 of 69 (33%) patients allocated to high-dose antivenom had an INR of < 2, as compared with 28 of 67 (42%) allocated to low-dose antivenom/FFP (absolute difference 8%; 95% confidence interval - 8% to 25%). Fifteen patients allocated to FFP did not receive it. Severe anaphylaxis occurred equally frequently in each group. One patient given FFP developed transfusion-related acute lung injury. Three deaths occurred in low-dose antivenom/FFP patients, including one intracranial hemorrhage. There was no difference in recovery rates of INR or fibrinogen, but there was more rapid initial recovery of factor V and FX in FFP patients. Conclusion FFP after antivenom administration in patients with Russell's viper bites did not hasten recovery of coagulopathy. Low-dose antivenom/FFP did not worsen VICC, suggesting that low-dose antivenom is sufficient. © 2017 The Authors. Journal of Thrombosis and Haemostasis published by Wiley Periodicals, Inc. on behalf of International Society on Thrombosis and Haemostasis.

Healthcare and Research Priorities of Adolescents and Young Adults with Systemic Lupus Erythematosus: A Mixed-methods Study.

PubMed

Tunnicliffe, David J; Singh-Grewal, Davinder; Craig, Jonathan C; Howell, Martin; Tugwell, Peter; Mackie, Fiona; Lin, Ming-Wei; O'Neill, Sean G; Ralph, Angelique F; Tong, Allison

2017-04-01

Managing juvenile-onset systemic lupus erythematosus (SLE) is particularly challenging. The disease may be severe, adolescent patients have complex medical and psychosocial needs, and patients must navigate the transition to adult services. To inform patient-centered care, we aimed to identify the healthcare and research priorities of young patients with SLE and describe the reasons underpinning their priorities. Face-to-face, semistructured interviews and focus groups were conducted with patients with SLE, aged from 14 to 26 years, from 5 centers in Australia. For each of the 5 allocation exercises, participants allocated 10 votes to (1) research topics; research questions on (2) medical management, (3) prevention and diagnosis, (4) lifestyle and psychosocial; and (5) healthcare specialties, and discussed the reasons for their choices. Descriptive statistics were calculated for votes and qualitative data were analyzed thematically. The 26 participants prioritized research that alleviated the psychological burden of SLE. They allocated their votes toward medical and mental health specialties in the management of SLE, while fewer votes were given to physiotherapy/occupational therapy and dietetics. The following 7 themes underpinned the participants' priorities: improving service shortfalls, strengthening well-being, ensuring cost efficiency, minimizing family/community burden, severity of comorbidity or complications, reducing lifestyle disruption, and fulfilling future goals. Young patients with SLE value comprehensive care with greater coordination among specialties. They prioritized research focused on alleviating poor psychological outcomes. The healthcare and research agenda for patients with SLE should include everyone involved, to ensure that the agenda aligns with patient priorities, needs, and values.

Inflammation-based prognostic score, prior to neoadjuvant chemoradiotherapy, predicts postoperative outcome in patients with esophageal squamous cell carcinoma.

PubMed

Kobayashi, Takashi; Teruya, Masanori; Kishiki, Tomokazu; Endo, Daisuke; Takenaka, Yoshiharu; Tanaka, Hozumi; Miki, Kenji; Kobayashi, Kaoru; Morita, Koji

2008-11-01

Recent studies have revealed that Glasgow prognostic score (GPS), an inflammation-based prognostic score, is associated with poor outcome in a variety of tumors. However, few studies have investigated whether GPS measured prior to neoadjuvant chemoradiotherapy (nCRT) is useful for postoperative prognosis of patients with advanced esophageal squamous cell carcinoma (ESCC). GPS was calculated on the basis of admission data as follows: patients with both an elevated C-reactive protein (>10 mg/L) and hypoalbuminaemia (<35 g/L) were allocated a GPS score of 2. Patients in whom only 1 of these biochemical abnormalities was present were allocated a GPS score of 1, and patients with a normal C-reactive protein and albumin were allocated a score of 0. All patients underwent radical en-bloc resection 3-4 weeks after nCRT. A total of 48 patients with clinical TNM stage II/III were enrolled. Univariate analyses revealed that there were significant differences in cancer-specific survival in relation to grade of response to nCRT (P = .004), lymph node status (P = .0065), lymphatic invasion (P = .0002), venous invasion (P = .0001), pathological TNM classification (P = .015), and GPS (P < .0001). GPS classification showed a close relationship with lymphatic invasion, venous invasion, and number of lymph node (P = .0292, .0473, and .0485, respectively). GPS was found to be the only independent predictor of cancer-specific survival (odds ratio, 0.17; 95% confidence interval, 0.06-0.52; P = .0019). GPS, measured prior to nCRT, is an independent novel predictor of postoperative outcome in patients with advanced ESCC.

The dominance of big pharma: power.

PubMed

Edgar, Andrew

2013-05-01

The purpose of this paper is to provide a normative model for the assessment of the exercise of power by Big Pharma. By drawing on the work of Steven Lukes, it will be argued that while Big Pharma is overtly highly regulated, so that its power is indeed restricted in the interests of patients and the general public, the industry is still able to exercise what Lukes describes as a third dimension of power. This entails concealing the conflicts of interest and grievances that Big Pharma may have with the health care system, physicians and patients, crucially through rhetorical engagements with Patient Advocacy Groups that seek to shape public opinion, and also by marginalising certain groups, excluding them from debates over health care resource allocation. Three issues will be examined: the construction of a conception of the patient as expert patient or consumer; the phenomenon of disease mongering; the suppression or distortion of debates over resource allocation.

Latanoprost and Dorzolamide for the Treatment of Pediatric Glaucoma: The Glaucoma Italian Pediatric Study (Gipsy), Design and Baseline Characteristics.

PubMed

Quaranta, Luciano; Biagioli, Elena; Galli, Francesca; Poli, Davide; Rulli, Eliana; Riva, Ivano; Hollander, Lital; Katsanos, Andreas; Longo, Antonio; Uva, Maurizio G; Torri, Valter; Weinreb, Robert N

2016-08-01

To investigate the efficacy of a treatment strategy with latanoprost and dorzolamide in primary pediatric glaucoma patients partially responsive to surgery. Single arm, prospective, interventional multicenter study. Primary pediatric glaucoma patients younger than 13 years after a single surgical procedure with IOP between 22 and 26 mmHg were considered eligible. At baseline, patients were allocated to latanoprost monotherapy once daily. Depending on intraocular pressure (IOP) reduction at first visit, the patients were allocated to one of three groups: continuation of latanoprost monotherapy, addition of dorzolamide twice daily, or switch to dorzolamide three times daily. The same approach for allocation in medication groups was used in all subsequent visits. Patients in the dorzolamide monotherapy group with IOP reduction <20% from baseline were considered non-responders and withdrawn. Study treatment and patient follow-up will continue for 3 years or until treatment failure. The primary endpoint is the percentage of responders. Secondary endpoints are time to treatment failure and frequency of adverse events. A total of 37 patients (69 eyes) were enrolled. The mean age was 4.0 ± 3.8 years, the female/male ratio was 1/1.7, and the majority of patients were Caucasian. Eighty percent of patients had bilateral glaucoma. Goniotomy was the most frequently performed surgery (38.6%), followed by trabeculotomy (22.8%), trabeculectomy (21.1%), and trabeculectomy plus trabeculotomy (17.5%). The baseline IOP was 23.6 ± 1.5 mmHg. The study population is representative of patients frequently encountered after the first surgery for primary pediatric glaucoma. The study will produce evidence on the medium-term efficacy of a defined pharmacological approach.

Comparison of an inflammation-based prognostic score (GPS) with performance status (ECOG-ps) in patients receiving palliative chemotherapy for gastroesophageal cancer.

PubMed

Crumley, Andrew B C; Stuart, Robert C; McKernan, Margaret; McDonald, Alexander C; McMillan, Donald C

2008-08-01

The aim of the present study was to compare an inflammation-based prognostic score (Glasgow Prognostic Score, GPS) with performance status (ECOG-ps) in patients receiving platinum-based chemotherapy for palliation of gastroesophageal cancer. Sixty-five patients presenting with gastroesophageal carcinoma to the Royal Infirmary, Glasgow between January 1999 and December 2005 and who received palliative chemotherapy or chemo-radiotherapy were studied. ECOG-ps, C-reactive protein, and albumin were recorded at diagnosis. Patients with both an elevated C-reactive protein (>10 mg/L) and hypoalbuminemia (<35 g/L) were allocated a GPS of 2. Patients in whom only one of these biochemical abnormalities was present were allocated a GPS of 1 and patients with a normal C-reactive protein and albumin were allocated a score of 0. Toxicity was recorded using the Common Toxicity Criteria. The minimum follow up was 14 months. During the follow-up period, 59 (91%) of the patients died. On univariate and multivariate survival analysis, only the GPS (hazard ratios 1.65, 95% CI 1.10-2.47, P < 0.05) was a significant independent predictor of cancer survival. In addition, in comparison with patients with GPS of 0, those patients with a GPS of 1 or 2 required more frequent chemotherapy dose reduction (P < 0.05), were less likely to exhibit a clinical response to treatment (P < 0.05), and had shorter survival (P < 0.05). The presence of a systemic inflammatory response, as evidenced by the GPS, appears to be superior to the subjective assessment of performance status (ECOG-ps) in predicting the response to platinum-based chemotherapy in patients with advanced gastroesophageal cancer.

No Effects of D-Cycloserine Enhancement in Exposure With Response Prevention Therapy in Panic Disorder With Agoraphobia: A Double-Blind, Randomized Controlled Trial.

PubMed

Hofmeijer-Sevink, Mieke Klein; Duits, Puck; Rijkeboer, Marleen M; Hoogendoorn, Adriaan W; van Megen, Harold J; Vulink, Nienke C; Denys, Damiaan A; van den Hout, Marcel A; van Balkom, Anton J; Cath, Danielle C

2017-10-01

D-cycloserine (DCS) is a partial N-methyl-D-aspartate receptor agonist that potentially augments response to exposure therapy in anxiety disorders by enhancing extinction learning. This randomized, double-blinded, placebo-controlled augmentation trial examined (1) the effectiveness of adding 125 mg of DCS to exposure therapy (before or directly after the first 6 treatment sessions) in patients with panic disorder with agoraphobia and (2) the effectiveness of DCS augmentation preceding exposure relative to DCS augmentation directly postexposure. Fifty-seven patients were allocated to 1 of 3 medication conditions (placebo and pre-exposure and postexposure DCS) as an addition to 6 exposure sessions within a 12-session exposure and response prevention protocol. The primary outcome measure was the mean score on the "alone" subscale of the Mobility Inventory (MI). No differences were found in treatment outcome between DCS and placebo, administered either pre-exposure or postexposure therapy, although at 3-month follow-up, the DCS postexposure group compared with DCS pre-exposure, exhibited greater symptom reduction on the MI-alone subscale. Ancillary analyses in specific subgroups (responders vs nonresponders, early vs late responders, severely vs mildly affected patients) did not reveal any between-group DCS versus placebo differences. Finally, the study did not find an effect of DCS relative to placebo to be specific for successful exposure sessions. This study does not find an effect of augmentation with DCS in patients with severe panic disorder and agoraphobia administered either pretreatment or directly posttreatment sessions. Moreover, no preferential effects are revealed in specific subgroups nor in successful exposure sessions. Yet, a small effect of DCS administration postexposure therapy cannot be ruled out, given the relatively small sample size of this study.

Effects of acuity-adaptable rooms on flow of patients and delivery of care.

PubMed

Hendrich, Ann L; Fay, Joy; Sorrells, Amy K

2004-01-01

Delayed transfers of patients between nursing units and lack of available beds are significant problems that increase costs and decrease quality of care and satisfaction among patients and staff. To test whether use of acuity-adaptable rooms helps solve problems with transfers of patients, satisfaction levels, and medical errors. A pre-post method was used to compare the effects of environmental design on various clinical and financial measures. Twelve outcome-based questions were formulated as the basis for inquiry. Two years of baseline data were collected before the unit moved and were compared with 3 years of data collected after the move. Significant improvements in quality and operational cost occurred after the move, including a large reduction in clinician handoffs and transfers; reductions in medication error and patient fall indexes; improvements in predictive indicators of patients' satisfaction; decrease in budgeted nursing hours per patient day and increased available nursing time for direct care without added cost; increase in patient days per bed, with a smaller bed base (number of beds per patient days). Some staff turnover occurred during the first year; turnover stabilized thereafter. Data in 5 key areas (flow of patients and hospital capacity, patients' dissatisfaction, sentinel events, mean length of stay, and allocation of nursing productivity) appear to be sufficient to test the business case for future investment in partial or complete replication of this model with appropriate populations of patients.

Optimal Control of Micro Grid Operation Mode Seamless Switching Based on Radau Allocation Method

NASA Astrophysics Data System (ADS)

Chen, Xiaomin; Wang, Gang

2017-05-01

The seamless switching process of micro grid operation mode directly affects the safety and stability of its operation. According to the switching process from island mode to grid-connected mode of micro grid, we establish a dynamic optimization model based on two grid-connected inverters. We use Radau allocation method to discretize the model, and use Newton iteration method to obtain the optimal solution. Finally, we implement the optimization mode in MATLAB and get the optimal control trajectory of the inverters.

Outcome based state budget allocation for diabetes prevention programs using multi-criteria optimization with robust weights.

PubMed

Mehrotra, Sanjay; Kim, Kibaek

2011-12-01

We consider the problem of outcomes based budget allocations to chronic disease prevention programs across the United States (US) to achieve greater geographical healthcare equity. We use Diabetes Prevention and Control Programs (DPCP) by the Center for Disease Control and Prevention (CDC) as an example. We present a multi-criteria robust weighted sum model for such multi-criteria decision making in a group decision setting. The principal component analysis and an inverse linear programming techniques are presented and used to study the actual 2009 budget allocation by CDC. Our results show that the CDC budget allocation process for the DPCPs is not likely model based. In our empirical study, the relative weights for different prevalence and comorbidity factors and the corresponding budgets obtained under different weight regions are discussed. Parametric analysis suggests that money should be allocated to states to promote diabetes education and to increase patient-healthcare provider interactions to reduce disparity across the US.

[The case manager--from words to deeds?].

PubMed

Lindegaard, Birthe Rosenkrantz; Qvist, Peter

2010-04-19

Allocation of a case manager is now mandatory for both in- and outpatients in Denmark. Case manager allocation is reported quarterly to the regions and results are generally satisfying. Knowledge about fulfillment of the case manager role is, however, sparse. This study aims to examine the degree of fulfillment of the case manager role for a sample of inpatients. Two medical and two surgical wards participated. Patients were interviewed in relation to discharge while staff assigned as case managers completed a survey. Both patients and case managers answered questions regarding the defined roles as case managers: Planning/coordination, continuous information and discharge planning. 107 of 125 eligible patients were interviewed. Only 25 declared themselves informed about the allocation of a case manager. The patients' assessment of the service provided by the staff in relation to case manager tasks was generally good, but the services were seldom provided by the named case manager. 22% of patients did not experience continuous information, while only 13% did not experience a generally coherent stay in hospital. 110 case managers completed the survey. Less than half felt themselves well informed about the case manager role. Only a few case managers feel that they succeed in fulfilling the role, particularly regarding the participation in discharge planning. There seems to be a need for a targeted effort to improve the conditions for case managers in Danish hospitals in order to meet the intentions of this initiative.

Physical Therapists' Ability to Identify Psychological Factors and Their Self-Reported Competence to Manage Chronic Low Back Pain.

PubMed

Brunner, Emanuel; Dankaerts, Wim; Meichtry, André; O'Sullivan, Kieran; Probst, Michel

2018-06-01

In the management of chronic low back pain (LBP), identifying and managing more patients who are at high risk and who have psychological barriers to recovery is important yet difficult. The objective of this study was to test physical therapists' ability to allocate patients into risk stratification groups, test correlations between therapists' assessments of psychological factors and patient questionnaires, and explore relationships between psychological factors and therapists' self-reported competence to manage patients with chronic LBP. This was a pragmatic, observational study. Patients completed the STarT Back Tool (SBT, for risk stratification), the Four-Dimensional Symptom Questionnaire (distress, depression, anxiety), and the Tampa Scale of Kinesiophobia (kinesiophobia) prior to the intake session. After this session, physical therapists estimated patient prognostic risk using the 3 SBT categories and rated patient psychological factors using a 0-to-10 scale. Finally, therapists reported their self-reported competence to manage the patient. Intraclass and Spearman rank correlations tested correlations between therapists' intuitive assessments and patient questionnaires. A linear-mixed model explored relationships between psychological factors and therapists' self-reported competence. Forty-nine patients were managed by 20 therapists. Therapists accurately estimated SBT risk allocation in only 41% of patients. Correlations between therapist perceptions and patient questionnaires were moderate for distress (r = 0.602) and fair for depression (r = 0.304) and anxiety (r = 0.327). There was no correlation for kinesiophobia (r = -0.007). Patient distress was identified as a negative predictor of therapists' self-reported competence. This was a cross-sectional study, conducted in only 1 center. Physical therapists were not very accurate at allocating patients into risk stratification groups or identifying psychological factors. Therapists' self-reported competence in managing patients was lowest when patients reported higher distress.

The patient-breast cancer care pathway: how could it be optimized?

PubMed

Baffert, Sandrine; Hoang, Huong Ly; Brédart, Anne; Asselain, Bernard; Alran, Séverine; Berseneff, Hélène; Huchon, Cyrille; Trichot, Caroline; Combes, Aline; Alves, Karine; Koskas, Martin; Nguyen, Thuy; Roulot, Aurélie; Rouzier, Roman; Héquet, Delphine

2015-05-12

A care pathway is defined as patient-focused global care that addresses temporal (effective and coordinated management throughout the illness) and spatial issues (treatment is provided near the health territory in or around the patient's home). Heterogeneity of the care pathways in breast cancer (BC) is presumed but not well evaluated. The OPTISOINS01 study aims to assess every aspect of the care pathway for early BC patients using a temporal and spatial scope. An observational, prospective, multicenter study in a regional health territory (Ile-de-France, France) in different types of structures: university or local hospitals and comprehensive cancer centers. We will include and follow during 1 year 1,000 patients. The study consists of 3 work-packages: - Cost of pathway The aim of this WP is to calculate the overall costs of the early BC pathway at 1 year from different perspectives (society, health insurance and patient) using a cost-of-illness analysis. Using a bottom-up method, we will assess direct costs, including medical direct costs and nonmedical direct costs (transportation, home modifications, home care services, and social services), and indirect costs (loss of production). - Patient satisfaction and work reintegration Three questionnaires will assess the patients' satisfaction and possible return to work: the occupational questionnaire for employed women; the questionnaire on the need for supportive care, SCNS-SF34 ('breast cancer' module, SCNS-BR8); and the OUTPASSAT-35 questionnaire. - Quality, coordination and access to innovation Quality will be evaluated based on visits and treatment within a set period, whether the setting offers a multidisciplinary consultative framework, the management by nurse coordinators, the use of a personalized care plan, the provision of information via documents about treatments and the provision of supportive care. The coordination between structures and caregivers will be evaluated at several levels. Day surgery, home hospitalization and one-stop breast clinic visits will be recorded to assess the patient's access to innovation. The assessment of care pathways encourages the implementation of new payment models. Our approach could help health care professionals and policymakers to establish other cost-of-illness studies and plan the allocation of resources on a patient basis rather than a visit basis.

Inferior Frontal Cortex Modulation with an Acute Dose of Heroin During Cognitive Control

PubMed Central

Schmidt, André; Walter, Marc; Gerber, Hana; Schmid, Otto; Smieskova, Renata; Bendfeldt, Kerstin; Wiesbeck, Gerhard A; Riecher-Rössler, Anita; Lang, Undine E; Rubia, Katya; McGuire, Philip; Borgwardt, Stefan

2013-01-01

Impairments in inhibitory control and in stimulus-driven attention are hallmarks of drug addiction and are associated with decreased activation in the right inferior frontal gyrus (IFG). Although previous studies indicate that the response inhibition function is impaired in abstinent heroin dependents, and that this is mediated by reduced IFG activity, it remains completely unknown whether and how an acute dose of heroin modulates IFG activity during cognitive control in heroin-dependent patients. This study investigates the acute effects of heroin administration on IFG activity during response inhibition and stimulus-driven attention in heroin-dependent patients. Using a cross-over, double-blind, placebo-controlled design, saline and heroin were administered to 26 heroin-dependent patients from stable heroin-assisted treatment, while performing a Go/No–Go event-related functional magnetic resonance imaging task to assess right IFG activity during motor response inhibition, as well as during oddball-driven attention allocation. Relative to saline, heroin significantly reduced right IFG activity during both successful response inhibition and oddball-driven attention allocation, whereas it did not change right IFG activity during response inhibition after correction for the effect of attention allocation. These heroin-induced effects were not related to changes in drug craving, state anxiety, behavioral performance, or co-consumption of psychostimulant drugs. This study demonstrates that heroin administration acutely impairs stimulus-driven attention allocation, as indicated by reduced IFG activity in response to infrequently presented stimuli, and does not specifically modulate IFG activity during response inhibition. PMID:23673865

45 CFR 1357.10 - Scope and definitions.

Code of Federal Regulations, 2010 CFR

2010-10-01

... improvement and allocation of resources. Child welfare services means public social services directed to... interaction with other families and with program staff; (5) Transportation, information and referral services...

7 CFR 250.24 - Distributing agency performance standards.

Code of Federal Regulations, 2010 CFR

2010-01-01

... commodity assistance levels; (4) Ordering and allocating donated food based on participation data for those... directly into their warehouses; (2) Solicit information and recommendations regarding the individual...

7 CFR 250.24 - Distributing agency performance standards.

Code of Federal Regulations, 2011 CFR

2011-01-01

... commodity assistance levels; (4) Ordering and allocating donated food based on participation data for those... directly into their warehouses; (2) Solicit information and recommendations regarding the individual...

Cost-effectiveness of atorvastatin in the prevention of cardiovascular events in diabetic patients: a French adaptation of CARDS.

PubMed

Lafuma, Antoine; Colin, Xavier; Solesse, Anne

2008-05-01

We estimated the cost-effectiveness of atorvastatin in the primary prevention of cardiovascular events in patients with type 2 diabetes using data from the Collaborative AtoRvastatin Diabetes Study (CARDS). A total of 2838 patients aged 40-75 years with type 2 diabetes and no documented history of cardiovascular disease and without elevated low-density-lipoprotein cholesterol were recruited in the UK and in Ireland. Patients were randomly allocated to atorvastatin 10mg daily (n=1428) or placebo (n=1410) and were followed up for a median of 3.9 years. Direct treatment costs and effectiveness were analysed to provide estimates of cost per event avoided and cost per life-year gained over the trial period and over a patient's lifetime. The incremental cost-effectiveness ratio over the trial period was estimated to be Euro 3862 per clinical event avoided. Over the patient's lifetime, the incremental cost per life-year gained was Euro 2506 when considering cardiovascular deaths, and Euro 1418 per year when considering all-cause death. Primary prevention of cardiovascular disease with atorvastatin is cost-effective in patients with type 2 diabetes, with the incremental cost-effectiveness ratio for this intervention falling within the current acceptance threshold.

Utilizing patient geographic information system data to plan telemedicine service locations.

PubMed

Soares, Neelkamal; Dewalle, Joseph; Marsh, Ben

2017-09-01

To understand potential utilization of clinical services at a rural integrated health care system by generating optimal groups of telemedicine locations from electronic health record (EHR) data using geographic information systems (GISs). This retrospective study extracted nonidentifiable grouped data of patients over a 2-year period from the EHR, including geomasked locations. Spatially optimal groupings were created using available telemedicine sites by calculating patients' average travel distance (ATD) to the closest clinic site. A total of 4027 visits by 2049 unique patients were analyzed. The best travel distances for site groupings of 3, 4, 5, or 6 site locations were ranked based on increasing ATD. Each one-site increase in the number of available telemedicine sites decreased minimum ATD by about 8%. For a given group size, the best groupings were very similar in minimum travel distance. There were significant differences in predicted patient load imbalance between otherwise similar groupings. A majority of the best site groupings used the same small number of sites, and urban sites were heavily used. With EHR geospatial data at an individual patient level, we can model potential telemedicine sites for specialty access in a rural geographic area. Relatively few sites could serve most of the population. Direct access to patient GIS data from an EHR provides direct knowledge of the client base compared to methods that allocate aggregated data. Geospatial data and methods can assist health care location planning, generating data about load, load balance, and spatial accessibility. © The Author 2017. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com

MIOTIC study: a prospective, multicenter, randomized study to evaluate the long-term efficacy of mobile phone-based Internet of Things in the management of patients with stable COPD.

PubMed

Zhang, Jing; Song, Yuan-Lin; Bai, Chun-Xue

2013-01-01

Chronic obstructive pulmonary disease (COPD) is a common disease that leads to huge economic and social burden. Efficient and effective management of stable COPD is essential to improve quality of life and reduce medical expenditure. The Internet of Things (IoT), a recent breakthrough in communication technology, seems promising in improving health care delivery, but its potential strengths in COPD management remain poorly understood. We have developed a mobile phone-based IoT (mIoT) platform and initiated a randomized, multicenter, controlled trial entitled the 'MIOTIC study' to investigate the influence of mIoT among stable COPD patients. In the MIOTIC study, at least 600 patients with stable GOLD group C or D COPD and with a history of at least two moderate-to-severe exacerbations within the previous year will be randomly allocated to the control group, which receives routine follow-up, or the intervention group, which receives mIoT management. Endpoints of the study include (1) frequency and severity of acute exacerbation; (2) symptomatic evaluation; (3) pre- and post-bronchodilator forced expiratory volume in 1 second (FEV1) and FEV1/forced vital capacity (FVC) measurement; (4) exercise capacity; and (5) direct medical cost per year. Results from this study should provide direct evidence for the suitability of mIoT in stable COPD patient management.

MIOTIC study: a prospective, multicenter, randomized study to evaluate the long-term efficacy of mobile phone-based Internet of Things in the management of patients with stable COPD

PubMed Central

Zhang, Jing; Song, Yuan-lin; Bai, Chun-xue

2013-01-01

Chronic obstructive pulmonary disease (COPD) is a common disease that leads to huge economic and social burden. Efficient and effective management of stable COPD is essential to improve quality of life and reduce medical expenditure. The Internet of Things (IoT), a recent breakthrough in communication technology, seems promising in improving health care delivery, but its potential strengths in COPD management remain poorly understood. We have developed a mobile phone-based IoT (mIoT) platform and initiated a randomized, multicenter, controlled trial entitled the ‘MIOTIC study’ to investigate the influence of mIoT among stable COPD patients. In the MIOTIC study, at least 600 patients with stable GOLD group C or D COPD and with a history of at least two moderate-to-severe exacerbations within the previous year will be randomly allocated to the control group, which receives routine follow-up, or the intervention group, which receives mIoT management. Endpoints of the study include (1) frequency and severity of acute exacerbation; (2) symptomatic evaluation; (3) pre- and post-bronchodilator forced expiratory volume in 1 second (FEV1) and FEV1/forced vital capacity (FVC) measurement; (4) exercise capacity; and (5) direct medical cost per year. Results from this study should provide direct evidence for the suitability of mIoT in stable COPD patient management. PMID:24082784

Ising game: Nonequilibrium steady states of resource-allocation systems

NASA Astrophysics Data System (ADS)

Xin, C.; Yang, G.; Huang, J. P.

2017-04-01

Resource-allocation systems are ubiquitous in the human society. But how external fields affect the state of such systems remains poorly explored due to the lack of a suitable model. Because the behavior of spins pursuing energy minimization required by physical laws is similar to that of humans chasing payoff maximization studied in game theory, here we combine the Ising model with the market-directed resource-allocation game, yielding an Ising game. Based on the Ising game, we show theoretical, simulative and experimental evidences for a formula, which offers a clear expression of nonequilibrium steady states (NESSs). Interestingly, the formula also reveals a convertible relationship between the external field (exogenous factor) and resource ratio (endogenous factor), and a class of saturation as the external field exceeds certain limits. This work suggests that the Ising game could be a suitable model for studying external-field effects on resource-allocation systems, and it could provide guidance both for seeking more relations between NESSs and equilibrium states and for regulating human systems by choosing NESSs appropriately.

Interactive Land-Use Optimization Using Laguerre Voronoi Diagram with Dynamic Generating Point Allocation

NASA Astrophysics Data System (ADS)

Chaidee, S.; Pakawanwong, P.; Suppakitpaisarn, V.; Teerasawat, P.

2017-09-01

In this work, we devise an efficient method for the land-use optimization problem based on Laguerre Voronoi diagram. Previous Voronoi diagram-based methods are more efficient and more suitable for interactive design than discrete optimization-based method, but, in many cases, their outputs do not satisfy area constraints. To cope with the problem, we propose a force-directed graph drawing algorithm, which automatically allocates generating points of Voronoi diagram to appropriate positions. Then, we construct a Laguerre Voronoi diagram based on these generating points, use linear programs to adjust each cell, and reconstruct the diagram based on the adjustment. We adopt the proposed method to the practical case study of Chiang Mai University's allocated land for a mixed-use complex. For this case study, compared to other Voronoi diagram-based method, we decrease the land allocation error by 62.557 %. Although our computation time is larger than the previous Voronoi-diagram-based method, it is still suitable for interactive design.

Human performance in a multiple-task environment: effects of automation reliability on visual attention allocation.

PubMed

Cullen, Ralph H; Rogers, Wendy A; Fisk, Arthur D

2013-11-01

Diagnostic automation has been posited to alleviate the high demands of multiple-task environments; however, mixed effects have been found pertaining to performance aid success. To better understand these effects, attention allocation must be studied directly. We developed a multiple-task environment to study the effects of automation on visual attention. Participants interacted with a system providing varying levels of automation and automation reliability and then were transferred to a system with no support. Attention allocation was measured by tracking the number of times each task was viewed. We found that participants receiving automation allocated their time according to the task frequency and that tasks that benefited most from automation were most harmed when it was removed. The results suggest that the degree to which automation affects multiple-task performance is dependent on the relative attributes of the tasks involved. Moreover, there is an inverse relationship between support and cost when automation fails. Copyright © 2013 Elsevier Ltd and The Ergonomics Society. All rights reserved.

Which patients do I treat? An experimental study with economists and physicians

PubMed Central

2012-01-01

This experiment investigates decisions made by prospective economists and physicians in an allocation problem which can be framed either medically or neutrally. The potential recipients differ with respect to their minimum needs as well as to how much they benefit from a treatment. We classify the allocators as either 'selfish', 'Rawlsian', or 'maximizing the number of recipients'. Economists tend to maximize their own payoff, whereas the physicians' choices are more in line with maximizing the number of recipients and with Rawlsianism. Regarding the framing, we observe that professional norms surface more clearly in familiar settings. Finally, we scrutinize how the probability of being served and the allocated quantity depend on a recipient's characteristics as well as on the allocator type. JEL Classification: A13, I19, C91, C72 PMID:22827912

Transcranial Direct Current Stimulation in Patients with Prolonged Disorders of Consciousness: Combined Behavioral and Event-Related Potential Evidence.

PubMed

Zhang, Ye; Song, Weiqun; Du, Jubao; Huo, Su; Shan, Guixiang; Li, Ran

2017-01-01

The electrophysiological evidence supporting the therapeutic efficacy of multiple transcranial direct current stimulation (tDCS) sessions on consciousness improvement in patients with prolonged disorders of consciousness (DOCs) has not been firmly established. To assess the effects of repeated tDCS in patients with prolonged DOCs by Coma Recovery Scale-Revised (CRS-R) score and event-related potential (ERP). Using a sham-controlled randomized double-blind design, 26 patients were randomly assigned to either a real [five vegetative state (VS) and eight minimally conscious state (MCS) patients] or sham (six VS and seven MCS patients) stimulation group. The patients in the real stimulation group underwent 20 anodal tDCS sessions of the left dorsolateral prefrontal cortex (DLPFC) over 10 consecutive working days. The CRS-R score and P300 amplitude and latency in a hierarchical cognitive assessment were recorded to evaluate the consciousness level before tDCS and immediately after the 20 sessions. The intra-group CRS-R analysis revealed a clinically significant improvement in the MCS patients in the real stimulation group. The inter-group CRS-R analysis showed a significant difference in CRS-R between VS and MCS patients at baseline in both the real and sham stimulation groups. The intra-group ERP analysis revealed a significant increase in P300 amplitude after tDCS in the MCS patients in the real stimulation group, but no significant differences in P300 latency. For the inter-group ERP analysis, we observed significant differences regarding the presence of P300 at baseline between the VS and MCS patients in both groups. The repeated anodal tDCS of the left DLPFC could produce clinically significant improvements in MCS patients. The observed tDCS-related consciousness improvements might be related to improvements in attention resource allocation (reflected by the P300 amplitude). The findings support the use of tDCS in clinical practice and ERP might serve as an efficient electrophysiological assessment tool in patients with DOCs.

Three-level global resource allocation model for hiv control: A hierarchical decision system approach.

PubMed

Kassa, Semu Mitiku

2018-02-01

Funds from various global organizations, such as, The Global Fund, The World Bank, etc. are not directly distributed to the targeted risk groups. Especially in the so-called third-world-countries, the major part of the fund in HIV prevention programs comes from these global funding organizations. The allocations of these funds usually pass through several levels of decision making bodies that have their own specific parameters to control and specific objectives to achieve. However, these decisions are made mostly in a heuristic manner and this may lead to a non-optimal allocation of the scarce resources. In this paper, a hierarchical mathematical optimization model is proposed to solve such a problem. Combining existing epidemiological models with the kind of interventions being on practice, a 3-level hierarchical decision making model in optimally allocating such resources has been developed and analyzed. When the impact of antiretroviral therapy (ART) is included in the model, it has been shown that the objective function of the lower level decision making structure is a non-convex minimization problem in the allocation variables even if all the production functions for the intervention programs are assumed to be linear.

A novel frame-level constant-distortion bit allocation for smooth H.264/AVC video quality

NASA Astrophysics Data System (ADS)

Liu, Li; Zhuang, Xinhua

2009-01-01

It is known that quality fluctuation has a major negative effect on visual perception. In previous work, we introduced a constant-distortion bit allocation method [1] for H.263+ encoder. However, the method in [1] can not be adapted to the newest H.264/AVC encoder directly as the well-known chicken-egg dilemma resulted from the rate-distortion optimization (RDO) decision process. To solve this problem, we propose a new two stage constant-distortion bit allocation (CDBA) algorithm with enhanced rate control for H.264/AVC encoder. In stage-1, the algorithm performs RD optimization process with a constant quantization QP. Based on prediction residual signals from stage-1 and target distortion for smooth video quality purpose, the frame-level bit target is allocated by using a close-form approximations of ratedistortion relationship similar to [1], and a fast stage-2 encoding process is performed with enhanced basic unit rate control. Experimental results show that, compared with original rate control algorithm provided by H.264/AVC reference software JM12.1, the proposed constant-distortion frame-level bit allocation scheme reduces quality fluctuation and delivers much smoother PSNR on all testing sequences.

Factors that influence case managers' resource allocation decisions in pediatric home care: an ethnographic study.

PubMed

Fraser, Kimberly D; Estabrooks, Carole; Allen, Marion; Strang, Vicki

2009-03-01

Case managers make decisions that directly affect the amount and type of services home care clients receive and subsequently affect the overall available health care resources of home care programs. A recent systematic review of the literature identified significant knowledge gaps with respect to resource allocation decision-making in home care. Using Spradley's methodology, we designed an ethnographic study of a children's home care program in Western Canada. The sample included 11 case managers and program leaders. Data sources included interviews, card sorts, and participant observation over a 5-month period. Data analyses included open coding, domain, taxonomic, and componential analysis. One of the key findings was a taxonomy of factors that influence case manager resource allocation decisions. The factors were grouped into one of four main categories: system-related, home care program-related, family related, or client-related. Family related factors have not been previously reported as influencing case manager resource allocation decision-making and nor has the team's role been reported as an influencing factor. The findings of this study are examined in light of Daniels and Sabin's Accountability for Reasonableness framework, which may be useful for future knowledge development about micro-level resource allocation theory.

Treatment costs and priority setting in health care: A qualitative study

PubMed Central

McKie, John; Shrimpton, Bradley; Richardson, Jeff; Hurworth, Rosalind

2009-01-01

Background The aim of this study is to investigate whether the public believes high cost patients should be a lower priority for public health care than low cost patients, other things being equal, in order to maximise health gains from the health budget. Semi-structured group discussions were used to help participants reflect critically upon their own views and gain exposure to alternative views, and in this way elicit underlying values rather than unreflective preferences. Participants were given two main tasks: first, to select from among three general principles for setting health care priorities the one that comes closest to their own views; second, to allocate a limited hospital budget between two groups of imaginary patients. Forty-one people, varying in age, occupation, income and education level, participated in a total of six group discussions with each group comprising between six and eight people. Results After discussion and deliberation, 30 participants rejected the most cost-effective principle for setting priorities, citing reasons such as 'moral values' and 'a personal belief that we shouldn't discriminate'. Only three participants chose to allocate the entire hospital budget to the low cost patients. Reasons for allocating some money to inefficient (high cost) patients included 'fairness' and the desire to give all patients a 'chance'. Conclusion Participants rejected a single-minded focus on efficiency – maximising health gains – when setting priorities in health care. There was a concern to avoid strategies that deny patients all hope of treatment, and a willingness to sacrifice health gains for a 'fair' public health system. PMID:19416546

19 CFR 10.197 - Direct costs of processing operations performed in a beneficiary country or countries.

Code of Federal Regulations, 2010 CFR

2010-04-01

... merchandise: (1) All actual labor costs involved in the growth, production, manufacture or assembly of the... the growth, production, manufacture, or assembly of the merchandise, such as administrative salaries... costs either directly incurred in, or which can be reasonably allocated to, the growth, production...

19 CFR 10.814 - Direct costs of processing operations.

Code of Federal Regulations, 2014 CFR

2014-04-01

... manufacture of the specific good, including fringe benefits, on-the-job training, and the costs of engineering..., design, engineering, and blueprint costs, to the extent that they are allocable to the specific good; (4... 19 Customs Duties 1 2014-04-01 2014-04-01 false Direct costs of processing operations. 10.814...

19 CFR 10.774 - Direct costs of processing operations.

Code of Federal Regulations, 2014 CFR

2014-04-01

... manufacture of the specific good, including fringe benefits, on-the-job training, and the costs of engineering..., design, engineering, and blueprint costs, to the extent that they are allocable to the specific good; (4... 19 Customs Duties 1 2014-04-01 2014-04-01 false Direct costs of processing operations. 10.774...

Target Marketing and Direct Mail: A Smart Campaign Combination.

ERIC Educational Resources Information Center

Brostoff, Mark J.

1994-01-01

Market segmentation is a marketing strategy that helps identify and classify a camp's product or service and determine the needs of a targeted market for the purpose of allocating marketing resources. Offers strategies for defining a target market and discusses the benefits of direct mail, deriving a mailing list, and suggestions for using a…

Computer-based malnutrition risk calculation may enhance the ability to identify pediatric patients at malnutrition-related risk for unfavorable outcome.

PubMed

Karagiozoglou-Lampoudi, Thomais; Daskalou, Efstratia; Lampoudis, Dimitrios; Apostolou, Aggeliki; Agakidis, Charalampos

2015-05-01

The study aimed to test the hypothesis that computer-based calculation of malnutrition risk may enhance the ability to identify pediatric patients at malnutrition-related risk for an unfavorable outcome. The Pediatric Digital Scaled MAlnutrition Risk screening Tool (PeDiSMART), incorporating the World Health Organization (WHO) growth reference data and malnutrition-related parameters, was used. This was a prospective cohort study of 500 pediatric patients aged 1 month to 17 years. Upon admission, the PeDiSMART score was calculated and anthropometry was performed. Pediatric Yorkhill Malnutrition Score (PYMS), Screening Tool Risk on Nutritional Status and Growth (STRONGkids), and Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) malnutrition screening tools were also applied. PeDiSMART's association with the clinical outcome measures (weight loss/nutrition support and hospitalization duration) was assessed and compared with the other screening tools. The PeDiSMART score was inversely correlated with anthropometry and bioelectrical impedance phase angle (BIA PhA). The score's grading scale was based on BIA Pha quartiles. Weight loss/nutrition support during hospitalization was significantly independently associated with the malnutrition risk group allocation on admission, after controlling for anthropometric parameters and age. Receiver operating characteristic curve analysis showed a sensitivity of 87% and a specificity of 75% and a significant area under the curve, which differed significantly from that of STRONGkids and STAMP. In the subgroups of patients with PeDiSMART-based risk allocation different from that based on the other tools, PeDiSMART allocation was more closely related to outcome measures. PeDiSMART, applicable to the full age range of patients hospitalized in pediatric departments, graded according to BIA PhA, and embeddable in medical electronic records, enhances efficacy and reproducibility in identifying pediatric patients at malnutrition-related risk for an unfavorable outcome. Patient allocation according to the PeDiSMART score on admission is associated with clinical outcome measures. © 2014 American Society for Parenteral and Enteral Nutrition.

Systematic evaluation of the methodology of randomized controlled trials of anticoagulation in patients with cancer.

PubMed

Rada, Gabriel; Schünemann, Holger J; Labedi, Nawman; El-Hachem, Pierre; Kairouz, Victor F; Akl, Elie A

2013-02-14

Randomized controlled trials (RCTs) that are inappropriately designed or executed may provide biased findings and mislead clinical practice. In view of recent interest in the treatment and prevention of thrombotic complications in cancer patients we evaluated the characteristics, risk of bias and their time trends in RCTs of anticoagulation in patients with cancer. We conducted a comprehensive search, including a search of four electronic databases (MEDLINE, EMBASE, ISI the Web of Science, and CENTRAL) up to February 2010. We included RCTs in which the intervention and/or comparison consisted of: vitamin K antagonists, unfractionated heparin (UFH), low molecular weight heparin (LMWH), direct thrombin inhibitors or fondaparinux. We performed descriptive analyses and assessed the association between the variables of interest and the year of publication. We included 67 RCTs with 24,071 participants. In twenty one trials (31%) DVT diagnosis was triggered by clinical suspicion; the remaining trials either screened for DVT or were unclear about their approach. 41 (61%), 22 (33%), and 11 (16%) trials respectively reported on major bleeding, minor bleeding, and thrombocytopenia. The percentages of trials satisfying risk of bias criteria were: adequate sequence generation (85%), adequate allocation concealment (61%), participants' blinding (39%), data collectors' blinding (44%), providers' blinding (41%), outcome assessors' blinding (75%), data analysts' blinding (15%), intention to treat analysis (57%), no selective outcome reporting (12%), no stopping early for benefit (97%). The mean follow-up rate was 96%. Adequate allocation concealment and the reporting of intention to treat analysis were the only two quality criteria that improved over time. Many RCTs of anticoagulation in patients with cancer appear to use insufficiently rigorous outcome assessment methods and to have deficiencies in key methodological features. It is not clear whether this reflects a problem in the design, conduct or the reporting of these trials, or both. Future trials should avoid the shortcomings described in this article.

Clinical and Aesthetic Outcome with Post-Extractive Implants with or without Soft Tissue Augmentation: A 2-Year Randomized Clinical Trial.

PubMed

Migliorati, Marco; Amorfini, Leonardo; Signori, Alessio; Biavati, Armando Silvestrini; Benedicenti, Stefano

2015-10-01

The aesthetic outcome of an implant-supported restoration is first of all dependent on the soft tissue volume. Because the labial bone plate resorbs in every direction after tooth extraction, even when an implant is placed immediately, most patients end up with compromised aesthetics. In this parallel-designed, randomized clinical trial, participants were randomly assigned to the test group (immediate load post-extractive implant treated with subepithelial connective tissue graft placed using the tunnel technique in the labial area) and control group (immediate load post-extractive implant treated without raising a flap) with an allocation ratio of 1:1. Both groups received deproteinized bovine bone mineral. Patients were observed at baseline, crown insertion, 1-year follow-up, and 2-year follow-up. Clinical, radiological and aesthetic parameters were recorded to assess primary treatment outcomes. A random permuted block system was blindly generated ensuring uniformity of the patient allocation during the trial by randomly distributing three participants to the test and three participants to the control group every six treated patients. At the 2-year examination, all 47 implants were successfully integrated, demonstrating stability and healthy peri-implant soft tissues as documented by standard clinical parameters. The results showed a soft tissue remodeling of -10% in thickness and -18% in highness in the non-grafted group, whereas in the grafted group there was a gain of 35% in thickness and a slight reduction of -11% in highness. Test group reported an increase of aesthetic result (mean pink aesthetic score [PES] 8) compared with control group (mean PES 6.65). This prospective study demonstrates the effectiveness of placing a soft tissue graft at the time of immediate implant placement in the aesthetic zone. At the 2-year follow-up, test group revealed a better aesthetic outcomes and stable facial soft tissues compared with control group. © 2013 Wiley Periodicals, Inc.

Providing patients with information about disease-modifying anti-rheumatic drugs: Individually or in groups? A pilot randomized controlled trial comparing adherence and satisfaction.

PubMed

Homer, Dawn; Nightingale, Peter; Jobanputra, Paresh

2009-06-01

Communicating information about disease-modifying anti-rheumatic drugs (DMARDs) before patients start treatment is a key role for some rheumatology clinical nurse specialists. This is done in our unit to promote understanding of the risks and benefits of drug therapy and encourage timely and reliable use of DMARDs. Information is routinely provided individually but this can lead to delays in starting treatment because of limited nursing resources. In this randomized trial we tested the feasibility of giving patients, who were about to start on a DMARD, information about the drug in groups and compared this with information given individually. Adults with a clinical diagnosis of rheumatoid arthritis or psoriatic arthritis who were referred to the nursing team for counselling about starting on methotrexate, sulfasalazine or leflunomide were included. Patients who had previously taken a DMARD were not excluded and those consenting were randomized to receive drug information individually or in groups (of three to six patients). We provided all patients with written materials about the relevant drug and discussed the risks and benefits of drug use verbally. Patients allocated to group counselling received this intervention in a teaching room, with a slide presentation. The primary outcome was adherence with medication use, ascertained by pill counts, self-report diaries and prescription dispensation. Secondary outcomes included satisfaction with information about medicines (SIMS) by questionnaire; time taken to provide information; adherence to scheduled hospital appointments and blood monitoring schedules; and DMARD continuation rates at four and twelve months. Of 127 eligible patients referred for counselling about DMARDs, 62 consented to take part: 32 were randomized to receive drug information individually and 30 to receiving it in groups. Patients allocated to the two different interventions were comparable for age and diagnoses at baseline but more patients allocated individual counselling had not taken a DMARD previously: 56% (18/32) versus 20% (6/30). More patients counselled in groups were adherent (27/30; 90%) compared with patients counselled individually (22/32; 69%; p = 0.06) by pill counts. However, on self-report diaries, similar proportions were adherent (group counselling 97% (29/30) versus individual 94% (30/32); p = 1.0). All but two prescriptions were dispensed. More patients allocated to individual counselling missed at least one blood monitoring visit (25% versus 17%; p = 0.54) and at least one scheduled clinic visit (19% versus 3%; p = 0.10). SIMS scores indicated high levels of patient satisfaction and were similar for both groups. The time taken to run group and individual counselling sessions were similar (median of 35 minutes versus 33 minutes, respectively). Nursing time per individual patient in those allocated group counselling was 11.6 minutes. Drug continuation rates were higher for those counselled in groups compared with those counselled individually: at four months, 73% versus 63 %; p = 0.42; at twelve months, 47% versus 38%; p = 0.61). Our pilot study demonstrated the feasibility of providing counselling on DMARDs to groups of patients with important time savings for specialist nurses and while maintaining high levels of patient satisfaction. There was a trend for better outcomes in terms of adherence and drug continuation rates for patients counselled in groups, indicating potential benefits from group interactions. However, these findings need to be investigated further in a larger, fully powered trial. 2008 John Wiley & Sons, Ltd.

The PROCARE consortium: toward an improved allocation strategy for kidney allografts.

PubMed

Otten, H G; Joosten, I; Allebes, W A; van der Meer, A; Hilbrands, L B; Baas, M; Spierings, E; Hack, C E; van Reekum, F; van Zuilen, A D; Verhaar, M C; Bots, M L; Seelen, M A J; Sanders, J S F; Hepkema, B G; Lambeck, A J; Bungener, L B; Roozendaal, C; Tilanus, M G J; Vanderlocht, J; Voorter, C E; Wieten, L; van Duijnhoven, E; Gelens, M; Christiaans, M; van Ittersum, F; Nurmohamed, A; Lardy, N M; Swelsen, W T; van Donselaar-van der Pant, K A M I; van der Weerd, N C; Ten Berge, I J M; Bemelman, F J; Hoitsma, A J; de Fijter, J W; Betjes, M G H; Roelen, D L; Claas, F H J

2014-10-01

Kidney transplantation is the best treatment option for patients with end-stage renal failure. At present, approximately 800 Dutch patients are registered on the active waiting list of Eurotransplant. The waiting time in the Netherlands for a kidney from a deceased donor is on average between 3 and 4 years. During this period, patients are fully dependent on dialysis, which replaces only partly the renal function, whereas the quality of life is limited. Mortality among patients on the waiting list is high. In order to increase the number of kidney donors, several initiatives have been undertaken by the Dutch Kidney Foundation including national calls for donor registration and providing information on organ donation and kidney transplantation. The aim of the national PROCARE consortium is to develop improved matching algorithms that will lead to a prolonged survival of transplanted donor kidneys and a reduced HLA immunization. The latter will positively affect the waiting time for a retransplantation. The present algorithm for allocation is among others based on matching for HLA antigens, which were originally defined by antibodies using serological typing techniques. However, several studies suggest that this algorithm needs adaptation and that other immune parameters which are currently not included may assist in improving graft survival rates. We will employ a multicenter-based evaluation on 5429 patients transplanted between 1995 and 2005 in the Netherlands. The association between key clinical endpoints and selected laboratory defined parameters will be examined, including Luminex-defined HLA antibody specificities, T and B cell epitopes recognized on the mismatched HLA antigens, non-HLA antibodies, and also polymorphisms in complement and Fc receptors functionally associated with effector functions of anti-graft antibodies. From these data, key parameters determining the success of kidney transplantation will be identified which will lead to the identification of additional parameters to be included in future matching algorithms aiming to extend survival of transplanted kidneys and to diminish HLA immunization. Computer simulation studies will reveal the number of patients having a direct benefit from improved matching, the effect on shortening of the waiting list, and the decrease in waiting time. Copyright © 2014. Published by Elsevier B.V.

Allocating health care resources: a questionnaire experiment on the predictive success of rules.

PubMed

Ahlert, Marlies; Schwettmann, Lars

2017-06-26

The topic of this paper is related to equity in health within a country. In public health care sectors of many countries decisions on priority setting with respect to treatment of different types of diseases or patient groups are implicitly or explicitly made. Priorities are realized by allocation decisions for medical resources where moral judgments play an important role with respect to goals and measures that should be applied. The aim of this study is to explore the moral intuitions held in the German society related to priorities in medical treatment. We use an experimental questionnaire method established in the Empirical Social Choice literature. Participants are asked to make decisions in a sequence of distributive problems where a limited amount of treatment time has to be allocated to hypothetically described patients. The decision problems serve as an intuition pump. Situations are systematically varied with respect to patients' initial health levels, their ability to benefit from treatment time, and the amount of treatment time available. Subjects are also asked to describe their deliberations. We focus on the acceptance of different allocation principles including equity concepts and utilitarian properties. We investigate rule characteristics like order preservation or monotonicity with respect to resources, severity, or effectiveness. We check the consistency of individual choices with stated reasoning. The goals and allocation principles revealed show that the moral intuitions held by our experimental subjects are much more complex than the principles commonly applied in health economic theory. Especially, cost-utility principles are rarely applied, whereas the goal of equality of health gain is observed more often. The principle not to leave any patient untreated is very dominant. We also observe the degrees to which extent certain monotonicity principles, known from welfare economics, are followed. Subjects were able to describe their moral judgments in written statements. We also find evidence that they followed their respective intuitions very consistently in their decisions. Findings of the kind presented in this paper may serve as an important input for the public and political discussion when decisions on priorities in the public health care sector are formed.

Quantifying and understanding reproductive allocation schedules in plants.

PubMed

Wenk, Elizabeth Hedi; Falster, Daniel S

2015-12-01

A plant's reproductive allocation (RA) schedule describes the fraction of surplus energy allocated to reproduction as it increases in size. While theorists use RA schedules as the connection between life history and energy allocation, little is known about RA schedules in real vegetation. Here we review what is known about RA schedules for perennial plants using studies either directly quantifying RA or that collected data from which the shape of an RA schedule can be inferred. We also briefly review theoretical models describing factors by which variation in RA may arise. We identified 34 studies from which aspects of an RA schedule could be inferred. Within those, RA schedules varied considerably across species: some species abruptly shift all resources from growth to reproduction; most others gradually shift resources into reproduction, but under a variety of graded schedules. Available data indicate the maximum fraction of energy allocated to production ranges from 0.1 to 1 and that shorter lived species tend to have higher initial RA and increase their RA more quickly than do longer-lived species. Overall, our findings indicate, little data exist about RA schedules in perennial plants. Available data suggest a wide range of schedules across species. Collection of more data on RA schedules would enable a tighter integration between observation and a variety of models predicting optimal energy allocation, plant growth rates, and biogeochemical cycles.

Allocation of nursing care hours in a combined ophthalmic nursing unit.

PubMed

Navarro, V B; Stout, W A; Tolley, F M

1995-04-01

Traditional service configuration with separate nursing units for outpatient and inpatient care is becoming ineffective for new patient care delivery models. With the new configuration of a combined nursing unit, it was necessary to rethink traditional reporting methodologies and calculation of hours of care. This project management plan is an initial attempt to develop a standard costing/productivity model for a combined unit. The methodology developed from this plan measures nursing care hours for each patient population to determine the number of full time equivalents (FTEs) for a combined unit and allocates FTEs based on inpatient (IP), outpatient (OP), and emergency room (ER) volumes.

A Bayesian adaptive design for biomarker trials with linked treatments.

PubMed

Wason, James M S; Abraham, Jean E; Baird, Richard D; Gournaris, Ioannis; Vallier, Anne-Laure; Brenton, James D; Earl, Helena M; Mander, Adrian P

2015-09-01

Response to treatments is highly heterogeneous in cancer. Increased availability of biomarkers and targeted treatments has led to the need for trial designs that efficiently test new treatments in biomarker-stratified patient subgroups. We propose a novel Bayesian adaptive randomisation (BAR) design for use in multi-arm phase II trials where biomarkers exist that are potentially predictive of a linked treatment's effect. The design is motivated in part by two phase II trials that are currently in development. The design starts by randomising patients to the control treatment or to experimental treatments that the biomarker profile suggests should be active. At interim analyses, data from treated patients are used to update the allocation probabilities. If the linked treatments are effective, the allocation remains high; if ineffective, the allocation changes over the course of the trial to unlinked treatments that are more effective. Our proposed design has high power to detect treatment effects if the pairings of treatment with biomarker are correct, but also performs well when alternative pairings are true. The design is consistently more powerful than parallel-groups stratified trials. This BAR design is a powerful approach to use when there are pairings of biomarkers with treatments available for testing simultaneously.

Bayesian adaptive phase II screening design for combination trials.

PubMed

Cai, Chunyan; Yuan, Ying; Johnson, Valen E

2013-01-01

Trials of combination therapies for the treatment of cancer are playing an increasingly important role in the battle against this disease. To more efficiently handle the large number of combination therapies that must be tested, we propose a novel Bayesian phase II adaptive screening design to simultaneously select among possible treatment combinations involving multiple agents. Our design is based on formulating the selection procedure as a Bayesian hypothesis testing problem in which the superiority of each treatment combination is equated to a single hypothesis. During the trial conduct, we use the current values of the posterior probabilities of all hypotheses to adaptively allocate patients to treatment combinations. Simulation studies show that the proposed design substantially outperforms the conventional multiarm balanced factorial trial design. The proposed design yields a significantly higher probability for selecting the best treatment while allocating substantially more patients to efficacious treatments. The proposed design is most appropriate for the trials combining multiple agents and screening out the efficacious combination to be further investigated. The proposed Bayesian adaptive phase II screening design substantially outperformed the conventional complete factorial design. Our design allocates more patients to better treatments while providing higher power to identify the best treatment at the end of the trial.

Hot topics in liver transplantation: organ allocation--extended criteria donor--living donor liver transplantation.

PubMed

Müllhaupt, Beat; Dimitroulis, Dimitrios; Gerlach, J Tilman; Clavien, Pierre-Alain

2008-01-01

Liver transplantation has become the mainstay for the treatment of end-stage liver disease, hepatocellular cancer and some metabolic disorders. Its main drawback, though, is the disparity between the number of donors and the patients needing a liver graft. In this review we will discuss the recent changes regarding organ allocation, extended donor criteria, living donor liver transplantation and potential room for improvement. The gap between the number of donors and patients needing a liver graft forced the transplant community to introduce an objective model such as the modified model for end-stage liver disease (MELD) in order to obtain a transparent and fair organ allocation system. The use of extended criteria donor livers such as organs from older donors or steatotic grafts is one possibility to reduce the gap between patients on the waiting list and available donors. Finally, living donor liver transplantation has become a standard procedure in specialized centers as another possibility to reduce the donor shortage. Recent data clearly indicate that center experience is of major importance in achieving good results. Great progress has been made in recent years. However, further research is needed to improve results in the future.

The Flex Track: Flexible Partitioning between Low- and High-Acuity Areas of an Emergency Department

PubMed Central

Laker, Lauren F.; Froehle, Craig M.; Lindsell, Christopher J.; Ward, Michael J.

2014-01-01

Study Objective EDs with both low- and high-acuity treatment areas often have fixed allocation of resources, regardless of demand. We demonstrate the utility of discrete-event simulation to evaluate flexible partitioning between low- and high-acuity ED areas to identify the best operational strategy for subsequent implementation. Methods A discrete-event simulation was used to model patient flow through a 50-bed, urban, teaching ED that handles 85,000 patient visits annually. The ED has historically allocated ten beds to a Fast Track for low-acuity patients. We estimated the effect of a Flex Track policy, which involved switching up to five of these Fast Track beds to serving both low- and high-acuity patients, on patient waiting times. When the high-acuity beds were not at capacity, low-acuity patients were given priority access to flexible beds. Otherwise, high-acuity patients were given priority access to flexible beds. Wait times were estimated for patients by disposition and emergency severity index (ESI) score. Results A Flex Track policy using three flexible beds produced the lowest mean patient waiting of 30.9 (95% CI 30.6–31.2) minutes. The typical Fast Track approach of rigidly separating high- and low–acuity beds produced a mean patient wait time of 40.6 (95% CI 40.2–50.0) minutes, 31% higher than the three-bed Flex Track. A completely flexible ED, where all beds can accommodate any patient, produced mean wait times of 35.1 (95% CI 34.8–35.4) minutes. The results from the three-bed Flex Track scenario were robust, performing well across a range of scenarios involving higher and lower patient volumes and care durations. Conclusion Using discrete-event simulation, we have shown that adding some flexibility into bed allocation between low- and high-acuity can provide substantial reductions in overall patient waiting and a more efficient ED. PMID:24954578

Evaluation of an inflammation-based prognostic score in patients with metastatic renal cancer.

PubMed

Ramsey, Sara; Lamb, Gavin W A; Aitchison, Michael; Graham, John; McMillan, Donald C

2007-01-15

Recently, it was shown that an inflammation-based prognostic score, the Glasgow Prognostic Score (GPS), provides additional prognostic information in patients with advanced cancer. The objective of the current study was to examine the value of the GPS compared with established scoring systems in predicting cancer-specific survival in patients with metastatic renal cancer. One hundred nineteen patients who underwent immunotherapy for metastatic renal cancer were recruited. The Memorial Sloan-Kettering Cancer Center (MSKCC) score and the Metastatic Renal Carcinoma Comprehensive Prognostic System (MRCCPS) score were calculated as described previously. Patients who had both an elevated C-reactive protein level (>10 mg/L) and hypoalbuminemia (<35 g/L) were allocated a GPS of 2. Patients who had only 1 of those 2 biochemical abnormalities were allocated a GPS of 1. Patients who had neither abnormality were allocated a GPS of 0. On multivariate analysis of significant individual factors, only calcium (hazard ratio [HR], 3.21; 95% confidence interval [95% CI], 1.51-6.83; P = .002), white cell count (HR, 1.66; 95% CI, 1.17-2.35; P = .004), albumin (HR, 2.63; 95% CI, 1.38-5.03; P = .003), and C-reactive protein (HR, 2.85; 95% CI; 1.49-5.45; P = .002) were associated independently with cancer-specific survival. On multivariate analysis of the different scoring systems, the MSKCC (HR, 1.88; 95% CI, 1.22-2.88; P = .004), the MRCCPS (HR, 1.42; 95% CI, 0.97-2.09; P = .071), and the GPS (HR, 2.35; 95% CI, 1.51-3.67; P < .001) were associated independently with cancer-specific survival. An inflammation-based prognostic score (GPS) predicted survival independent of established scoring systems in patients with metastatic renal cancer.

Can(not) take my eyes off it: attention bias for food in overweight participants.

PubMed

Werthmann, Jessica; Roefs, Anne; Nederkoorn, Chantal; Mogg, Karin; Bradley, Brendan P; Jansen, Anita

2011-09-01

The aim of the current study was to investigate attention biases for food cues, craving, and overeating in overweight and healthy-weight participants. Specifically, it was tested whether attention allocation processes toward high-fat foods differ between overweight and normal weight individuals and whether selective attention biases for food cues are related to craving and food intake. Eye movements were recorded as a direct index of attention allocation in a sample of 22 overweight/obese and 29 healthy-weight female students during a visual probe task with food pictures. In addition, self-reported craving and actual food intake during a bogus "taste-test" were assessed. Overweight participants showed an approach-avoidance pattern of attention allocation toward high-fat food. Overweight participants directed their first gaze more often toward food pictures than healthy-weight individuals, but subsequently showed reduced maintenance of attention on these pictures. For overweight participants, craving was related to initial orientation toward food. Moreover, overweight participants consumed significantly more snack food than healthy-weight participants. Results emphasize the importance of identifying different attention bias components in overweight individuals with regard to craving and subsequent overeating.

Traffic Behavior Recognition Using the Pachinko Allocation Model

PubMed Central

Huynh-The, Thien; Banos, Oresti; Le, Ba-Vui; Bui, Dinh-Mao; Yoon, Yongik; Lee, Sungyoung

2015-01-01

CCTV-based behavior recognition systems have gained considerable attention in recent years in the transportation surveillance domain for identifying unusual patterns, such as traffic jams, accidents, dangerous driving and other abnormal behaviors. In this paper, a novel approach for traffic behavior modeling is presented for video-based road surveillance. The proposed system combines the pachinko allocation model (PAM) and support vector machine (SVM) for a hierarchical representation and identification of traffic behavior. A background subtraction technique using Gaussian mixture models (GMMs) and an object tracking mechanism based on Kalman filters are utilized to firstly construct the object trajectories. Then, the sparse features comprising the locations and directions of the moving objects are modeled by PAM into traffic topics, namely activities and behaviors. As a key innovation, PAM captures not only the correlation among the activities, but also among the behaviors based on the arbitrary directed acyclic graph (DAG). The SVM classifier is then utilized on top to train and recognize the traffic activity and behavior. The proposed model shows more flexibility and greater expressive power than the commonly-used latent Dirichlet allocation (LDA) approach, leading to a higher recognition accuracy in the behavior classification. PMID:26151213

Optimal allocation of thermodynamic irreversibility for the integrated design of propulsion and thermal management systems

NASA Astrophysics Data System (ADS)

Maser, Adam Charles

More electric aircraft systems, high power avionics, and a reduction in heat sink capacity have placed a larger emphasis on correctly satisfying aircraft thermal management requirements during conceptual design. Thermal management systems must be capable of dealing with these rising heat loads, while simultaneously meeting mission performance. Since all subsystem power and cooling requirements are ultimately traced back to the engine, the growing interactions between the propulsion and thermal management systems are becoming more significant. As a result, it is necessary to consider their integrated performance during the conceptual design of the aircraft gas turbine engine cycle to ensure that thermal requirements are met. This can be accomplished by using thermodynamic subsystem modeling and simulation while conducting the necessary design trades to establish the engine cycle. However, this approach also poses technical challenges associated with the existence of elaborate aircraft subsystem interactions. This research addresses these challenges through the creation of a parsimonious, transparent thermodynamic model of propulsion and thermal management systems performance with a focus on capturing the physics that have the largest impact on propulsion design choices. This modeling environment, known as Cycle Refinement for Aircraft Thermodynamically Optimized Subsystems (CRATOS), is capable of operating in on-design (parametric) and off-design (performance) modes and includes a system-level solver to enforce design constraints. A key aspect of this approach is the incorporation of physics-based formulations involving the concurrent usage of the first and second laws of thermodynamics, which are necessary to achieve a clearer view of the component-level losses across the propulsion and thermal management systems. This is facilitated by the direct prediction of the exergy destruction distribution throughout the system and the resulting quantification of available work losses over the time history of the mission. The characterization of the thermodynamic irreversibility distribution helps give the propulsion systems designer an absolute and consistent view of the tradeoffs associated with the design of the entire integrated system. Consequently, this leads directly to the question of the proper allocation of irreversibility across each of the components. The process of searching for the most favorable allocation of this irreversibility is the central theme of the research and must take into account production cost and vehicle mission performance. The production cost element is accomplished by including an engine component weight and cost prediction capability within the system model. The vehicle mission performance is obtained by directly linking the propulsion and thermal management model to a vehicle performance model and flying it through a mission profile. A canonical propulsion and thermal management systems architecture is then presented to experimentally test each element of the methodology separately: first the integrated modeling and simulation, then the irreversibility, cost, and mission performance considerations, and then finally the proper technique to perform the optimal allocation. A goal of this research is the description of the optimal allocation of system irreversibility to enable an engine cycle design with improved performance and cost at the vehicle-level. To do this, a numerical optimization was first used to minimize system-level production and operating costs by fixing the performance requirements and identifying the best settings for all of the design variables. There are two major drawbacks to this approach: It does not allow the designer to directly trade off the performance requirements and it does not allow the individual component losses to directly factor into the optimization. An irreversibility allocation approach based on the economic concept of resource allocation is then compared to the numerical optimization. By posing the problem in economic terms, exergy destruction is treated as a true common currency to barter for improved efficiency, cost, and performance. This allows the designer to clearly see how changes in the irreversibility distribution impact the overall system. The inverse design is first performed through a filtered Monte Carlo to allow the designer to view the irreversibility design space. The designer can then directly perform the allocation using the exergy destruction, which helps to place the design choices on an even thermodynamic footing. Finally, two use cases are presented to show how the irreversibility allocation approach can assist the designer. The first describes a situation where the designer can better address competing system-level requirements; the second describes a different situation where the designer can choose from a number of options to improve a system in a manner that is more robust to future requirements.

Franchise fees reexamined

DOE Office of Scientific and Technical Information (OSTI.GOV)

Osteryoung, J.S.

The author examines franchise fees imposed by local governments and allocated by electric utilities to see if the fees are more equitably applied by the spread or direct method. Examples are drawn from Florida to illustrate how, under the spread method, customers living outside the franchise area contribute 60 percent of the allocated fees but have no control over how they are calculated or spent by the utility. Some cities use excess franchise fees to lower municipal taxes or to provide extra municipal services not available to those in the nonfranchise area. Also at issue is the value of themore » small amount of land used for utility right-of-way, which is of no value to the nonfranchise area customer. The author concludes that franchise fees imposed for the purpose of raising municipal revenues should be directly applied to only those customers living within the franchise area. Direct application of fees, by drawing the customer's attention to the total cost of utilities, could help to restrain future costs. (DCK)« less

Allocating cancer-directed expenditures: tensions between prevention, early detection and treatment is unnecessary.

PubMed

Hillner, Bruce E; Smith, Thomas J

2011-01-01

In most countries, the allocation of financial resources for cancer prevention, early detection, and treatment come from different nonrelated "silos." Primary prevention benefits have the greatest economic return since the cancer benefits are intertwined with other major health conditions. Smoking alone accounts for about one-third cancer deaths. In most affluent countries, vaccines for selected viral caused cancers are (wisely) widely available if not optimally utilized. Estimating the additional cancer burden from obesity is still evolving. Age-targeted, less frequent but higher rates of participation in early detection of cervical, breast, and colorectal cancer will likely be prudent expenditures.The last 20 years in high-income countries, there has seen an explosion in demand and the costs of cancer drug or biologic therapy, a modest growth in some forms of radiation, yet minimal or declining surgical costs for primary disease control. Expenditures for cancer drugs are now the world leader of any medication category. While a few have truly led to marked benefits, all have been priced at levels that strain or break budgets. We comment on ten steps or principles that can be applied in most countries that can meaningfully reduce cancer care costs with minimal impact on survival and maintain or enhance quality of patient's life especially with advanced disease. We emphasize limiting systemic therapies for metastatic disease to fully ambulatory patients, those who previously responded to therapy, and earlier initiation of palliative care. Changing behaviors, incentives, expectations, and the framing of treatment effects are necessary to "bend" the current unrelenting cancer care cost curve.

Two-dimensional priority-based dynamic resource allocation algorithm for QoS in WDM/TDM PON networks

NASA Astrophysics Data System (ADS)

Sun, Yixin; Liu, Bo; Zhang, Lijia; Xin, Xiangjun; Zhang, Qi; Rao, Lan

2018-01-01

Wavelength division multiplexing/time division multiplexing (WDM/TDM) passive optical networks (PON) is being viewed as a promising solution for delivering multiple services and applications. The hybrid WDM / TDM PON uses the wavelength and bandwidth allocation strategy to control the distribution of the wavelength channels in the uplink direction, so that it can ensure the high bandwidth requirements of multiple Optical Network Units (ONUs) while improving the wavelength resource utilization. Through the investigation of the presented dynamic bandwidth allocation algorithms, these algorithms can't satisfy the requirements of different levels of service very well while adapting to the structural characteristics of mixed WDM / TDM PON system. This paper introduces a novel wavelength and bandwidth allocation algorithm to efficiently utilize the bandwidth and support QoS (Quality of Service) guarantees in WDM/TDM PON. Two priority based polling subcycles are introduced in order to increase system efficiency and improve system performance. The fixed priority polling subcycle and dynamic priority polling subcycle follow different principles to implement wavelength and bandwidth allocation according to the priority of different levels of service. A simulation was conducted to study the performance of the priority based polling in dynamic resource allocation algorithm in WDM/TDM PON. The results show that the performance of delay-sensitive services is greatly improved without degrading QoS guarantees for other services. Compared with the traditional dynamic bandwidth allocation algorithms, this algorithm can meet bandwidth needs of different priority traffic class, achieve low loss rate performance, and ensure real-time of high priority traffic class in terms of overall traffic on the network.

Ramsey waits: allocating public health service resources when there is rationing by waiting.

PubMed

Gravelle, Hugh; Siciliani, Luigi

2008-09-01

The optimal allocation of a public health care budget across treatments must take account of the way in which care is rationed within treatments since this will affect their marginal value. We investigate the optimal allocation rules for public health care systems where user charges are fixed and care is rationed by waiting. The optimal waiting time is higher for treatments with demands more elastic to waiting time, higher costs, lower charges, smaller marginal welfare loss from waiting by treated patients, and smaller marginal welfare losses from under-consumption of care. The results hold for a wide range of welfarist and non-welfarist objective functions and for systems in which there is also a private health care sector. They imply that allocation rules based purely on cost effectiveness ratios are suboptimal because they assume that there is no rationing within treatments.

High Emergency Lung Transplantation: dramatic decrease of waiting list death rate without relevant higher post-transplant mortality.

PubMed

Roux, Antoine; Beaumont-Azuar, Laurence; Hamid, Abdul Monem; De Miranda, Sandra; Grenet, Dominique; Briend, Guillaume; Bonnette, Pierre; Puyo, Philippe; Parquin, François; Devaquet, Jerome; Trebbia, Gregoire; Cuquemelle, Elise; Douvry, Benoit; Picard, Clément; Le Guen, Morgan; Chapelier, Alain; Stern, Marc; Sage, Edouard

2015-09-01

Many candidates for lung transplantation (LT) die on the waiting list, raising the question of graft availability and strategy for organ allocation. We report the experience of the new organ allocation program, "High Emergency Lung Transplantation" (HELT), since its implementation in our center in 2007. Retrospective analysis of 201 lung transplant patients, of whom 37 received HELT from 1st July 2007 to 31th May 2012. HELT candidates had a higher impairment grade on respiratory status and higher Lung Allocation Score (LAS). HELT patients had increased incidence of perioperative complications (e.g., perioperative bleeding) and extracorporeal circulatory assistance (75% vs. 36.6%, P = 0.0005). No significant difference was observed between HELT and non-HELT patients in mechanical ventilation duration (15.5 days vs. 11 days, P = 0.27), intensive care unit length of stay (15 days vs. 10 days, P = 0.22) or survival rate at 12 (81% vs. 80%), and 24 months post-LT (72.9% vs. 75.0%). Lastly, mortality on the waiting list was spectacularly reduced from 19% to 2% when compared to the non-HELT 2004-2007 group. Despite a more severe clinical status of patients on the waiting list, HELT provided similar results to conventional LT. These results were associated with a dramatic reduction in the mortality rate of patients on the waiting list. © 2015 Steunstichting ESOT.

National and regional asthma programmes in Europe.

PubMed

Selroos, Olof; Kupczyk, Maciej; Kuna, Piotr; Łacwik, Piotr; Bousquet, Jean; Brennan, David; Palkonen, Susanna; Contreras, Javier; FitzGerald, Mark; Hedlin, Gunilla; Johnston, Sebastian L; Louis, Renaud; Metcalf, Leanne; Walker, Samantha; Moreno-Galdó, Antonio; Papadopoulos, Nikolaos G; Rosado-Pinto, José; Powell, Pippa; Haahtela, Tari

2015-09-01

This review presents seven national asthma programmes to support the European Asthma Research and Innovation Partnership in developing strategies to reduce asthma mortality and morbidity across Europe. From published data it appears that in order to influence asthma care, national/regional asthma programmes are more effective than conventional treatment guidelines. An asthma programme should start with the universal commitments of stakeholders at all levels and the programme has to be endorsed by political and governmental bodies. When the national problems have been identified, the goals of the programme have to be clearly defined with measures to evaluate progress. An action plan has to be developed, including defined re-allocation of patients and existing resources, if necessary, between primary care and specialised healthcare units or hospital centres. Patients should be involved in guided self-management education and structured follow-up in relation to disease severity. The three evaluated programmes show that, thanks to rigorous efforts, it is possible to improve patients' quality of life and reduce hospitalisation, asthma mortality, sick leave and disability pensions. The direct and indirect costs, both for the individual patient and for society, can be significantly reduced. The results can form the basis for development of further programme activities in Europe. Copyright ©ERS 2015.

A cost minimization analysis of early correction of anterior crossbite-a randomized controlled trial.

PubMed

Wiedel, Anna-Paulina; Norlund, Anders; Petrén, Sofia; Bondemark, Lars

2016-04-01

Economic evaluations provide an important basis for allocation of resources and health services planning. The aim of this study was to evaluate and compare the costs of correcting anterior crossbite with functional shift, using fixed or removable appliances (FA or RA) and to relate the costs to the effects, using cost-minimization analysis. Sixty-two patients with anterior crossbite and functional shift were randomized in blocks of 10. Thirty-one patients were randomized to be treated with brackets and arch wire (FA) and 31 with an acrylic plate (RA). Duration of treatment and number and estimated length of appointments and cancellations were registered. Direct costs (premises, staff salaries, material, and laboratory costs) and indirect costs (the accompanying parents' loss of income while absent from work) were calculated and evaluated with reference to successful outcome alone, to successful and unsuccessful outcomes and to re-treatment when required. Societal costs were defined as the sum of direct and indirect costs. Treatment with FA or RA. There were no significant differences between FA and RA with respect to direct costs for treatment time, but both indirect costs and direct costs for material were significantly lower for FA. The total societal costs were lower for FA than for RA. Costs depend on local factors and should not be directly extrapolated to other locations. The analysis disclosed significant economic benefits for FA over RA. Even when only successful outcomes were assessed, treatment with RA was more expensive. This trial was not registered. The protocol was not published before trial commencement. © The Author 2015. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.

A cost minimization analysis of early correction of anterior crossbite—a randomized controlled trial

PubMed Central

Norlund, Anders; Petrén, Sofia; Bondemark, Lars

2016-01-01

Summary Objective: Economic evaluations provide an important basis for allocation of resources and health services planning. The aim of this study was to evaluate and compare the costs of correcting anterior crossbite with functional shift, using fixed or removable appliances (FA or RA) and to relate the costs to the effects, using cost-minimization analysis. Design, Setting, and Participants: Sixty-two patients with anterior crossbite and functional shift were randomized in blocks of 10. Thirty-one patients were randomized to be treated with brackets and arch wire (FA) and 31 with an acrylic plate (RA). Duration of treatment and number and estimated length of appointments and cancellations were registered. Direct costs (premises, staff salaries, material, and laboratory costs) and indirect costs (the accompanying parents’ loss of income while absent from work) were calculated and evaluated with reference to successful outcome alone, to successful and unsuccessful outcomes and to re-treatment when required. Societal costs were defined as the sum of direct and indirect costs. Interventions: Treatment with FA or RA. Results: There were no significant differences between FA and RA with respect to direct costs for treatment time, but both indirect costs and direct costs for material were significantly lower for FA. The total societal costs were lower for FA than for RA. Limitations: Costs depend on local factors and should not be directly extrapolated to other locations. Conclusion: The analysis disclosed significant economic benefits for FA over RA. Even when only successful outcomes were assessed, treatment with RA was more expensive. Trial registration: This trial was not registered. Protocol: The protocol was not published before trial commencement. PMID:25940585

PACS 2000: quality control using the task allocation chart

NASA Astrophysics Data System (ADS)

Norton, Gary S.; Romlein, John R.; Lyche, David K.; Richardson, Ronald R., Jr.

2000-05-01

Medical imaging's technological evolution in the next century will continue to include Picture Archive and Communication Systems (PACS) and teleradiology. It is difficult to predict radiology's future in the new millennium with both computed radiography and direct digital capture competing as the primary image acquisition methods for routine radiography. Changes in Computed Axial Tomography (CT) and Magnetic Resonance Imaging (MRI) continue to amaze the healthcare community. No matter how the acquisition, display, and archive functions change, Quality Control (QC) of the radiographic imaging chain will remain an important step in the imaging process. The Task Allocation Chart (TAC) is a tool that can be used in a medical facility's QC process to indicate the testing responsibilities of the image stakeholders and the medical informatics department. The TAC shows a grid of equipment to be serviced, tasks to be performed, and the organization assigned to perform each task. Additionally, skills, tasks, time, and references for each task can be provided. QC of the PACS must be stressed as a primary element of a PACS' implementation. The TAC can be used to clarify responsibilities during warranty and paid maintenance periods. Establishing a TAC a part of a PACS implementation has a positive affect on patient care and clinical acceptance.

Value Driven Outcomes (VDO): a pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes

PubMed Central

Kawamoto, Kensaku; Martin, Cary J; Williams, Kip; Tu, Ming-Chieh; Park, Charlton G; Hunter, Cheri; Staes, Catherine J; Bray, Bruce E; Deshmukh, Vikrant G; Holbrook, Reid A; Morris, Scott J; Fedderson, Matthew B; Sletta, Amy; Turnbull, James; Mulvihill, Sean J; Crabtree, Gordon L; Entwistle, David E; McKenna, Quinn L; Strong, Michael B; Pendleton, Robert C; Lee, Vivian S

2015-01-01

Objective To develop expeditiously a pragmatic, modular, and extensible software framework for understanding and improving healthcare value (costs relative to outcomes). Materials and methods In 2012, a multidisciplinary team was assembled by the leadership of the University of Utah Health Sciences Center and charged with rapidly developing a pragmatic and actionable analytics framework for understanding and enhancing healthcare value. Based on an analysis of relevant prior work, a value analytics framework known as Value Driven Outcomes (VDO) was developed using an agile methodology. Evaluation consisted of measurement against project objectives, including implementation timeliness, system performance, completeness, accuracy, extensibility, adoption, satisfaction, and the ability to support value improvement. Results A modular, extensible framework was developed to allocate clinical care costs to individual patient encounters. For example, labor costs in a hospital unit are allocated to patients based on the hours they spent in the unit; actual medication acquisition costs are allocated to patients based on utilization; and radiology costs are allocated based on the minutes required for study performance. Relevant process and outcome measures are also available. A visualization layer facilitates the identification of value improvement opportunities, such as high-volume, high-cost case types with high variability in costs across providers. Initial implementation was completed within 6 months, and all project objectives were fulfilled. The framework has been improved iteratively and is now a foundational tool for delivering high-value care. Conclusions The framework described can be expeditiously implemented to provide a pragmatic, modular, and extensible approach to understanding and improving healthcare value. PMID:25324556

Molecular genetics research in ADHD: ethical considerations concerning patients' benefit and resource allocation.

PubMed

Rothenberger, Lillian Geza

2012-12-01

Immense resource allocations have led to great data output in genetic research. Concerning ADHD resources spent on genetic research are less than those spent on clinical research. But there are successful efforts made to increase support for molecular genetics research in ADHD. Concerning genetics no evidence based conclusive results have significant impact on prevention, diagnosis or treatment yet. With regard to ethical aspects like the patients' benefit and limited resources the question arises if it is indicated to think about a new balance of resource allocation between molecular genetics and non-genetics research in ADHD. An ethical reflection was performed focusing on recent genetic studies and reviews based on a selective literature search. There are plausible reasons why genetic research results in ADHD are somehow disappointing for clinical practice so far. Researchers try to overcome these gaps systematically, without knowing what the potential future benefits for the patients might be. Non-genetic diagnostic/therapeutic research may lead to clinically relevant findings within a shorter period of time. On the other hand, non-genetic research in ADHD may be nurtured by genetic approaches. But, with the latter there exist significant risks of harm like stigmatization and concerns regarding data protection. Isolated speeding up resources of genetic research in ADHD seems questionable from an ethical point of view. There is a need to find a new balance of resource allocation between genetic and non-genetic research in ADHD, probably by integrating genetics more systematically into clinical research. A transdisciplinary debate is recommended. Copyright © 2012 Wiley Periodicals, Inc.

19 CFR 10.197 - Direct costs of processing operations performed in a beneficiary country or countries.

Code of Federal Regulations, 2013 CFR

2013-04-01

... specific merchandise, including fringe benefits, on-the-job training, and the cost of engineering..., engineering, and blueprint costs insofar as they are allocable to the specific merchandise and; (4) Costs of... 19 Customs Duties 1 2013-04-01 2013-04-01 false Direct costs of processing operations performed in...

19 CFR 10.197 - Direct costs of processing operations performed in a beneficiary country or countries.

Code of Federal Regulations, 2014 CFR

2014-04-01

... specific merchandise, including fringe benefits, on-the-job training, and the cost of engineering..., engineering, and blueprint costs insofar as they are allocable to the specific merchandise and; (4) Costs of... 19 Customs Duties 1 2014-04-01 2014-04-01 false Direct costs of processing operations performed in...

11 CFR 106.6 - Allocation of expenses between federal and non-federal activities by separate segregated funds...

Code of Federal Regulations, 2010 CFR

2010-01-01

... District of Columbia ordered that paragraphs (c) and (f) of § 106.6 are vacated. See Final Order, EMILY's... instructions direct the separate segregated fund's or nonconnected committee's employee or volunteer to refer... instructions direct the separate segregated fund's or nonconnected committee's employee or volunteer to refer...

11 CFR 106.6 - Allocation of expenses between federal and non-federal activities by separate segregated funds...

Code of Federal Regulations, 2011 CFR

2011-01-01

... Final Order, EMILY's List v. FEC, No. 05-0049 (D.D.C. Nov. 30, 2009). [55 FR 26071, June 26, 1990, as... instructions direct the separate segregated fund's or nonconnected committee's employee or volunteer to refer... instructions direct the separate segregated fund's or nonconnected committee's employee or volunteer to refer...

26 CFR 1.263(a)-2T - Amounts paid to acquire or produce tangible property (temporary).

Code of Federal Regulations, 2012 CFR

2012-04-01

..., see section 263A requiring taxpayers to capitalize the direct and indirect costs of producing property... direct and allocable indirect costs (including otherwise deductible costs) to be capitalized to property... company to move storage tanks from Y's plant to X's plant. Under paragraph (f)(2)(ii)(A) of this section...

26 CFR 1.263(a)-2T - Amounts paid to acquire or produce tangible property (temporary).

Code of Federal Regulations, 2013 CFR

2013-04-01

..., see section 263A requiring taxpayers to capitalize the direct and indirect costs of producing property... direct and allocable indirect costs (including otherwise deductible costs) to be capitalized to property... company to move storage tanks from Y's plant to X's plant. Under paragraph (f)(2)(ii)(A) of this section...

75 FR 8327 - Golden Pass Pipeline LLC; Notice of Request Under Blanket Authorization

Federal Register 2010, 2011, 2012, 2013, 2014

2010-02-24

... for its actual direct and indirect costs, including direct and allocated overhead, incurred in... Rules (18 CFR 385.214) a motion to intervene or notice of intervention and, pursuant to section 157.205... comments, protests, and interventions via the internet in lieu of paper. See 18 CFR 385.2001(a)(1)(iii) and...

Deep brain stimulation and ethics: perspectives from a multisite qualitative study of Canadian neurosurgical centers.

PubMed

Bell, Emily; Maxwell, Bruce; McAndrews, Mary Pat; Sadikot, Abbas; Racine, Eric

2011-12-01

Deep brain stimulation (DBS) is an approved neurosurgical intervention for motor disorders such as Parkinson disease. The emergence of psychiatric uses for DBS combined with the fact that it is an invasive and expensive procedure creates important ethical and social challenges in the delivery of care that need further examination. We endeavored to examine health care provider perspectives on ethical and social challenges encountered in DBS. Health care providers working in Canadian DBS surgery programs participated in a semistructured interview to identify and characterize ethical and social challenges of DBS. A content analysis of the interviews was conducted. Several key ethical issues, such as patient screening and resource allocation, were identified by members of neurosurgical teams. Providers described challenges in selecting patients for DBS on the basis of unclear evidence-based guidance regarding behavioral issues or cognitive criteria. Varied contexts of resource allocation, including some very challenging schemas, were also reported. In addition, the management of patients in the community was highlighted as a source of ethical and clinical complexity, given the need for coordinated long-term care. This study provides insights into the complexity of ethical challenges that providers face in the use of DBS across different neurosurgical centers. We propose actions for health care providers for the long-term care and postoperative monitoring of patients with DBS. More data on patient perspectives in DBS would complement the understanding of key challenges, as well as contribute to best practices, for patient selection, management, and resource allocation. Copyright © 2011 Elsevier Inc. All rights reserved.

Assignment of Dental School Patients Using Periodontal Treatment Need Indices.

ERIC Educational Resources Information Center

Mubarak, Ala

1990-01-01

The validity of the Periodontal Treatment Need System and the Community Periodontal Index for Treatment Need as screening tests for allocation of patients to dental students was assessed and compared. Sixty-one patients reporting to the Department of Periodontology at the University of Oslo were studied. (MLW)

Clinical trial allocation in multinational pharmaceutical companies - a qualitative study on influential factors.

PubMed

Dombernowsky, Tilde; Haedersdal, Merete; Lassen, Ulrik; Thomsen, Simon F

2017-06-01

Clinical trial allocation in multinational pharmaceutical companies includes country selection and site selection. With emphasis on site selection, the overall aim of this study was to examine which factors pharmaceutical companies value most when allocating clinical trials. The specific aims were (1) to identify key decision makers during country and site selection, respectively, (2) to evaluate by which parameters subsidiaries are primarily assessed by headquarters with regard to conducting clinical trials, and (3) to evaluate which site-related qualities companies value most when selecting trial sites. Eleven semistructured interviews were conducted among employees engaged in trial allocation at 11 pharmaceutical companies. The interviews were analyzed by deductive content analysis, which included coding of data to a categorization matrix containing categories of site-related qualities. The results suggest that headquarters and regional departments are key decision makers during country selection, whereas subsidiaries decide on site selection. Study participants argued that headquarters primarily value timely patient recruitment and quality of data when assessing subsidiaries. The site-related qualities most commonly emphasized during interviews were study population availability, timely patient recruitment, resources at the site, and site personnel's interest and commitment. Costs of running the trials were described as less important. Site personnel experience in conducting trials was described as valuable but not imperative. In conclusion, multinational pharmaceutical companies consider recruitment-related factors as crucial when allocating clinical trials. Quality of data and site personnel's interest and commitment are also essential, whereas costs seem less important. While valued, site personnel experience in conducting clinical trials is not imperative.

Economic evaluation of uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: results from the randomized EMMY trial.

PubMed

Volkers, Nicole A; Hehenkamp, Wouter J K; Smit, Patrick; Ankum, Willem M; Reekers, Jim A; Birnie, Erwin

2008-07-01

To investigate whether uterine artery embolization (UAE) is a cost-effective alternative to hysterectomy for patients with symptomatic uterine fibroids, the authors performed an economic evaluation alongside the multicenter randomized EMMY (EMbolization versus hysterectoMY) trial. Between February 2002 and February 2004, 177 patients were randomized to undergo UAE (n = 88) or hysterectomy (n = 89) and followed up until 24 months after initial treatment allocation. Conditional on the equivalence of clinical outcome, a cost minimization analysis was performed according to the intention to treat principle. Costs included health care costs inside and outside the hospital as well as costs related to absence from work (societal perspective). Cumulative standardized costs were estimated as volumes multiplied with prices. The nonparametric bootstrap method was used to quantify differences in mean (95% confidence interval [CI]) costs between the strategies. In total, 81 patients underwent UAE and 75 underwent hysterectomy. In the UAE group, 19 patients (23%) underwent secondary hysterectomies. The mean total costs per patient in the UAE group were significantly lower than those in the hysterectomy group ($11,626 vs $18,563; mean difference, -$6,936 [-37%], 95% CI: -$9,548, $4,281). The direct medical in-hospital costs were significantly lower in the UAE group: $6,688 vs $8,313 (mean difference, -$1,624 [-20%], 95% CI: -$2,605, -$586). Direct medical out-of-hospital and direct nonmedical costs were low in both groups (mean cost difference, $156 in favor of hysterectomy). The costs related to absence from work differed significantly between the treatment strategies in favor of UAE (mean difference, -$5,453; 95% CI: -$7,718, -$3,107). The costs of absence from work accounted for 79% of the difference in total costs. The 24-month cumulative cost of UAE is lower than that of hysterectomy. From a societal economic perspective, UAE is the superior treatment strategy in women with symptomatic uterine fibroids.

Ninety-day mortality and major complications are not affected by use of lung allocation score.

PubMed

McCue, Jonathan D; Mooney, Josh; Quail, Jacob; Arrington, Amanda; Herrington, Cynthia; Dahlberg, Peter S

2008-02-01

In May 2005 the Organ Procurement Transplant Network (OPTN) and United Network for Organ Sharing (UNOS) implemented the donor lung allocation score (LAS) system to prioritize organ allocation among prospective transplant recipients. The purpose of our study was to determine the impact of LAS implementation on 90-day survival, early complications and incidence of severe primary graft dysfunction (PGD) after the transplant procedure. Early outcomes among 78 patients receiving transplants after the initiation of the scoring system were compared with those of the 78 previous patients. Survival rates at 90 days and 1 year were the primary end-points of the study. Arterial blood-gas measurements were collected for all patients at the time of ICU arrival and at 12, 24 and 48 hours after surgery to determine the distribution of International Society of Heart and Lung Transplant (ISHLT) PGD grade. Major complications within 30 days post-transplant were recorded. We found a small but significant 1-year survival advantage among post-LAS implementation patients, which was largely due to decreased early mortality in comparison to the control cohort. The incidence of ISHLT Grade 3 PGD measured within the first 24 hours after transplant did not differ between groups, nor was there an increase in the rate of major post-operative complications. Implementation of the LAS system has not been associated with an increase in early mortality, immediate PGD or major complications.

HPS2-THRIVE randomized placebo-controlled trial in 25 673 high-risk patients of ER niacin/laropiprant: trial design, pre-specified muscle and liver outcomes, and reasons for stopping study treatment.

PubMed

2013-05-01

Niacin has potentially favourable effects on lipids, but its effect on cardiovascular outcomes is uncertain. HPS2-THRIVE is a large randomized trial assessing the effects of extended release (ER) niacin in patients at high risk of vascular events. Prior to randomization, 42 424 patients with occlusive arterial disease were given simvastatin 40 mg plus, if required, ezetimibe 10 mg daily to standardize their low-density lipoprotein (LDL)-lowering therapy. The ability to remain compliant with ER niacin 2 g plus laropiprant 40 mg daily (ERN/LRPT) for ~1 month was then assessed in 38 369 patients and about one-third were excluded (mainly due to niacin side effects). A total of 25 673 patients were randomized between ERN/LRPT daily vs. placebo and were followed for a median of 3.9 years. By the end of the study, 25% of participants allocated ERN/LRPT vs. 17% allocated placebo had stopped their study treatment. The most common medical reasons for stopping ERN/LRPT were related to skin, gastrointestinal, diabetes, and musculoskeletal side effects. When added to statin-based LDL-lowering therapy, allocation to ERN/LRPT increased the risk of definite myopathy [75 (0.16%/year) vs. 17 (0.04%/year): risk ratio 4.4; 95% CI 2.6-7.5; P < 0.0001]; 7 vs. 5 were rhabdomyolysis. Any myopathy (definite or incipient) was more common among participants in China [138 (0.66%/year) vs. 27 (0.13%/year)] than among those in Europe [17 (0.07%/year) vs. 11 (0.04%/year)]. Consecutive alanine transaminase >3× upper limit of normal, in the absence of muscle damage, was seen in 48 (0.10%/year) ERN/LRPT vs. 30 (0.06%/year) placebo allocated participants. The risk of myopathy was increased by adding ERN/LRPT to simvastatin 40 mg daily (with or without ezetimibe), particularly in Chinese patients whose myopathy rates on simvastatin were higher. Despite the side effects of ERN/LRPT, among individuals who were able to tolerate it for ~1 month, three-quarters continued to take it for ~4 years.

Product line development: a strategy for clinical success in academic centers.

PubMed

Turnipseed, William D; Lund, Dennis P; Sollenberger, Donna

2007-10-01

Academic medical centers, which have traditionally been relatively inefficient, have increasing difficulty in meeting the missions of patient care, teaching, and research in a progressively competitive medical marketplace. One strategy for improved efficiency in patient care while keeping quality high is utilization of a product line matrix. This study addresses the outcome of utilizing a product line strategy consisting of 3 service lines during the past 5 years at the University of Wisconsin Hospital and Clinics (UWHC). Service lines in heart and vascular surgery, oncology, and pediatrics have been organized since 2001, and report directly to hospital leadership as a product line. Service line leadership consists of a combination of medical leaders plus representatives of hospital administration, and service lines are allowed direct access to resources for program development, marketing, and resource allocation. Measurements of patient numbers, market share, length of stay, net margin, and patient satisfaction have been gathered and compared with the preproduct line era. In the 3 service lines, UWHC has seen variable but steady growth in patient numbers, enhanced market share, positive net margins, and improved patient satisfaction during the period of measurement. During this same period, the insurance milieu has resulted in consistent downward pressure on reimbursement, which has been offset by improved patient care efficiency as measured by length of stay, enhanced preferred provider status, and gains in market share. Scorecard measures of quality are also being developed and show enhanced teaching and research opportunities for students and trainees as well as improved Press Ganey patient satisfaction scores. At UWHC, the development of a product line matrix consisting of 3 service lines has resulted in more patient care efficiency, enhanced patient satisfaction, improved margin for the hospital, and enlargement of teaching and research opportunities. The key to successful implementation of the product line concept is a close working relationship between the hospital administration and service line medical leadership.

Allocating a scarce mental health treatment to the underweight and overweight.

PubMed

Gajre, Meera; McClelland, Alastair; Furnham, Adrian

2017-09-05

This is one of a number of programmatic studies on the allocation of scarce medical resources. This study investigated whether certain characteristics about patients influence the priority they are assigned for a scarce mental health treatment. Similar studies for physical treatments have found that young, poor, and mentally healthy patients are given the highest priority. Each participant completed one questionnaire where they ranked a list of eight hypothetical patients in order of priority for treatment for anorexia or obesity. The patients varied on three dimensions: age, social class and mental health history. This involved a ranking of prioritisation for treatment. Participants gave the young patients, from a low social class background, who had a mental health history the highest priority for treatment. This is in contrast to previous studies indicating that the mentally unwell are discriminated against. Participants seemed to be using social class as a proxy measure of ability to pay which they weighted very highly.

Effect of transcranial direct-current stimulation combined with treadmill training on balance and functional performance in children with cerebral palsy: a double-blind randomized controlled trial.

PubMed

Duarte, Natália de Almeida Carvalho; Grecco, Luanda André Collange; Galli, Manuela; Fregni, Felipe; Oliveira, Cláudia Santos

2014-01-01

Cerebral palsy refers to permanent, mutable motor development disorders stemming from a primary brain lesion, causing secondary musculoskeletal problems and limitations in activities of daily living. The aim of the present study was to determine the effects of gait training combined with transcranial direct-current stimulation over the primary motor cortex on balance and functional performance in children with cerebral palsy. A double-blind randomized controlled study was carried out with 24 children aged five to 12 years with cerebral palsy randomly allocated to two intervention groups (blocks of six and stratified based on GMFCS level (levels I-II or level III).The experimental group (12 children) was submitted to treadmill training and anodal stimulation of the primary motor cortex. The control group (12 children) was submitted to treadmill training and placebo transcranial direct-current stimulation. Training was performed in five weekly sessions for 2 weeks. Evaluations consisted of stabilometric analysis as well as the administration of the Pediatric Balance Scale and Pediatric Evaluation of Disability Inventory one week before the intervention, one week after the completion of the intervention and one month after the completion of the intervention. All patients and two examiners were blinded to the allocation of the children to the different groups. The experimental group exhibited better results in comparison to the control group with regard to anteroposterior sway (eyes open and closed; p<0.05), mediolateral sway (eyes closed; p<0.05) and the Pediatric Balance Scale both one week and one month after the completion of the protocol. Gait training on a treadmill combined with anodal stimulation of the primary motor cortex led to improvements in static balance and functional performance in children with cerebral palsy. Ensaiosclinicos.gov.br/RBR-9B5DH7.

Comparison of three problem-based learning conditions (real patients, digital and paper) with lecture-based learning in a dermatology course: a prospective randomized study from China.

PubMed

Li, Jie; Li, Qing Ling; Li, Ji; Chen, Ming Liang; Xie, Hong Fu; Li, Ya Ping; Chen, Xiang

2013-01-01

The precise effect and the quality of different cases used in dermatology problem-based learning (PBL) curricula are yet unclear. To prospectively compare the impact of real patients, digital, paper PBL (PPBL) and traditional lecture-based learning (LBL) on academic results and student perceptions. A total of 120 students were randomly allocated into either real-patients PBL (RPBL) group studied via real-patient cases, digital PBL (DPBL) group studied via digital-form cases, PPBL group studied via paper-form cases, or conventional group who received didactic lectures. Academic results were assessed through review of written examination, objective structured clinical examination and student performance scores. A five-point Likert scale questionnaire was used to evaluate student perceptions. Compared to those receiving lectures only, all PBL participants had better results for written examination, clinical examination and overall performance. Students in RPBL group exhibited better overall performance than those in the other two PBL groups. Real-patient cases were more effective in helping develop students' self-directed learning skills, improving their confidence in future patient encounters and encouraging them to learn more about the discussed condition, compared to digital and paper cases. Both real patient and digital triggers are helpful in improving students' clinical problem-handling skills. However, real patients provide greater benefits to students.

Plasticity in Human Pitch Perception Induced by Tonotopically Mismatched Electro-Acoustic Stimulation

PubMed Central

Reiss, Lina A.J.; Turner, Christopher W.; Karsten, Sue A.; Gantz, Bruce J.

2013-01-01

Under normal conditions, the acoustic pitch percept of a pure tone is determined mainly by the tonotopic place of the stimulation along the cochlea. Unlike acoustic stimulation, electric stimulation of a cochlear implant (CI) allows for the direct manipulation of the place of stimulation in human subjects. CI sound processors analyze the range of frequencies needed for speech perception and allocate portions of this range to the small number of electrodes distributed in the cochlea. Because the allocation is assigned independently of the original resonant frequency of the basilar membrane associated with the location of each electrode, CI users who have access to residual hearing in either or both ears often have tonotopic mismatches between the acoustic and electric stimulation. Here we demonstrate plasticity of place pitch representations of up to 3 octaves in Hybrid CI users after experience with combined electro-acoustic stimulation. The pitch percept evoked by single CI electrodes, measured relative to acoustic tones presented to the non-implanted ear, changed over time in directions that reduced the electro-acoustic pitch mismatch introduced by the CI programming. This trend was particularly apparent when the allocations of stimulus frequencies to electrodes were changed over time, with pitch changes even reversing direction in some subjects. These findings show that pitch plasticity can occur more rapidly and on a greater scale in the mature auditory system than previously thought possible. Overall, the results suggest that the adult auditory system can impose perceptual order on disordered arrays of inputs. PMID:24157931

From strategy to action: how top managers' support increases middle managers' commitment to innovation implementation in health care organizations.

PubMed

Birken, Sarah A; Lee, Shoou-Yih Daniel; Weiner, Bryan J; Chin, Marshall H; Chiu, Michael; Schaefer, Cynthia T

2015-01-01

Evidence suggests that top managers' support influences middle managers' commitment to innovation implementation. What remains unclear is how top managers' support influences middle managers' commitment. Results may be used to improve dismal rates of innovation implementation. We used a mixed-method sequential design. We surveyed (n = 120) and interviewed (n = 16) middle managers implementing an innovation intended to reduce health disparities in 120 U.S. health centers to assess whether top managers' support directly influences middle managers' commitment; by allocating implementation policies and practices; or by moderating the influence of implementation policies and practices on middle managers' commitment. For quantitative analyses, multivariable regression assessed direct and moderated effects; a mediation model assessed mediating effects. We used template analysis to assess qualitative data. We found support for each hypothesized relationship: Results suggest that top managers increase middle managers' commitment by directly conveying to middle managers that innovation implementation is an organizational priority (β = 0.37, p = .09); allocating implementation policies and practices including performance reviews, human resources, training, and funding (bootstrapped estimate for performance reviews = 0.09; 95% confidence interval [0.03, 0.17]); and encouraging middle managers to leverage performance reviews and human resources to achieve innovation implementation. Top managers can demonstrate their support directly by conveying to middle managers that an initiative is an organizational priority, allocating implementation policies and practices such as human resources and funding to facilitate innovation implementation, and convincing middle managers that innovation implementation is possible using available implementation policies and practices. Middle managers may maximize the influence of top managers' support on their commitment by communicating with top managers about what kind of support would be most effective in increasing their commitment to innovation implementation.

From Strategy to Action: How Top Managers’ Support Increases Middle Managers’ Commitment to Innovation Implementation in Healthcare Organizations

PubMed Central

Lee, Shoou-Yih Daniel; Weiner, Bryan J.; Chin, Marshall H.; Chiu, Michael; Schaefer, Cynthia T.

2014-01-01

Background Evidence suggests that top managers’ support influences middle managers’ commitment to innovation implementation. What remains unclear is how top managers’ support influences middle managers’ commitment. Results may be used to improve dismal rates of innovation implementation. Methods We used a mixed-method sequential design. We surveyed (n = 120) and interviewed (n = 16) middle managers implementing an innovation intended to reduce health disparities in 120 US health centers to assess whether top managers’ support influences middle managers’ commitment directly, by allocating implementation policies and practices, or by moderating the influence of implementation policies and practices on middle managers’ commitment. For quantitative analyses, multivariable regression assessed direct and moderated effects; a mediation model assessed mediating effects. We used template analysis to assess qualitative data. Findings We found support for each hypothesized relationship: Results suggest that top managers increase middle managers’ commitment by directly conveying to middle managers that innovation implementation is an organizational priority (β = 0.37, p = 0.09); allocating implementation policies and practices including performance reviews, human resources, training, and funding (bootstrapped estimate for performance reviews = 0.09; 95 percent CI: 0.03, 0.17); and encouraging middle managers to leverage performance reviews and human resources to achieve innovation implementation. Practice Implications Top managers can demonstrate their support by directly conveying to middle managers that an initiative is an organizational priority, allocating implementation policies and practices such as human resources and funding to facilitate innovation implementation, and convincing middle managers that innovation implementation is possible using available implementation policies and practices. Middle managers may maximize the influence of top managers’ support on their commitment by communicating with top managers about what kind of support would be most effective in increasing their commitment to innovation implementation. PMID:24566252

Optimizing 4DCBCT projection allocation to respiratory bins.

PubMed

O'Brien, Ricky T; Kipritidis, John; Shieh, Chun-Chien; Keall, Paul J

2014-10-07

4D cone beam computed tomography (4DCBCT) is an emerging image guidance strategy used in radiotherapy where projections acquired during a scan are sorted into respiratory bins based on the respiratory phase or displacement. 4DCBCT reduces the motion blur caused by respiratory motion but increases streaking artefacts due to projection under-sampling as a result of the irregular nature of patient breathing and the binning algorithms used. For displacement binning the streak artefacts are so severe that displacement binning is rarely used clinically. The purpose of this study is to investigate if sharing projections between respiratory bins and adjusting the location of respiratory bins in an optimal manner can reduce or eliminate streak artefacts in 4DCBCT images. We introduce a mathematical optimization framework and a heuristic solution method, which we will call the optimized projection allocation algorithm, to determine where to position the respiratory bins and which projections to source from neighbouring respiratory bins. Five 4DCBCT datasets from three patients were used to reconstruct 4DCBCT images. Projections were sorted into respiratory bins using equispaced, equal density and optimized projection allocation. The standard deviation of the angular separation between projections was used to assess streaking and the consistency of the segmented volume of a fiducial gold marker was used to assess motion blur. The standard deviation of the angular separation between projections using displacement binning and optimized projection allocation was 30%-50% smaller than conventional phase based binning and 59%-76% smaller than conventional displacement binning indicating more uniformly spaced projections and fewer streaking artefacts. The standard deviation in the marker volume was 20%-90% smaller when using optimized projection allocation than using conventional phase based binning suggesting more uniform marker segmentation and less motion blur. Images reconstructed using displacement binning and the optimized projection allocation algorithm were clearer, contained visibly fewer streak artefacts and produced more consistent marker segmentation than those reconstructed with either equispaced or equal-density binning. The optimized projection allocation algorithm significantly improves image quality in 4DCBCT images and provides, for the first time, a method to consistently generate high quality displacement binned 4DCBCT images in clinical applications.

Health policy in a new key: setting democratic priorities.

PubMed

Jennings, B

1993-01-01

Health policy in the United States is entering an era in which explicitly value-based allocation decisions require direct attention. Policies concerning access to care, financing, and utilization management will necessarily have redistributive effects. For these policies to command social legitimacy and political support, some consensus will have to emerge around the values and ideals justifying these policies. This article addresses the problems of conceptual clarification and democratic process raised by the prospect of an explicitly value-based allocation policy. It offers a conceptual matrix distinguishing the scope of the issue of allocation in health care. Drawing on the activities of community health decisions projects in several states, it also offers suggestions about building a participatory and educational process at the grassroots level that might lead to a democratic consensus suitable for guiding policy choice.

Costs of task allocation with local feedback: Effects of colony size and extra workers in social insects and other multi-agent systems.

PubMed

Radeva, Tsvetomira; Dornhaus, Anna; Lynch, Nancy; Nagpal, Radhika; Su, Hsin-Hao

2017-12-01

Adaptive collective systems are common in biology and beyond. Typically, such systems require a task allocation algorithm: a mechanism or rule-set by which individuals select particular roles. Here we study the performance of such task allocation mechanisms measured in terms of the time for individuals to allocate to tasks. We ask: (1) Is task allocation fundamentally difficult, and thus costly? (2) Does the performance of task allocation mechanisms depend on the number of individuals? And (3) what other parameters may affect their efficiency? We use techniques from distributed computing theory to develop a model of a social insect colony, where workers have to be allocated to a set of tasks; however, our model is generalizable to other systems. We show, first, that the ability of workers to quickly assess demand for work in tasks they are not currently engaged in crucially affects whether task allocation is quickly achieved or not. This indicates that in social insect tasks such as thermoregulation, where temperature may provide a global and near instantaneous stimulus to measure the need for cooling, for example, it should be easy to match the number of workers to the need for work. In other tasks, such as nest repair, it may be impossible for workers not directly at the work site to know that this task needs more workers. We argue that this affects whether task allocation mechanisms are under strong selection. Second, we show that colony size does not affect task allocation performance under our assumptions. This implies that when effects of colony size are found, they are not inherent in the process of task allocation itself, but due to processes not modeled here, such as higher variation in task demand for smaller colonies, benefits of specialized workers, or constant overhead costs. Third, we show that the ratio of the number of available workers to the workload crucially affects performance. Thus, workers in excess of those needed to complete all tasks improve task allocation performance. This provides a potential explanation for the phenomenon that social insect colonies commonly contain inactive workers: these may be a 'surplus' set of workers that improves colony function by speeding up optimal allocation of workers to tasks. Overall our study shows how limitations at the individual level can affect group level outcomes, and suggests new hypotheses that can be explored empirically.

Costs of task allocation with local feedback: Effects of colony size and extra workers in social insects and other multi-agent systems

PubMed Central

Dornhaus, Anna; Su, Hsin-Hao

2017-01-01

Adaptive collective systems are common in biology and beyond. Typically, such systems require a task allocation algorithm: a mechanism or rule-set by which individuals select particular roles. Here we study the performance of such task allocation mechanisms measured in terms of the time for individuals to allocate to tasks. We ask: (1) Is task allocation fundamentally difficult, and thus costly? (2) Does the performance of task allocation mechanisms depend on the number of individuals? And (3) what other parameters may affect their efficiency? We use techniques from distributed computing theory to develop a model of a social insect colony, where workers have to be allocated to a set of tasks; however, our model is generalizable to other systems. We show, first, that the ability of workers to quickly assess demand for work in tasks they are not currently engaged in crucially affects whether task allocation is quickly achieved or not. This indicates that in social insect tasks such as thermoregulation, where temperature may provide a global and near instantaneous stimulus to measure the need for cooling, for example, it should be easy to match the number of workers to the need for work. In other tasks, such as nest repair, it may be impossible for workers not directly at the work site to know that this task needs more workers. We argue that this affects whether task allocation mechanisms are under strong selection. Second, we show that colony size does not affect task allocation performance under our assumptions. This implies that when effects of colony size are found, they are not inherent in the process of task allocation itself, but due to processes not modeled here, such as higher variation in task demand for smaller colonies, benefits of specialized workers, or constant overhead costs. Third, we show that the ratio of the number of available workers to the workload crucially affects performance. Thus, workers in excess of those needed to complete all tasks improve task allocation performance. This provides a potential explanation for the phenomenon that social insect colonies commonly contain inactive workers: these may be a ‘surplus’ set of workers that improves colony function by speeding up optimal allocation of workers to tasks. Overall our study shows how limitations at the individual level can affect group level outcomes, and suggests new hypotheses that can be explored empirically. PMID:29240763

Acoustic detail guides attention allocation in a selective listening task.

PubMed

Wöstmann, Malte; Schröger, Erich; Obleser, Jonas

2015-05-01

The flexible allocation of attention enables us to perceive and behave successfully despite irrelevant distractors. How do acoustic challenges influence this allocation of attention, and to what extent is this ability preserved in normally aging listeners? Younger and healthy older participants performed a masked auditory number comparison while EEG was recorded. To vary selective attention demands, we manipulated perceptual separability of spoken digits from a masking talker by varying acoustic detail (temporal fine structure). Listening conditions were adjusted individually to equalize stimulus audibility as well as the overall level of performance across participants. Accuracy increased, and response times decreased with more acoustic detail. The decrease in response times with more acoustic detail was stronger in the group of older participants. The onset of the distracting speech masker triggered a prominent contingent negative variation (CNV) in the EEG. Notably, CNV magnitude decreased parametrically with increasing acoustic detail in both age groups. Within identical levels of acoustic detail, larger CNV magnitude was associated with improved accuracy. Across age groups, neuropsychological markers further linked early CNV magnitude directly to individual attentional capacity. Results demonstrate for the first time that, in a demanding listening task, instantaneous acoustic conditions guide the allocation of attention. Second, such basic neural mechanisms of preparatory attention allocation seem preserved in healthy aging, despite impending sensory decline.

Cost of equity in homeland security resource allocation in the face of a strategic attacker.

PubMed

Shan, Xiaojun; Zhuang, Jun

2013-06-01

Hundreds of billions of dollars have been spent in homeland security since September 11, 2001. Many mathematical models have been developed to study strategic interactions between governments (defenders) and terrorists (attackers). However, few studies have considered the tradeoff between equity and efficiency in homeland security resource allocation. In this article, we fill this gap by developing a novel model in which a government allocates defensive resources among multiple potential targets, while reserving a portion of defensive resources (represented by the equity coefficient) for equal distribution (according to geographical areas, population, density, etc.). Such a way to model equity is one of many alternatives, but was directly inspired by homeland security resource allocation practice. The government is faced with a strategic terrorist (adaptive adversary) whose attack probabilities are endogenously determined in the model. We study the effect of the equity coefficient on the optimal defensive resource allocations and the corresponding expected loss. We find that the cost of equity (in terms of increased expected loss) increases convexly in the equity coefficient. Furthermore, such cost is lower when: (a) government uses per-valuation equity; (b) the cost-effectiveness coefficient of defense increases; and (c) the total defense budget increases. Our model, results, and insights could be used to assist policy making. © 2012 Society for Risk Analysis.

Evolutionary consequence of a change in life cycle complexity: A link between precocious development and evolution toward female-biased sex allocation in a hermaphroditic parasite.

PubMed

Kasl, Emily L; McAllister, Chris T; Robison, Henry W; Connior, Matthew B; Font, William F; Criscione, Charles D

2015-12-01

The evolutionary consequences of changes in the complex life cycles of parasites are not limited to the traits that directly affect transmission. For instance, mating systems that are altered due to precocious sexual maturation in what is typically regarded as an intermediate host may impact opportunities for outcrossing. In turn, reproductive traits may evolve to optimize sex allocation. Here, we test the hypothesis that sex allocation evolved toward a more female-biased function in populations of the hermaphroditic digenean trematode Alloglossidium progeneticum that can precociously reproduce in their second hosts. In these precocious populations, parasites are forced to self-fertilize as they remain encysted in their second hosts. In contrast, parasites in obligate three-host populations have more opportunities to outcross in their third host. We found strong support that in populations with precocious development, allocation to male resources was greatly reduced. We also identified a potential phenotypically plastic response in a body size sex allocation relationship that may be driven by the competition for mates. These results emphasize how changes in life cycle patterns that alter mating systems can impact the evolution of reproductive traits in parasites. © 2015 The Author(s). Evolution © 2015 The Society for the Study of Evolution.

Optimal allocation of resources for suppressing epidemic spreading on networks

NASA Astrophysics Data System (ADS)

Chen, Hanshuang; Li, Guofeng; Zhang, Haifeng; Hou, Zhonghuai

2017-07-01

Efficient allocation of limited medical resources is crucial for controlling epidemic spreading on networks. Based on the susceptible-infected-susceptible model, we solve the optimization problem of how best to allocate the limited resources so as to minimize prevalence, providing that the curing rate of each node is positively correlated to its medical resource. By quenched mean-field theory and heterogeneous mean-field (HMF) theory, we prove that an epidemic outbreak will be suppressed to the greatest extent if the curing rate of each node is directly proportional to its degree, under which the effective infection rate λ has a maximal threshold λcopt=1 / , where is the average degree of the underlying network. For a weak infection region (λ ≳λcopt ), we combine perturbation theory with the Lagrange multiplier method (LMM) to derive the analytical expression of optimal allocation of the curing rates and the corresponding minimized prevalence. For a general infection region (λ >λcopt ), the high-dimensional optimization problem is converted into numerically solving low-dimensional nonlinear equations by the HMF theory and LMM. Counterintuitively, in the strong infection region the low-degree nodes should be allocated more medical resources than the high-degree nodes to minimize prevalence. Finally, we use simulated annealing to validate the theoretical results.

Contribution and efficiency of labor allocation analysis of income in household industry using raw material of agricultural commodity in South Sulawesi.

NASA Astrophysics Data System (ADS)

Tenriawaru, A. N.; Mahyuddin; Jamil, M. H.; Fudjaja, L.; Nurbaya, S.

2018-05-01

In South Sulawesi, various home industry businesses have grown. This industry is actually the basis of community livelihoods that need to be developed and nurtured by the government so family income get increased and the absorption of workers will improve the regional economy in general. The purpose of this study is to analyse the contribution of income, and efficiency of labour allocation in household industries made from raw agricultural commodities. The method of determining the respondents is done by direct appointment (purposive) on the industry players made from raw agricultural commodities. The type of research is quantitative descriptive and data are analysed using income analysis, cost analysis, income contribution analysis, Working Day (HOK) analysis and efficiency analysis of labour allocation. The results showed that the average income earned per year ranged from IDR. 16,866,867.- up to IDR. 125,271,500.-. There are 2 industries that have high contribution to family income such as banana chips industry and rice milling industry with value of 96.3% and 68.7% respectively. In the meantime, there are 5 industries with high average labour allocation efficiency of IDR. 218,135.- / HOK per day and above the efficiency standard of labour allocation based on UMR in South Sulawesi Province.

Cardiac transplantation: candidate identification, evaluation, and management.

PubMed

McCalmont, Vicki; Ohler, Linda

2008-01-01

For more than 40 years, cardiac transplantation has been a treatment option for patients with severe heart failure in whom optimal medical management is no longer effective. Critical care nurses are integrally involved in the care of patients with severe heart failure who may benefit from cardiac transplantation and are in a special position to recognize potential candidates for transplantation. Understanding patient selection criteria, the evaluation process, and how patients are managed while awaiting transplantation is key to the knowledge and skills required. It is also important to understand the allocation of donor hearts as part of this process. The waiting period for a suitable donor heart can be long and a patient's condition may deteriorate, requiring an increase in pharmacologic bridges with intravenous inotropic agents or mechanical bridges with circulatory assist devices. Critical care nurses become important as a personal bridge to transplantation through their education of patients and families and helping them cope with their fears during the waiting period. Critical care nurses who possess knowledge of patient selection and organ allocation processes along with the skills of caring for this complex patient population can contribute to better outcomes for patients with heart failure who may be candidates for cardiac transplantation.

What is a health emergency? The difference in definition and understanding between patients and health professionals.

PubMed

Morgans, Amee; Burgess, Stephen J

2011-08-01

Investigations into 'inappropriate' use of emergency health services are limited by the lack of definition of what constitutes a health emergency. Position papers from Australian and international sources emphasise the patient's right to access emergency healthcare, and the responsibility of emergency health care workers to provide treatment to all patients. However, discordance between the two perspectives remain, with literature labelling patient use of emergency health services as 'inappropriate'. To define a 'health emergency' and compare patient and health professionals perspectives. A sample of 600 emergency department (ED) patients were surveyed about a recent health experience and asked to rate their perceived urgency. This rating was compared to their triage score allocated at the hospital ED. No significant relationship was found between the two ratings of urgency (P=0.51). CONCLUSIONS; Differing definitions of a 'health emergency' may explain patient help-seeking behaviour when accessing emergency health resources including hospital ED and ambulance services. A new definition of health emergency that encapsulates the health professional and patient perspectives is proposed. An agreed definition of when emergency health resources should be used has the potential to improve emergency health services demand and patient flow issues, and optimise emergency health resource allocation.

Evaluation of an inflammation-based prognostic score in patients with inoperable gastro-oesophageal cancer.

PubMed

Crumley, A B C; McMillan, D C; McKernan, M; McDonald, A C; Stuart, R C

2006-03-13

There is increasing evidence that the presence of an ongoing systemic inflammatory response is associated with poor outcome in patients with advanced cancer. The aim of the present study was to examine whether an inflammation-based prognostic score (Glasgow Prognostic score, GPS) was associated with survival, in patients with inoperable gastro-oesophageal cancer. Patients diagnosed with inoperable gastro-oesophageal carcinoma and who had measurement of albumin and C-reactive protein concentrations, at the time of diagnosis, were studied (n=258). Clinical information was obtained from a gastro-oesophageal cancer database and analysis of the case notes. Patients with both an elevated C-reactive protein (>10 mg l(-1)) and hypoalbuminaemia (<35 g l(-1)) were allocated a GPS score of 2. Patients in whom only one of these biochemical abnormalities was present were allocated a GPS score of 1, and patients with a normal C-reactive protein and albumin were allocated a score of 0. On multivariate survival analysis, age (hazard ratio (HR) 1.22, 95% CI 1.02-1.46, P<0.05), stage (HR 1.55, 95% CI 1.30-1.83, P<0.001), the GPS (HR 1.51, 95% CI 1.22-1.86, P<0.001) and treatment (HR 2.53, 95% CI 1.80-3.56, P<0.001) were significant independent predictors of cancer survival. A 12-month cancer-specific survival in patients with stage I/II disease receiving active treatment was 67 and 60% for a GPS of 0 and 1, respectively. For stage III/IV disease, 12 months cancer-specific survival was 57, 25 and 12% for a GPS of 0, 1 and 2, respectively. In the present study, the GPS predicted cancer-specific survival, independent of stage and treatment received, in patients with inoperable gastro-oesophageal cancer. Moreover, the GPS may be used in combination with conventional staging techniques to improve the prediction of survival in patients with inoperable gastro-oesophageal cancer.

Direct potable reuse microbial risk assessment methodology: Sensitivity analysis and application to State log credit allocations.

PubMed

Soller, Jeffrey A; Eftim, Sorina E; Nappier, Sharon P

2018-01-01

Understanding pathogen risks is a critically important consideration in the design of water treatment, particularly for potable reuse projects. As an extension to our published microbial risk assessment methodology to estimate infection risks associated with Direct Potable Reuse (DPR) treatment train unit process combinations, herein, we (1) provide an updated compilation of pathogen density data in raw wastewater and dose-response models; (2) conduct a series of sensitivity analyses to consider potential risk implications using updated data; (3) evaluate the risks associated with log credit allocations in the United States; and (4) identify reference pathogen reductions needed to consistently meet currently applied benchmark risk levels. Sensitivity analyses illustrated changes in cumulative annual risks estimates, the significance of which depends on the pathogen group driving the risk for a given treatment train. For example, updates to norovirus (NoV) raw wastewater values and use of a NoV dose-response approach, capturing the full range of uncertainty, increased risks associated with one of the treatment trains evaluated, but not the other. Additionally, compared to traditional log-credit allocation approaches, our results indicate that the risk methodology provides more nuanced information about how consistently public health benchmarks are achieved. Our results indicate that viruses need to be reduced by 14 logs or more to consistently achieve currently applied benchmark levels of protection associated with DPR. The refined methodology, updated model inputs, and log credit allocation comparisons will be useful to regulators considering DPR projects and design engineers as they consider which unit treatment processes should be employed for particular projects. Published by Elsevier Ltd.

Economic constraints and quality assurance in mental health services: sensitive indicators.

PubMed

el-Guebaly, N; Papineau, D

1984-03-01

Clinicians in the field of mental health are met with the dual challenge of increased accountability and shrinking resources. Funds are often allocated through the use of crude administrative monitors. This is of little solace to the clinician faced with unmet patients' wants and needs. A set of clinical monitors is outlined requiring the practitioner's cooperation. The presentation of an accurate composite picture is a must in the process of resource allocation. Such clinical monitors include the analysis of characteristics of patients such as the repeaters at emergency, "the revolving door" pool of patients and those falling in between networks. Reviews of waiting lists and lengths of stay, an evaluation of nursing care variables, the auditing of the choice of therapeutic modalities and the use of restraints are other suggested contributors to the assessment of service needs.

Rescue allocation for liver transplantation within Eurotransplant: the Heidelberg experience.

PubMed

Schemmer, Peter; Nickkholgh, Arash; Gerling, Till; Weitz, Jürgen; Büchler, Markus W; Schmidt, Jan

2009-12-01

Organ shortage has driven many transplant centers to extend their criteria for organ acceptance. Graft allocation policies have been modified accordingly. This report focuses on the impact of applying the so-called rescue allocation (RA) strategy for liver transplantation (LT) in a single center within the Eurotransplant (ET) area. Liver grafts are considered for RA when the regular organ allocation is declined by at least three centers or is averted because of donor instability/unfavorable logistical reasons, thus entering a competitive or a single-recipient rescue organ offer procedure, respectively. The accepting center has the advantage to select a recipient from its own waiting list for these RA grafts. Among 253 livers accepted at the University of Heidelberg between January 2004 and December 2006, we transplanted 85 (34%) rescue-allocated livers. The indications for LT were hepatocellular carcinoma (HCC, 43%), chronic liver disease (55%), and acute liver failure (2%). Median cold ischemia time for RA grafts was 10 h (range: 4-17). The MELD score (mean +/- SD) was 13 +/- 7 (range: 6-40) and was 12 +/- 7 for recipients with HCC. Three (3.5%) primary non-functions (PNF) occurred after transplantation of RA livers. One-year patient and graft survival were 84% and 75%, respectively. A comparison between the recipients of RA livers and regularly allocated livers revealed no significant difference regarding initial poor function (IPF), PNF, and surgical complications. Furthermore, a median follow-up of 16 months revealed no significant difference regarding patient and graft survival between the two groups. The use of RA organs has increased the donor pool and transplantation dynamics with satisfying results. The unique possibility to match livers with recipients, which is left to the discretion of accepting center, should be judged according to the center's experience to decrease the waiting times for a timely rescue of organs/recipients while avoiding futile transplantations.

Justice and the allocation of healthcare resources: should indirect, non-health effects count?

PubMed

Lippert-Rasmussen, Kasper; Lauridsen, Sigurd

2010-08-01

Alternative allocations of a fixed bundle of healthcare resources often involve significantly different indirect, non-health effects. The question arises whether these effects must figure in accounts of the conditions under which a distribution of healthcare resources is morally justifiable. In this article we defend a Scanlonian, affirmative answer to this question: healthcare resource managers should sometimes select an allocation which has worse direct, health-related effects but better indirect, nonhealth effects; they should do this when the interests served by such a policy are more urgent than the healthcare interests better served by an alternative allocation. We note that there is a prima facie case for the claim that such benefits (and costs) are relevant--i.e. they are real benefits, and in other contexts our decisions can permissibly be guided by them. We then proceed to rebut three lines of argument that might be thought to defeat this prima facie case: they appeal to fairness, the Kantian Formula of Humanity as an End in Itself, and the equal moral worth of persons, respectively.

Incremental cost effectiveness evaluation in clinical research.

PubMed

Krummenauer, Frank; Landwehr, I

2005-01-28

The health economic evaluation of therapeutic and diagnostic strategies is of increasing importance in clinical research. Therefore also clinical trialists have to involve health economic aspects more frequently. However, whereas they are quite familiar with classical effect measures in clinical trials, the corresponding parameters in health economic evaluation of therapeutic and diagnostic procedures are still not this common. The concepts of incremental cost effectiveness ratios (ICERs) and incremental net health benefit (INHB) will be illustrated and contrasted along the cost effectiveness evaluation of cataract surgery with monofocal and multifocal intraocular lenses. ICERs relate the costs of a treatment to its clinical benefit in terms of a ratio expression (indexed as Euro per clinical benefit unit). Therefore ICERs can be directly compared to a pre-specified willingness to pay (WTP) benchmark, which represents the maximum costs, health insurers would invest to achieve one clinical benefit unit. INHBs estimate a treatment's net clinical benefit after accounting for its cost increase versus an established therapeutic standard. Resource allocation rules can be formulated by means of both effect measures. Both the ICER and the INHB approach enable the definition of directional resource allocation rules. The allocation decisions arising from these rules are identical, as long as the willingness to pay benchmark is fixed in advance. Therefore both strategies crucially call for a priori determination of both the underlying clinical benefit endpoint (such as gain in vision lines after cataract surgery or gain in quality-adjusted life years) and the corresponding willingness to pay benchmark. The use of incremental cost effectiveness and net health benefit estimates provides a rationale for health economic allocation discussions and founding decisions. It implies the same requirements on trial protocols as yet established for clinical trials, that is the a priori definition of primary hypotheses (formulated as an allocation rule involving a pre-specified willingness to pay benchmark) and the primary clinical benefit endpoint (as a rationale for effectiveness evaluation).

Designing evaluation studies to optimally inform policy: what factors do policy-makers in China consider when making resource allocation decisions on healthcare worker training programmes?

PubMed

Wu, Shishi; Legido-Quigley, Helena; Spencer, Julia; Coker, Richard James; Khan, Mishal Sameer

2018-02-23

In light of the gap in evidence to inform future resource allocation decisions about healthcare provider (HCP) training in low- and middle-income countries (LMICs), and the considerable donor investments being made towards training interventions, evaluation studies that are optimally designed to inform local policy-makers are needed. The aim of our study is to understand what features of HCP training evaluation studies are important for decision-making by policy-makers in LMICs. We investigate the extent to which evaluations based on the widely used Kirkpatrick model - focusing on direct outcomes of training, namely reaction of trainees, learning, behaviour change and improvements in programmatic health indicators - align with policy-makers' evidence needs for resource allocation decisions. We use China as a case study where resource allocation decisions about potential scale-up (using domestic funding) are being made about an externally funded pilot HCP training programme. Qualitative data were collected from high-level officials involved in resource allocation at the national and provincial level in China through ten face-to-face, in-depth interviews and two focus group discussions consisting of ten participants each. Data were analysed manually using an interpretive thematic analysis approach. Our study indicates that Chinese officials not only consider information about the direct outcomes of a training programme, as captured in the Kirkpatrick model, but also need information on the resources required to implement the training, the wider or indirect impacts of training, and the sustainability and scalability to other settings within the country. In addition to considering findings presented in evaluation studies, we found that Chinese policy-makers pay close attention to whether the evaluations were robust and to the composition of the evaluation team. Our qualitative study indicates that training programme evaluations that focus narrowly on direct training outcomes may not provide sufficient information for policy-makers to make decisions on future training programmes. Based on our findings, we have developed an evidence-based framework, which incorporates but expands beyond the Kirkpatrick model, to provide conceptual and practical guidance that aids in the design of training programme evaluations better suited to meet the information needs of policy-makers and to inform policy decisions.

Aircraft transfer of pediatric patients with intractable cardiac or airway problems – single-institutional experience of a specialty hospital.

PubMed

Ando, Makoto; Takahashi, Yukihiro; Park, In-Sam; Tomoike, Hitonobu

2015-01-01

There is currently a well-established network for the allocation of donor organs for transplantation in Japan, and emergency patients are often transported by the "Doctor Helicopter". However, interhospital transfer of patients, which can require aircraft with specialized equipment, depends on arrangement by each responsible hospital. Since 2009 there were 41 interhospital aviation transfers of pediatric patients with intractable cardiac or airway diseases seeking surgical treatment at Sakakibara Heart Institute. Of these, 22 were newborns, 21 were on continuous drip infusion and 14 on mechanical ventilator support. In 15 cases (36.6%), a commercial airliner was used, with the remaining using chartered emergency aircraft (eg, local fire department helicopter, Self-Defense-Forces of Japan and the Doctor Helicopter). The median transfer time was 239 min for commercial airliners, 51 min for chartered aircraft departing directly from the referring hospital and 120.5 min for chartered aircraft departing from a nearby location. The efficiency of the transfer exemplified by the percentage of the time on board the aircraft was significantly lower for commercial airliners compared with chartered emergency aircraft. Further efforts and cooperation with government are required to obtain geographically uniform availability of carriers with optimal medical equipment to improve pediatric patient outcomes.

Daily Physical Activity in Total Hip Arthroplasty Patients Undergoing Different Surgical Approaches: A Cohort Study.

PubMed

Engdal, Monika; Foss, Olav A; Taraldsen, Kristin; Husby, Vigdis S; Winther, Siri B

2017-07-01

Muscle weakness due to trauma from the surgical approach is anticipated to affect the ability of the patient to undertake daily physical activity early after total hip arthroplasty (THA). The objective of this study was to compare daily physical activity on days 1 to 4 after discharge, in patients following THA performed by 1 of 3 surgical approaches. A cohort study included 60 hip osteoarthritis patients, scheduled for THA, allocated to direct lateral approach, posterior approach, or anterior approach. Daily physical activity was measured by an accelerometer, with upright time per 24 hours as primary outcome and walking time, number of steps, and number of upright events per 24 hours as secondary outcomes. There were no statistically significant group differences in any of the measures of daily physical activity (P > 0.290) or between days of follow-up (P > 0.155). Overall, the median participant had 3.50 hours (interquartile range, 2.85-4.81 hours) of upright time, and participants showed wide variation in all outcomes of daily physical activity. There were no differences in daily physical activity between THA patients undergoing different surgical approaches. The surgical approach may not be a limiting factor for daily physical activity early after surgery in a fast-track treatment course.

An experimental maintenance management system.

DOT National Transportation Integrated Search

1979-01-01

The purpose of this study was to evaluate Virginia's maintenance management system and to recommend modifications directed at improving it. The study revealed that (1) the current system of allocating maintenance monies is based upon centerline milea...

75 FR 61853 - Advisory Committee to the Internal Revenue Service; Meeting

Federal Register 2010, 2011, 2012, 2013, 2014

2010-10-06

... taxation and tax reporting, withholding tax issues, Identity Theft, Form 1099-DIV, Box 10, foreign tax paid... basis allocation for direct rollovers. Last minute agenda changes may preclude advance notice. Due to...

Economic Burden of Rheumatoid Arthritis in Italy: Possible Consequences on Anti-Citrullinated Protein Antibody-Positive Patients.

PubMed

Mennini, Francesco Saverio; Marcellusi, Andrea; Gitto, Lara; Iannone, Florenzo

2017-04-01

Rheumatoid arthritis (RA) is an autoimmune disease with a substantial medical and economic burden. In Italy, it affects approximately 280,000 people, therefore representing the musculoskeletal disease with the highest economic impact in terms of costs for the National Health Service and the social security system. The aim of this study was to estimate the annual economic burden of RA in Italy and determine the potential cost reduction considering the most effective biologic treatment for early rapidly progressing RA (ERPRA) patients. The model developed considers both direct costs that are mainly due to the pharmacological treatments, and indirect costs, which also include the productivity lost because of the disease. A systematic literature review provided the epidemiological and economic data used to inform the model. A one-way probabilistic sensitivity analysis based on 5000 Monte Carlo simulations was performed. Furthermore, specific scenario analyses were developed for those patients presenting an ERPRA, with the aim of evaluating the effectiveness of different biologic treatments for this subgroup of patients and estimating potential cost reduction. The total economic burden associated with RA was estimated to be €2.0 billion per year (95% confidence interval [CI] €1.8-2.3 billion). Forty-five percent of the expenditure was due to indirect costs (95% CI €0.8-1.0 billion); 45% depended on direct medical costs (95% CI €0.7-1.1 billion), and the residual 10% was determined by direct non-medical costs (95% CI €0.16-0.25 billion). In particular, the costs estimated for ERPRA patients totalled €76,171,181, of which approximately €18 million was associated with patients with a high level of anti-citrullinated protein antibodies (ACPA). The results of the analysis outline how it is possible to obtain a cost reduction for ERPRA patients of between €1 and €3 million by varying the number of patients with a high level of immunoglobulin G treated with the most effective biologic drug. In fact, the latter may determine higher efficacy outcomes, especially for poor prognostic ERPRA patients, ensuing higher levels of productivity. This study presents a pioneering approach to estimate the direct and indirect costs of RA. The model developed is a useful tool for policy makers as it allows to understand the economic implications of RA treatment in Italy, identify the most effective allocation of resources, and select the most appropriate treatment for ERPRA patients.

Using patient acuity data to manage patient care outcomes and patient care costs.

PubMed

Van Slyck, A; Johnson, K R

2001-01-01

This article describes actual reported uses for patient acuity data that go beyond historical uses in determining staffing allocations. These expanded uses include managing patient care outcomes and health care costs. The article offers the patient care executive examples of how objective, valid, and reliable data are used to drive approaches to effectively influence decision making in an increasingly competitive health care environment.

Telephone-Based Coping Skills Training for Patients Awaiting Lung Transplantation

ERIC Educational Resources Information Center

Blumenthal, James A.; Babyak, Michael A.; Keefe, Francis J.; Davis, R. Duane; LaCaille, Rick A.; Carney, Robert M.; Freedland, Kenneth E.; Trulock, Elbert; Palmer, Scott M.

2006-01-01

Impaired quality of life is associated with increased mortality in patients with advanced lung disease. Using a randomized controlled trial with allocation concealment and blinded outcome assessment at 2 tertiary care teaching hospitals, the authors randomly assigned 328 patients with end-stage lung disease awaiting lung transplantation to 12…

Exploring perceived control and self-rated health in re-admissions among younger adults: A retrospective study.

PubMed

Gabay, Gillie

2016-05-01

Although health promotion calls for patient empowerment, it is not integrated in reducing re-admissions. This study examines the link among patient perceived control, self-rated health and fewer hospital re-admissions. An empirical explorative retrospective cross-sectional study with 208 respondents aged 40-65 with poor health and identical health plans. All measures hold good psychometric properties. Self-rated health was strongly related to fewer re-admissions. Perceived control moderated the relationship between self-rated health and fewer re-admissions. Perceived control and self-rated health, together, contributed 5.2% to the variance in re-admissions. Perceived control and perceived health status each explained a different share of the variance of re-admissions. Together, these perceptions reduced re-admissions by .40. Patient-clinician communication upon discharge may be a new direction to reduce re-admissions, improve delivery of care and promote health. To reduce re-admissions, managements need to invest in restructuring the patient discharge process. A physician-patient dialogue shaping patient perceptions about their health status, perceived room for health improvement, and available internal and external resources may make a difference. Findings stress the need to allocate more time and resources for discharge communication processes and for physician training on psycho-social skills that may empower patients upon discharge. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Nursing home reimbursement and the allocation of rehabilitation therapy resources.

PubMed

Murtaugh, C M; Cooney, L M; DerSimonian, R R; Smits, H L; Fetter, R B

1988-10-01

Most public funding methods for long-term care do not adequately match payment rates with patient need for services. Case-mix payment systems are designed to encourage a more efficient and equitable allocation of limited health care resources. Even nursing home case-mix payment systems, however, do not currently provide the proper incentives to match rehabilitation therapy resources to a patient's needs. We were able to determine by a review of over 8,500 patients in 65 nursing homes that certain diagnoses, partial dependence in activities of daily living (ADLs), clear mental status, and improving medical status are associated with the provision of rehabilitation services to nursing home residents. These patient characteristics are clinically reasonable predictors of the need for therapy and should be considered for use in nursing home case-mix reimbursement systems. Primary payment source also was associated with the provision of rehabilitation services even after taking into account significant patient characteristics. It is unclear how much of the variation in service use across payers is due to differences in patient need as opposed to differences in the financial incentives associated with current payment methods.

Comparison of the safety and efficacy of a fixed-dose combination regimen and separate formulations for pulmonary tuberculosis treatment.

PubMed

Wu, Jiun-Ting; Chiu, Chien-Tung; Wei, Yu-Feng; Lai, Yung-Fa

2015-06-01

Fixed-dose combination formulations, which simplify the administration of drugs and prevent the development of drug resistance, have been recommended as a standard anti-tuberculosis treatment regimen. However, the composition and dosage recommendations for fixed-dose combination formulations differ from those for separate formulations. Thus, questions about the effectiveness and side effects of combination formulations remain. The aim of this study was to compare the safety and efficacy of these two types of anti-tuberculosis regimens for pulmonary tuberculosis treatment. A prospective, randomized controlled study was conducted using the directly observed treatment short-course strategy. Patients were randomly allocated to one of two short-course regimens. One year after completing the treatment, these patients' outcomes were analyzed. ClinicalTrials.gov: NCT00979290. A total of 161 patients were enrolled, 142 of whom were evaluable for safety assessment. The two regimens had a similar incidence of adverse effects. In the per-protocol population, serum bilirubin concentrations at the peak level, at week 4, and at week 8 were significantly higher for the fixed-dose combination formulation than for the separate formulations. All patients had negative sputum cultures at the end of the treatment, and no relapse occurred after one year of follow-up. In this randomized study, transient higher serum bilirubin levels were noted for the fixed-dose combination regimen compared with the separate formulations during treatment. However, no significant difference in safety or efficacy was found between the groups when the directly observed treatment short-course strategy was used.

Competing risks of death in younger and older postmenopausal breast cancer patients

PubMed Central

Chapman, Judy-Anne W; Pritchard, Kathleen I; Goss, Paul E; Ingle, James N; Muss, Hyman B; Dent, Susan F; Vandenberg, Ted A; Findlay, Brian; Gelmon, Karen A; Wilson, Carolyn F; Shepherd, Lois E; Pollak, Michael N

2014-01-01

AIM: To show a new paradigm of simultaneously testing whether breast cancer therapies impact other causes of death. METHODS: MA.14 allocated 667 postmenopausal women to 5 years of tamoxifen 20 mg/daily ± 2 years of octreotide 90 mg, given by depot intramuscular injections monthly. Event-free survival was the primary endpoint of MA.14; at median 7.9 years, the tamoxifen+octreotide and tamoxifen arms had similar event-free survival (P = 0.62). Overall survival was a secondary endpoint, and the two trial arms also had similar overall survival (P = 0.86). We used the median 9.8 years follow-up to examine by intention-to-treat, the multivariate time-to-breast cancer-specific (BrCa) and other cause (OC) mortality with log-normal survival analysis adjusted by treatment and stratification factors. We tested whether baseline factors including Insulin-like growth factor 1 (IGF1), IGF binding protein-3, C-peptide, body mass index, and 25-hydroxy vitamin D were associated with (1) all cause mortality, and if so and (2) cause-specific mortality. We also fit step-wise forward cause-specific adjusted models. RESULTS: The analyses were performed on 329 patients allocated tamoxifen and 329 allocated tamoxifen+octreotide. The median age of MA.14 patients was 60.1 years: 447 (82%) < 70 years and 120 (18%) ≥ 70 years. There were 170 deaths: 106 (62.3%) BrCa; 55 (32.4%) OC, of which 24 were other malignancies, 31 other causes of death; 9 (5.3%) patients with unknown cause of death were excluded from competing risk assessments. BrCa and OC deaths were not significantly different by treatment arm (P = 0.40): tamoxifen patients experienced 50 BrCa and 32 OC deaths, while tamoxifen + octreotide patients experienced 56 BrCa and 23 OC deaths. Proportionately more deaths (P = 0.004) were from BrCa for patients < 70 years, where 70% of deaths were due to BrCa, compared to 54% for those ≥ 70 years of age. The proportion of deaths from OC increased with increasing body mass index (BMI) (P = 0.02). Higher pathologic T and N were associated with more BrCa deaths (P < 0.0001 and 0.002, respectively). The cumulative hazard plot for BrCa and OC mortality indicated the concurrent accrual of both types of death throughout follow-up, that is the existence of competing risks of mortality. MA.14 therapy did not impact mortality (P = 0.77). Three baseline patient and tumor characteristics were differentially associated with cause of death: older patients experienced more OC (P = 0.01) mortality; patients with T1 tumors and hormone receptor positive tumors had less BrCa mortality (respectively, P = 0.01, P = 0.06). Additionally, step-wise cause-specific models indicated that patients with node negative disease experienced less BrCa mortality (P = 0.002); there was weak evidence that, lower C-peptide (P = 0.08) was associated with less BrCa mortality, while higher BMI (P = 0.01) was associated with worse OC mortality. CONCLUSION: We demonstrate here a new paradigm of simultaneous testing of therapeutics directed at multiple diseases for which postmenopausal women are concurrently at risk. Octreotide LAR did not significantly impact breast cancer or other cause mortality, although different baseline factors influenced type of death. PMID:25493245

Direct and indirect costs of asthma in Canada, 1990.

PubMed Central

Krahn, M D; Berka, C; Langlois, P; Detsky, A S

1996-01-01

OBJECTIVE: To calculate the direct and indirect costs of asthma in Canada. DESIGN: Cost-of-illness study. SETTING: Canada. PATIENTS: All Canadians receiving inpatient or outpatient care for asthma in 1990. OUTCOME MEASURES: Direct costs incurred by inpatient care, emergency services, physician and nursing services, ambulance use, drugs and devices, outpatient diagnostic tests, research and education. Indirect costs from productivity loss due to absence from work, inability to to perform housekeeping activities, need to care for children with asthma who were absent from school, time spent travelling and waiting for medical care, and premature death from asthma. All costs are in 1990 Canadian dollars. RESULTS: Depending on assumptions, the total cost of asthma was estimated to be between $504 million and $648 million. Direct costs were $306 million. The single largest component of direct costs was the cost of drugs ($124 million). The largest component of indirect costs was illness-related disability ($76 million). CONCLUSIONS: Annual costs of treating asthma are comparable to the individual cost of infectious diseases, hematological diseases, congenital defects, perinatal illnesses, home care and ambulance services. Asthma costs may increase in the future, given current morbidity and mortality trends. Further evaluation of the effectiveness and cost-effectiveness of available asthma interventions in addition to aggregate cost data are required to determine whether resource allocation for the treatment of asthma can be improved. PMID:8634960

Direct cost of dengue hospitalization in Zhongshan, China: Associations with demographics, virus types and hospital accreditation.

PubMed

Zhang, Jing Hua; Yuan, Juan; Wang, Tao

2017-08-01

Zhongshan City of Guangdong Province (China) is a key provincial and national level area for dengue fever prevention and control. The aim of this study is to analyze how the direct hospitalization costs and the length of stay of dengue hospitalization cases vary according to associated factors such as the demographics, virus types and hospital accreditation. This study is based on retrospective census data from the Chinese National Disease Surveillance Reporting System. Totally, the hospital administrative data of 1432 confirmed dengue inpatients during 2013-2014 was obtained. A quantile regression model was applied to analyze how the direct cost of Dengue hospitalization varies with the patient demographics and hospital accreditation across the data distribution. The Length of Stay (LOS) was also examined. The average direct hospitalization cost of a dengue case in this study is US$ 499.64 during 2013, which corresponded to about 3.71% of the gross domestic product per capita in Zhongshan that year. The mean of the Length of Stay (LOS) is 7.2 days. The multivariate quantile regression results suggest that, after controlling potential compounding variables, the median hospitalization costs of male dengue patients were significantly higher than female ones by about US$ 18.23 (p<0.1). The hospitalization cost difference between the pediatric and the adult patients is estimated to be about US$ 75.25 at the median (p<0.01), but it increases sharply among the top 25 percentiles and reaches US$ 329 at the 90th percentile (p<0.01). The difference between the senior (older than 64 years old) and the adult patients increases steadily across percentiles, especially sharply among the top quartiles too. The LOS of the city-level hospitals is significantly shorter than that in the township-level hospitals by one day at the median (p<0.05), but no significant differences in their hospitalization costs. The direct hospitalization costs of dengue cases vary widely according to the associated demographics factors, virus types and hospital accreditations. The findings in this study provide information for adopting hospitalization strategy, cost containment and patient allocation in dengue prevention and control. Also the results can be used as the cost-effective reference for future dengue vaccine adoption strategy in China.

A Bayesian adaptive design for biomarker trials with linked treatments

PubMed Central

Wason, James M S; Abraham, Jean E; Baird, Richard D; Gournaris, Ioannis; Vallier, Anne-Laure; Brenton, James D; Earl, Helena M; Mander, Adrian P

2015-01-01

Background: Response to treatments is highly heterogeneous in cancer. Increased availability of biomarkers and targeted treatments has led to the need for trial designs that efficiently test new treatments in biomarker-stratified patient subgroups. Methods: We propose a novel Bayesian adaptive randomisation (BAR) design for use in multi-arm phase II trials where biomarkers exist that are potentially predictive of a linked treatment's effect. The design is motivated in part by two phase II trials that are currently in development. The design starts by randomising patients to the control treatment or to experimental treatments that the biomarker profile suggests should be active. At interim analyses, data from treated patients are used to update the allocation probabilities. If the linked treatments are effective, the allocation remains high; if ineffective, the allocation changes over the course of the trial to unlinked treatments that are more effective. Results: Our proposed design has high power to detect treatment effects if the pairings of treatment with biomarker are correct, but also performs well when alternative pairings are true. The design is consistently more powerful than parallel-groups stratified trials. Conclusions: This BAR design is a powerful approach to use when there are pairings of biomarkers with treatments available for testing simultaneously. PMID:26263479

Ethical Challenges in the Provision of Dialysis in Resource-Constrained Environments.

PubMed

Luyckx, Valerie A; Miljeteig, Ingrid; Ejigu, Addisu M; Moosa, M Rafique

2017-05-01

The number of patients requiring dialysis by 2030 is projected to double worldwide, with the largest increase expected in low- and middle-income countries (LMICs). Dialysis is seldom considered a high priority by health care funders, consequently, few LMICs develop policies regarding dialysis allocation. Dialysis facilities may exist, but access remains highly inequitable in LMICs. High out-of-pocket payments make dialysis unsustainable and plunge many families into poverty. Patients, families, and clinicians suffer significant emotional and moral distress from daily life-and-death decisions imposed by dialysis. The health system's obligation to provide financial risk protection is an important component of global and national strategies to achieve universal health coverage. An ethical imperative therefore exists to develop transparent dialysis priority-setting guidelines to facilitate public understanding and acceptance of the realistic limits within the health system, and facilitate fair allocation of scarce resources. In this article, we present ethical challenges faced by patients, families, clinicians, and policy makers where dialysis is not universally accessible and discuss the potential ethical consequences of various dialysis allocation strategies. Finally, we suggest an ethical framework for use in policy development for priority setting of dialysis care. The accountability for reasonableness framework is proposed as a procedurally fair decision-making, priority-setting process. Copyright © 2017 Elsevier Inc. All rights reserved.

[Orthopedic and trauma surgery in the German DRG System 2007].

PubMed

Franz, D; Kaufmann, M; Siebert, C H; Windolf, J; Roeder, N

2007-03-01

The German Diagnosis-Related Groups (DRG) System was further developed into its 2007 version. For orthopedic and trauma surgery, significant changes were made in terms of the coding of diagnoses and medical procedures, as well as in the DRG structure itself. The German Societies for Trauma Surgery and for Orthopedics and Orthopedic Surgery (Deutsch Gesellschaft für Unfallchirurgie, DGU; and Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie, DGOOC) once again cooperated constructively with the German DRG Institute InEK. Among other innovations, new International Classification of Diseases (ICD) codes for second-degree burns were implemented. Procedure codes for joint operations, endoprosthetic-surgery and spine surgery were restructured. Furthermore, a specific code for septic surgery was introduced in 2007. In addition, the DRG structure was improved. Case allocation of patients with more than one significant operation was established. Further DRG subdivisions were established according to the patients age and the Patient Clinical Complexity Level (PCCL). DRG developments for 2007 have improved appropriate case allocation, but once again increased the system's complexity. Clinicians need an ever growing amount of specific coding know-how. Still, further adjustments to the German DRG system are required to allow for a correct allocation of cases and funds.

Bayesian adaptive phase II screening design for combination trials

PubMed Central

Cai, Chunyan; Yuan, Ying; Johnson, Valen E

2013-01-01

Background Trials of combination therapies for the treatment of cancer are playing an increasingly important role in the battle against this disease. To more efficiently handle the large number of combination therapies that must be tested, we propose a novel Bayesian phase II adaptive screening design to simultaneously select among possible treatment combinations involving multiple agents. Methods Our design is based on formulating the selection procedure as a Bayesian hypothesis testing problem in which the superiority of each treatment combination is equated to a single hypothesis. During the trial conduct, we use the current values of the posterior probabilities of all hypotheses to adaptively allocate patients to treatment combinations. Results Simulation studies show that the proposed design substantially outperforms the conventional multiarm balanced factorial trial design. The proposed design yields a significantly higher probability for selecting the best treatment while allocating substantially more patients to efficacious treatments. Limitations The proposed design is most appropriate for the trials combining multiple agents and screening out the efficacious combination to be further investigated. Conclusions The proposed Bayesian adaptive phase II screening design substantially outperformed the conventional complete factorial design. Our design allocates more patients to better treatments while providing higher power to identify the best treatment at the end of the trial. PMID:23359875

Impact of advance directives and a health care proxy on doctors' decisions: a randomized trial.

PubMed

Escher, Monica; Perneger, Thomas V; Rudaz, Sandrine; Dayer, Pierre; Perrier, Arnaud

2014-01-01

Advance directives or proxy designations are widely recommended, but how they affect doctors' decision making is not well known. The aim of this study was to quantify the influence of advance directives and proxy opinions on doctors' decisions. We mailed to all the generalists and internists in French-speaking Switzerland (N = 1962) three vignettes describing difficult decisions involving incapacitated patients. In each case, the advance directive requested that further care be withheld. One vignette tested the impact of a written advance directive vs. a proxy. Another compared the impact of a handwritten directive vs. a formalized document. The third vignette compared the impact of a family member vs. a doctor as a proxy. Each vignette was prepared in three or four versions, including a control version in which no directive or proxy was present. Vignettes were randomly allocated to respondents. We used logistic regression to predict the decision to forgo a medical intervention. Compared with the control condition, the odds of forgoing a medical intervention were increased by the written advance directive (odds ratio [OR] 7.3; P < 0.001), the proxy (OR 7.9; P < 0.001), and the combination of the two (OR 35.7; P < 0.001). The handwritten directive had the same impact (OR 13.3) as the formalized directive (OR 13.8). The effect of proxy opinion was slightly stronger when provided by a doctor (OR 11.3) rather than by family (OR 7.8). Advance directives and proxy opinions are equally effective in influencing doctors' decisions, but having both has the strongest effect. The format of the advance directive and the identity of the proxy have little influence on decisions. Copyright © 2014 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.

The egg-sharing model for human therapeutic cloning research: managing donor selection criteria, the proportion of shared oocytes allocated to research, and amount of financial subsidy given to the donor.

PubMed

Heng, Boon Chin; Tong, Guo Qing; Stojkovic, Miodrag

2006-01-01

Recent advances in human therapeutic cloning made by Hwang and colleagues have opened up new avenues of therapy for various human diseases. However, the major bottleneck of this new technology is the severe shortage of human donor oocytes. Egg-sharing in return for subsidized fertility treatment has been suggested as an ethically justifiable and practical solution to overcome the shortage of donor oocytes for therapeutic cloning. Because the utilization of shared oocytes in therapeutic cloning research does not result in any therapeutic benefit to a second party, this would necessitate a different management strategy compared to their use for the assisted conception of infertile women who are unable to produce any oocytes of their own. It is proposed that the pool of prospective egg-sharers in therapeutic cloning research be limited only to younger women (below 30 years of age) with indications for either male partner sub-fertility or tubal blockage. With regards to the proportion of the shared gametes being allocated to research, a threshold number of retrieved oocytes should be set that if not exceeded, would result in the patient being automatically removed from the egg-sharing scheme. Any excess supernumerary oocyte above this threshold number can be contributed to science, and allocation should be done in a randomized manner. Perhaps, a total of 10 retrieved oocytes from the patient may be considered a suitable threshold, since the chances of conception are unlikely to be impaired. With regards to the amount of subsidy being given to the patient, it is suggested that the proportion of financial subsidy should be equal to the proportion of the patient's oocytes being allocated to research. No doubt, the promise of future therapeutic benefit may be offered to the patient instead of financial subsidy. However, this is ethically controversial because therapeutic cloning has not yet been demonstrated to be a viable model of clinical therapy and any promises made to the patient might turn out to be illusionary. Hence, it is proposed that a tangible financial subsidy on the medical fees might be the better option for the patient's welfare.

Effects of Fronto-Temporal Transcranial Direct Current Stimulation on Auditory Verbal Hallucinations and Resting-State Functional Connectivity of the Left Temporo-Parietal Junction in Patients With Schizophrenia

PubMed Central

Mondino, Marine; Jardri, Renaud; Suaud-Chagny, Marie-Françoise; Saoud, Mohamed; Poulet, Emmanuel; Brunelin, Jérôme

2016-01-01

Auditory verbal hallucinations (AVH) in patients with schizophrenia are associated with abnormal hyperactivity in the left temporo-parietal junction (TPJ) and abnormal connectivity between frontal and temporal areas. Recent findings suggest that fronto-temporal transcranial Direct Current stimulation (tDCS) with the cathode placed over the left TPJ and the anode over the left prefrontal cortex can alleviate treatment-resistant AVH in patients with schizophrenia. However, brain correlates of the AVH reduction are unclear. Here, we investigated the effect of tDCS on the resting-state functional connectivity (rs-FC) of the left TPJ. Twenty-three patients with schizophrenia and treatment-resistant AVH were randomly allocated to receive 10 sessions of active (2 mA, 20min) or sham tDCS (2 sessions/d for 5 d). We compared the rs-FC of the left TPJ between patients before and after they received active or sham tDCS. Relative to sham tDCS, active tDCS significantly reduced AVH as well as the negative symptoms. Active tDCS also reduced rs-FC of the left TPJ with the left anterior insula and the right inferior frontal gyrus and increased rs-FC of the left TPJ with the left angular gyrus, the left dorsolateral prefrontal cortex and the precuneus. The reduction of AVH severity was correlated with the reduction of the rs-FC between the left TPJ and the left anterior insula. These findings suggest that the reduction of AVH induced by tDCS is associated with a modulation of the rs-FC within an AVH-related brain network, including brain areas involved in inner speech production and monitoring. PMID:26303936

A prospective study to determine the costs incurred by families of children newly diagnosed with cancer in Ontario.

PubMed

Tsimicalis, Argerie; Stevens, Bonnie; Ungar, Wendy J; McKeever, Patricia; Greenberg, Mark; Agha, Mohammad; Guerriere, Denise; Barr, Ronald; Naqvi, Ahmed; Moineddin, Rahim

2012-10-01

A diagnosis of cancer in childhood places a considerable economic burden on families, although costs are not well described. The objectives of this study were to identify and determine independent predictors of the direct and time costs incurred by such families. A prospective, cost-of-illness study was conducted in families of children newly diagnosed with cancer. Parents recorded the resources consumed and costs incurred during 1 week per month for three consecutive months beginning the fourth week following diagnosis and listed any additional costs incurred since then. Descriptive and multiple regression analyses were performed to describe families' costs (expressed in 2007 Canadian dollars) and to determine direct and time cost predictors. In total, 28 fathers and 71 mothers participated. The median total direct and time costs in 3 months were $CAD3503 and $CAD23 130, respectively, per family. The largest component of direct costs was travel and of time costs was time allocated previously for unpaid activities. There were no statistically significant predictors of direct costs. Six per cent of the variance for time costs was explained by language spoken at home. Families of children with cancer are confronted with a wide range of direct and time costs, the largest being travel and time allocated previously for unpaid activities. Copyright © 2011 John Wiley & Sons, Ltd.

Anisotropies in the perceived spatial displacement of motion-defined contours: opposite biases in the upper-left and lower-right visual quadrants.

PubMed

Fan, Zhao; Harris, John

2010-10-12

In a recent study (Fan, Z., & Harris, J. (2008). Perceived spatial displacement of motion-defined contours in peripheral vision. Vision Research, 48(28), 2793-2804), we demonstrated that virtual contours defined by two regions of dots moving in opposite directions were displaced perceptually in the direction of motion of the dots in the more eccentric region when the contours were viewed in the right visual field. Here, we show that the magnitude and/or direction of these displacements varies in different quadrants of the visual field. When contours were presented in the lower visual field, the direction of perceived contour displacement was consistent with that when both contours were presented in the right visual field. However, this illusory motion-induced spatial displacement disappeared when both contours were presented in the upper visual field. Also, perceived contour displacement in the direction of the more eccentric dots was larger in the right than in the left visual field, perhaps because of a hemispheric asymmetry in attentional allocation. Quadrant-based analyses suggest that the pattern of results arises from opposite directions of perceived contour displacement in the upper-left and lower-right visual quadrants, which depend on the relative strengths of two effects: a greater sensitivity to centripetal motion, and an asymmetry in the allocation of spatial attention. Copyright © 2010 Elsevier Ltd. All rights reserved.

Self-management support using an Internet-linked tablet computer (the EDGE platform)-based intervention in chronic obstructive pulmonary disease: protocol for the EDGE-COPD randomised controlled trial.

PubMed

Farmer, Andrew; Toms, Christy; Hardinge, Maxine; Williams, Veronika; Rutter, Heather; Tarassenko, Lionel

2014-01-08

The potential for telehealth-based interventions to provide remote support, education and improve self-management for long-term conditions is increasingly recognised. This trial aims to determine whether an intervention delivered through an easy-to-use tablet computer can improve the quality of life of patients with chronic obstructive pulmonary disease (COPD) by providing personalised self-management information and education. The EDGE (sElf management anD support proGrammE) for COPD is a multicentre, randomised controlled trial designed to assess the efficacy of an Internet-linked tablet computer-based intervention (the EDGE platform) in improving quality of life in patients with moderate to very severe COPD compared with usual care. Eligible patients are randomly allocated to receive the tablet computer-based intervention or usual care in a 2:1 ratio using a web-based randomisation system. Participants are recruited from respiratory outpatient clinics and pulmonary rehabilitation courses as well as from those recently discharged from hospital with a COPD-related admission and from primary care clinics. Participants allocated to the tablet computer-based intervention complete a daily symptom diary and record clinical symptoms using a Bluetooth-linked pulse oximeter. Participants allocated to receive usual care are provided with all the information given to those allocated to the intervention but without the use of the tablet computer or the facility to monitor their symptoms or physiological variables. The primary outcome of quality of life is measured using the St George's Respiratory Questionnaire for COPD patients (SGRQ-C) baseline, 6 and 12 months. Secondary outcome measures are recorded at these intervals in addition to 3 months. The Research Ethics Committee for Berkshire-South Central has provided ethical approval for the conduct of the study in the recruiting regions. The results of the study will be disseminated through peer review publications and conference presentations. Current controlled trials ISRCTN40367841.

Analysis of pediatric lung donor allocation policy: a call for change?

PubMed

Gajarski, Robert; Bowman, Diana M

2015-04-01

In an unprecedented legal ruling in June 2013, a US federal district court judge decided that the existing policy for donor lung allocation be vacated to save the life of a ten-year-old girl dying from cystic fibrosis. This case has fueled much controversy in the United States among policy makers, ethicists, and physicians who treat other patients awaiting transplant. This article examines the creation of the current US lung allocation policy and its impact on outcomes and analyzes the multidimensionality of the ruling. After analyzing the current policy and investigating alternatives for donor pool expansion, the article concludes by articulating options that may mitigate the need for current policy revision. Copyright © 2015 by Duke University Press.

The ASCENT (Allocation System Changes for Equity in Kidney Transplantation) Study: a Randomized Effectiveness-Implementation Study to Improve Kidney Transplant Waitlisting and Reduce Racial Disparity.

PubMed

Patzer, Rachel E; Smith, Kayla; Basu, Mohua; Gander, Jennifer; Mohan, Sumit; Escoffery, Cam; Plantinga, Laura; Melanson, Taylor; Kalloo, Sean; Green, Gary; Berlin, Alex; Renville, Gary; Browne, Teri; Turgeon, Nicole; Caponi, Susan; Zhang, Rebecca; Pastan, Stephen

2017-05-01

The United Network for Organ Sharing (UNOS) implemented a new Kidney Allocation System (KAS) in December 2014 that is expected to substantially reduce racial disparities in kidney transplantation among waitlisted patients. However, not all dialysis facility clinical providers and end stage renal disease (ESRD) patients are aware of how the policy change could improve access to transplant. We describe the ASCENT (Allocation System Changes for Equity in KidNey Transplantation) study, a randomized controlled effectiveness-implementation study designed to test the effectiveness of a multicomponent intervention to improve access to the early steps of kidney transplantation among dialysis facilities across the United States. The multicomponent intervention consists of an educational webinar for dialysis medical directors, an educational video for patients and an educational video for dialysis staff, and a dialysis-facility specific transplant performance feedback report. Materials will be developed by a multidisciplinary dissemination advisory board and will undergo formative testing in dialysis facilities across the United States. This study is estimated to enroll ~600 U.S. dialysis facilities with low waitlisting in all 18 ESRD Networks. The co-primary outcomes include change in waitlisting, and waitlist disparity at 1 year; secondary outcomes include changes in facility medical director knowledge about KAS, staff training regarding KAS, patient education regarding transplant, and a medical director's intent to refer patients for transplant evaluation. The results from the ASCENT study will demonstrate the feasibility and effectiveness of a multicomponent intervention designed to increase access to the deceased-donor kidney waitlist and reduce racial disparities in waitlisting.

Rethinking the cost of healthcare in low-resource settings: the value of time-driven activity-based costing

PubMed Central

McBain, Ryan K; Jerome, Gregory; Warsh, Jonathan; Browning, Micaela; Mistry, Bipin; Faure, Peterson Abnis I; Pierre, Claire; Fang, Anna P; Mugunga, Jean Claude; Rhatigan, Joseph; Leandre, Fernet; Kaplan, Robert

2016-01-01

Low-income and middle-income countries account for over 80% of the world's infectious disease burden, but <20% of global expenditures on health. In this context, judicious resource allocation can mean the difference between life and death, not just for individual patients, but entire patient populations. Understanding the cost of healthcare delivery is a prerequisite for allocating health resources, such as staff and medicines, in a way that is effective, efficient, just and fair. Nevertheless, health costs are often poorly understood, undermining effectiveness and efficiency of service delivery. We outline shortcomings, and consequences, of common approaches to estimating the cost of healthcare in low-resource settings, as well as advantages of a newly introduced approach in healthcare known as time-driven activity-based costing (TDABC). TDABC is a patient-centred approach to cost analysis, meaning that it begins by studying the flow of individual patients through the health system, and measuring the human, equipment and facility resources used to treat the patients. The benefits of this approach are numerous: fewer assumptions need to be made, heterogeneity in expenditures can be studied, service delivery can be modelled and streamlined and stronger linkages can be established between resource allocation and health outcomes. TDABC has demonstrated significant benefits for improving health service delivery in high-income countries but has yet to be adopted in resource-limited settings. We provide an illustrative case study of its application throughout a network of hospitals in Haiti, as well as a simplified framework for policymakers to apply this approach in low-resource settings around the world. PMID:28588971

Rethinking the cost of healthcare in low-resource settings: the value of time-driven activity-based costing.

PubMed

McBain, Ryan K; Jerome, Gregory; Warsh, Jonathan; Browning, Micaela; Mistry, Bipin; Faure, Peterson Abnis I; Pierre, Claire; Fang, Anna P; Mugunga, Jean Claude; Rhatigan, Joseph; Leandre, Fernet; Kaplan, Robert

2016-01-01

Low-income and middle-income countries account for over 80% of the world's infectious disease burden, but <20% of global expenditures on health. In this context, judicious resource allocation can mean the difference between life and death, not just for individual patients, but entire patient populations. Understanding the cost of healthcare delivery is a prerequisite for allocating health resources, such as staff and medicines, in a way that is effective, efficient, just and fair. Nevertheless, health costs are often poorly understood, undermining effectiveness and efficiency of service delivery. We outline shortcomings, and consequences, of common approaches to estimating the cost of healthcare in low-resource settings, as well as advantages of a newly introduced approach in healthcare known as time-driven activity-based costing (TDABC). TDABC is a patient-centred approach to cost analysis, meaning that it begins by studying the flow of individual patients through the health system, and measuring the human, equipment and facility resources used to treat the patients. The benefits of this approach are numerous: fewer assumptions need to be made, heterogeneity in expenditures can be studied, service delivery can be modelled and streamlined and stronger linkages can be established between resource allocation and health outcomes. TDABC has demonstrated significant benefits for improving health service delivery in high-income countries but has yet to be adopted in resource-limited settings. We provide an illustrative case study of its application throughout a network of hospitals in Haiti, as well as a simplified framework for policymakers to apply this approach in low-resource settings around the world.

Value Driven Outcomes (VDO): a pragmatic, modular, and extensible software framework for understanding and improving health care costs and outcomes.

PubMed

Kawamoto, Kensaku; Martin, Cary J; Williams, Kip; Tu, Ming-Chieh; Park, Charlton G; Hunter, Cheri; Staes, Catherine J; Bray, Bruce E; Deshmukh, Vikrant G; Holbrook, Reid A; Morris, Scott J; Fedderson, Matthew B; Sletta, Amy; Turnbull, James; Mulvihill, Sean J; Crabtree, Gordon L; Entwistle, David E; McKenna, Quinn L; Strong, Michael B; Pendleton, Robert C; Lee, Vivian S

2015-01-01

To develop expeditiously a pragmatic, modular, and extensible software framework for understanding and improving healthcare value (costs relative to outcomes). In 2012, a multidisciplinary team was assembled by the leadership of the University of Utah Health Sciences Center and charged with rapidly developing a pragmatic and actionable analytics framework for understanding and enhancing healthcare value. Based on an analysis of relevant prior work, a value analytics framework known as Value Driven Outcomes (VDO) was developed using an agile methodology. Evaluation consisted of measurement against project objectives, including implementation timeliness, system performance, completeness, accuracy, extensibility, adoption, satisfaction, and the ability to support value improvement. A modular, extensible framework was developed to allocate clinical care costs to individual patient encounters. For example, labor costs in a hospital unit are allocated to patients based on the hours they spent in the unit; actual medication acquisition costs are allocated to patients based on utilization; and radiology costs are allocated based on the minutes required for study performance. Relevant process and outcome measures are also available. A visualization layer facilitates the identification of value improvement opportunities, such as high-volume, high-cost case types with high variability in costs across providers. Initial implementation was completed within 6 months, and all project objectives were fulfilled. The framework has been improved iteratively and is now a foundational tool for delivering high-value care. The framework described can be expeditiously implemented to provide a pragmatic, modular, and extensible approach to understanding and improving healthcare value. © The Author 2014. Published by Oxford University Press on behalf of the American Medical Informatics Association.

Improving Hospital-Wide Early Resource Allocation through Machine Learning.

PubMed

Gartner, Daniel; Padman, Rema

2015-01-01

The objective of this paper is to evaluate the extent to which early determination of diagnosis-related groups (DRGs) can be used for better allocation of scarce hospital resources. When elective patients seek admission, the true DRG, currently determined only at discharge, is unknown. We approach the problem of early DRG determination in three stages: (1) test how much a Naïve Bayes classifier can improve classification accuracy as compared to a hospital's current approach; (2) develop a statistical program that makes admission and scheduling decisions based on the patients' clincial pathways and scarce hospital resources; and (3) feed the DRG as classified by the Naïve Bayes classifier and the hospitals' baseline approach into the model (which we evaluate in simulation). Our results reveal that the DRG grouper performs poorly in classifying the DRG correctly before admission while the Naïve Bayes approach substantially improves the classification task. The results from the connection of the classification method with the mathematical program also reveal that resource allocation decisions can be more effective and efficient with the hybrid approach.

Tree carbon allocation dynamics determined using a carbon mass balance approach.

PubMed

Klein, Tamir; Hoch, Günter

2015-01-01

Tree internal carbon (C) fluxes between compound and compartment pools are difficult to measure directly. Here we used a C mass balance approach to decipher these fluxes and provide a full description of tree C allocation dynamics. We collected independent measurements of tree C sinks, source and pools in Pinus halepensis in a semi-arid forest, and converted all fluxes to g C per tree d(-1) . Using this data set, a process flowchart was created to describe and quantify the tree C allocation on diurnal to annual time-scales. The annual C source of 24.5 kg C per tree yr(-1) was balanced by C sinks of 23.5 kg C per tree yr(-1) , which partitioned into 70%, 17% and 13% between respiration, growth, and litter (plus export to soil), respectively. Large imbalances (up to 57 g C per tree d(-1) ) were observed as C excess during the wet season, and as C deficit during the dry season. Concurrent changes in C reserves (starch) were sufficient to buffer these transient C imbalances. The C pool dynamics calculated using the flowchart were in general agreement with the observed pool sizes, providing confidence regarding our estimations of the timing, magnitude, and direction of the internal C fluxes. © 2014 The Authors. New Phytologist © 2014 New Phytologist Trust.

Dynamic allocation of same-day requests in multi-physician primary care practices in the presence of prescheduled appointments.

PubMed

Balasubramanian, Hari; Biehl, Sebastian; Dai, Longjie; Muriel, Ana

2014-03-01

Appointments in primary care are of two types: 1) prescheduled appointments, which are booked in advance of a given workday; and 2) same-day appointments, which are booked as calls come during the workday. The challenge for practices is to provide preferred time slots for prescheduled appointments and yet see as many same-day patients as possible during regular work hours. It is also important, to the extent possible, to match same-day patients with their own providers (so as to maximize continuity of care). In this paper, we present a mathematical framework (a stochastic dynamic program) for same-day patient allocation in multi-physician practices in which calls for same-day appointments come in dynamically over a workday. Allocation decisions have to be made in the presence of prescheduled appointments and without complete demand information. The objective is to maximize a weighted measure that includes the number of same-day patients seen during regular work hours as well as the continuity provided to these patients. Our experimental design is motivated by empirical data we collected at a 3-provider family medicine practice in Massachusetts. Our results show that the location of prescheduled appointments - i.e. where in the day these appointments are booked - has a significant impact on the number of same-day patients a practice can see during regular work hours, as well as the continuity the practice is able to provide. We find that a 2-Blocks policy which books prescheduled appointments in two clusters - early morning and early afternoon - works very well. We also provide a simple, easily implementable policy for schedulers to assign incoming same-day requests to appointment slots. Our results show that this policy provides near-optimal same-day assignments in a variety of settings.

A Generic Guidance and Control Structure for Six-Degree-of-Freedom Conceptual Aircraft Design

NASA Technical Reports Server (NTRS)

Cotting, M. Christopher; Cox, Timothy H.

2005-01-01

A control system framework is presented for both real-time and batch six-degree-of-freedom simulation. This framework allows stabilization and control with multiple command options, from body rate control to waypoint guidance. Also, pilot commands can be used to operate the simulation in a pilot-in-the-loop environment. This control system framework is created by using direct vehicle state feedback with nonlinear dynamic inversion. A direct control allocation scheme is used to command aircraft effectors. Online B-matrix estimation is used in the control allocation algorithm for maximum algorithm flexibility. Primary uses for this framework include conceptual design and early preliminary design of aircraft, where vehicle models change rapidly and a knowledge of vehicle six-degree-of-freedom performance is required. A simulated airbreathing hypersonic vehicle and a simulated high performance fighter are controlled to demonstrate the flexibility and utility of the control system.

Worldwide survey of direct-to-listener digital audio delivery systems development since WARC-1992

NASA Technical Reports Server (NTRS)

Messer, Dion D.

1993-01-01

Each country was allocated frequency band(s) for direct-to-listener digital audio broadcasting at WARC-92. These allocations were near 1500, 2300, and 2600 MHz. In addition, some countries are encouraging the development of digital audio broadcasting services for terrestrial delivery only in the VHF bands (at frequencies from roughly 50 to 300 MHz) and in the medium-wave broadcasting band (AM band) (from roughly 0.5 to 1.7 MHz). The development activity increase was explosive. Current development, as of February 1993, as it is known to the author is summarized. The information given includes the following characteristics, as appropriate, for each planned system: coverage areas, audio quality, number of audio channels, delivery via satellite/terrestrial or both, carrier frequency bands, modulation methods, source coding, and channel coding. Most proponents claim that they will be operational in 3 or 4 years.

Constraint monitoring in TOSCA

NASA Technical Reports Server (NTRS)

Beck, Howard

1992-01-01

The Job-Shop Scheduling Problem (JSSP) deals with the allocation of resources over time to factory operations. Allocations are subject to various constraints (e.g., production precedence relationships, factory capacity constraints, and limits on the allowable number of machine setups) which must be satisfied for a schedule to be valid. The identification of constraint violations and the monitoring of constraint threats plays a vital role in schedule generation in terms of the following: (1) directing the scheduling process; and (2) informing scheduling decisions. This paper describes a general mechanism for identifying constraint violations and monitoring threats to the satisfaction of constraints throughout schedule generation.

The flex track: flexible partitioning between low- and high-acuity areas of an emergency department.

PubMed

Laker, Lauren F; Froehle, Craig M; Lindsell, Christopher J; Ward, Michael J

2014-12-01

Emergency departments (EDs) with both low- and high-acuity treatment areas often have fixed allocation of resources, regardless of demand. We demonstrate the utility of discrete-event simulation to evaluate flexible partitioning between low- and high-acuity ED areas to identify the best operational strategy for subsequent implementation. A discrete-event simulation was used to model patient flow through a 50-bed, urban, teaching ED that handles 85,000 patient visits annually. The ED has historically allocated 10 beds to a fast track for low-acuity patients. We estimated the effect of a flex track policy, which involved switching up to 5 of these fast track beds to serving both low- and high-acuity patients, on patient waiting times. When the high-acuity beds were not at capacity, low-acuity patients were given priority access to flexible beds. Otherwise, high-acuity patients were given priority access to flexible beds. Wait times were estimated for patients by disposition and Emergency Severity Index score. A flex track policy using 3 flexible beds produced the lowest mean patient waiting time of 30.9 minutes (95% confidence interval [CI] 30.6 to 31.2 minutes). The typical fast track approach of rigidly separating high- and low-acuity beds produced a mean patient wait time of 40.6 minutes (95% CI 40.2 to 50.0 minutes), 31% higher than that of the 3-bed flex track. A completely flexible ED, in which all beds can accommodate any patient, produced mean wait times of 35.1 minutes (95% CI 34.8 to 35.4 minutes). The results from the 3-bed flex track scenario were robust, performing well across a range of scenarios involving higher and lower patient volumes and care durations. Using discrete-event simulation, we have shown that adding some flexibility into bed allocation between low and high acuity can provide substantial reductions in overall patient waiting and a more efficient ED. Copyright © 2014 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.

Neural circuitry governing anxious individuals' mis-allocation of working memory to threat.

PubMed

Stout, Daniel M; Shackman, Alexander J; Pedersen, Walker S; Miskovich, Tara A; Larson, Christine L

2017-08-18

Dispositional anxiety is a trait-like phenotype that confers increased risk for a range of debilitating neuropsychiatric disorders. Like many patients with anxiety disorders, individuals with elevated levels of dispositional anxiety are prone to intrusive and distressing thoughts in the absence of immediate threat. Recent electrophysiological research suggests that these symptoms are rooted in the mis-allocation of working memory (WM) resources to threat-related information. Here, functional MRI was used to identify the network of brain regions that support WM for faces and to quantify the allocation of neural resources to threat-related distracters in 81 young adults. Results revealed widespread evidence of mis-allocation. This was evident in both face-selective regions of the fusiform cortex and domain-general regions of the prefrontal and parietal cortices. This bias was exaggerated among individuals with a more anxious disposition. Mediation analyses provided compelling evidence that anxious individuals' tendency to mis-allocate WM resources to threat-related distracters is statistically explained by heightened amygdala reactivity. Collectively, these results provide a neurocognitive framework for understanding the pathways linking anxious phenotypes to the development of internalizing psychopathology and set the stage for developing improved intervention strategies.

Implementing seasonal carbon allocation into a dynamic vegetation model

NASA Astrophysics Data System (ADS)

Vermeulen, Marleen; Kruijt, Bart; Hickler, Thomas; Forrest, Matthew; Kabat, Pavel

2014-05-01

Long-term measurements of terrestrial fluxes through the FLUXNET Eddy Covariance network have revealed that carbon and water fluxes can be highly variable from year-to-year. This so-called interannual variability (IAV) of ecosystems is not fully understood because a direct relation with environmental drivers cannot always be found. Many dynamic vegetation models allocate NPP to leaves, stems, and root compartments on an annual basis, and thus do not account for seasonal changes in productivity in response to changes in environmental stressors. We introduce this vegetation seasonality into dynamic vegetation model LPJ-GUESS by implementing a new carbon allocation scheme on a daily basis. We focus in particular on modelling the observed flux seasonality of the Amazon basin, and validate our new model against fluxdata and MODIS GPP products. We expect that introducing seasonal variability into the model improves estimates of annual productivity and IAV, and therefore the model's representation of ecosystem carbon budgets as a whole.