Using value-based health care principles to "fix" orthopaedic care delivery

Despite differences in the structure of health care delivery systems, health care spending continues to outpace gross domestic product (GDP) and average wage globally. This highlights the stark reality that health systems today are – in many cases – financially unsustainable. Further, most health care services today are paid for via a fee-for-service or payment for each service provided mechanism, which does not ensure a focus on optimal health outcomes for patients; this includes clinical outcomes most important to them, such as function, pain, andquality of life. As such, bold reforms are needed to better align incentives to “bend” the cost curve and to ensure high-quality health care and the best possible patient outcomes. This dissertation includes scientific studies that highlight how the core principles of value-based health care, which focuses on maximizing the outcomes achieved per dollar spent, may be able to begin to address some of the issues plaguing our strained health care delivery systems globally, including within orthopaedic surgery.LUMC / Geneeskund

Statistical Theory for Incoherent Light Propagation in Nonlinear Media

A novel statistical approach based on the Wigner transform is proposed for the description of partially incoherent optical wave dynamics in nonlinear media. An evolution equation for the Wigner transform is derived from a nonlinear Schrodinger equation with arbitrary nonlinearity. It is shown that random phase fluctuations of an incoherent plane wave lead to a Landau-like damping effect, which can stabilize the modulational instability. In the limit of the geometrical optics approximation, incoherent, localized, and stationary wave-fields are shown to exist for a wide class of nonlinear media.Comment: 4 pages, REVTeX4. Submitted to Physical Review E. Revised manuscrip

Are detailed, patient-level social determinant of health factors associated with physical function and mental health at presentation among new patients with orthopaedic conditions?

Background: It is well documented that routinely collected patient sociodemographic characteristics (such as race and insurance type) and geography-based social determinants of health (SDoH) measures (for example, the Area Deprivation Index) are associated with health disparities, including symptom severity at presentation. However, the association of patient-level SDoH factors (such as housing status) on musculoskeletal health disparities is not as well documented. Such insight might help with the development of more-targeted interventions to help address health disparities in orthopaedic surgery. Questions/purposes: (1) What percentage of patients presenting for new patient visits in an orthopaedic surgery clinic who were unemployed but seeking work reported transportation issues that could limit their ability to attend a medical appointment or acquire medications, reported trouble paying for medications, and/or had no current housing? (2) Accounting for traditional sociodemographic factors and patient-level SDoH measures, what factors are associated with poorer patient-reported outcome physical health scores at presentation? (3) Accounting for traditional sociodemographic factor patient-level SDoH measures, what factors are associated with poorer patient-reported outcome mental health scores at presentation? Methods: New patient encounters at one Level 1 trauma center clinic visit from March 2018 to December 2020 were identified. Included patients had to meet two criteria: they had completed the Patient-Reported Outcome Measure Information System (PROMIS) Global-10 at their new orthopaedic surgery clinic encounter as part of routine clinical care, and they had visited their primary care physician and completed a series of specific SDoH questions. The SDoH questionnaire was developed in our institution to improve data that drive interventions to address health disparities as part of our accountable care organization work. Over the study period, the SDoH questionnaire was only distributed at primary care provider visits. The SDoH questions focused on transportation, housing, employment, and ability to pay for medications. Because we do not have a way to determine how many patients had both primary care provider office visits and new orthopaedic surgery clinic visits over the study period, we were unable to determine how many patients could have been included; however, 9057 patients were evaluated in this cross-sectional study. The mean age was 61 +/- 15 years, and most patients self-reported being of White race (83% [7561 of 9057]). Approximately half the patient sample had commercial insurance (46% [4167 of 9057]). To get a better sense of how this study cohort compared with the overall patient population seen at the participating center during the time in question, we reviewed all new patient clinic encounters (n = 135,223). The demographic information between the full patient sample and our study subgroup appeared similar. Using our study cohort, two multivariable linear regression models were created to determine which traditional metrics (for example, self-reported race or insurance type) and patient-specific SDoH factors (for example, lack of reliable transportation) were associated with worse physical and mental health symptoms (that is, lower PROMIS scores) at new patient encounters. The variance inflation factor was used to assess for multicollinearity. For all analyses, p values Orthopaedics, Trauma Surgery and Rehabilitatio

Primordial black holes in braneworld cosmologies: astrophysical constraints

In two recent papers we explored the modifications to primordial black hole physics when one moves to the simplest braneworld model, Randall--Sundrum type II. Both the evaporation law and the cosmological evolution of the population can be modified, and additionally accretion of energy from the background can be dominant over evaporation at high energies. In this paper we present a detailed study of how this impacts upon various astrophysical constraints, analyzing constraints from the present density, from the present high-energy photon background radiation, from distortion of the microwave background spectrum, and from processes affecting light element abundances both during and after nucleosynthesis. Typically, the constraints on the formation rate of primordial black holes weaken as compared to the standard cosmology if black hole accretion is unimportant at high energies, but can be strengthened in the case of efficient accretion.Comment: 17 pages RevTeX4 file with three figures incorporated; final paper in series astro-ph/0205149 and astro-ph/0208299. Minor changes to match version accepted by Physical Review

Digital medical history implementation to triage orthopaedic patients during COVID-19: findings from a rapid cycle, semi-randomised A/B testing quality improvement project

Introduction: The COVID-19 pandemic severely impacted musculoskeletal care. To better triage the notable backlog of patients, we assessed whether a digital medical history (DMH), a summary of health information and concerns completed by the patient prior to a clinic visit, could be routinely collected and utilised.Methods: We analysed 640 patients using a rapid cycle, semi-randomised A/B testing approach. Four rapid cycles of different randomised interventions were conducted across five unique patient groups. Descriptive statistics were used to report DMH completion rates by cycle/patient group and intervention. Multivariable logistic regression was used to determine whether age or anatomic injury location was associated DMH completion.Ethical Approval: N/A (Quality Improvement Project)Results: Across all patients, the DMH completion rate was 48% (307/640). Phone calls were time consuming and resource intensive without an increased completion rate. The highest rate of DMH completion was among patients who were referred and called the clinic themselves (78% of patients [63 out of 81 patients]). Across all patients, increasing age (odds ratio [OR]: 0.985 (95% CI: 0.976-0.995), p = 0.002), patients with back concerns (OR: 0.395 (95% CI: 0.234-0.666), p = 0.001), and patients with non-specific/other musculoskeletal concerns (OR: 0.331 (95% CI: 0.176-0.623), p = 0.001) were associated with decreased odds of DMH completion.Discussion and Conclusion: DMHs can be valuable in helping triage orthopaedic patients in resource-strapped settings, times of crisis, or as we transition towards value-based health care delivery. However, further work is needed to continue to increase the completion rate about 50%.Orthopaedics, Trauma Surgery and Rehabilitatio

The scintillation and ionization yield of liquid xenon for nuclear recoils

XENON10 is an experiment designed to directly detect particle dark matter. It is a dual phase (liquid/gas) xenon time-projection chamber with 3D position imaging. Particle interactions generate a primary scintillation signal (S1) and ionization signal (S2), which are both functions of the deposited recoil energy and the incident particle type. We present a new precision measurement of the relative scintillation yield \leff and the absolute ionization yield Q_y, for nuclear recoils in xenon. A dark matter particle is expected to deposit energy by scattering from a xenon nucleus. Knowledge of \leff is therefore crucial for establishing the energy threshold of the experiment; this in turn determines the sensitivity to particle dark matter. Our \leff measurement is in agreement with recent theoretical predictions above 15 keV nuclear recoil energy, and the energy threshold of the measurement is 4 keV. A knowledge of the ionization yield \Qy is necessary to establish the trigger threshold of the experiment. The ionization yield \Qy is measured in two ways, both in agreement with previous measurements and with a factor of 10 lower energy threshold.Comment: 8 pages, 9 figures. To be published in Nucl. Instrum. Methods

Weak lensing, dark matter and dark energy

Weak gravitational lensing is rapidly becoming one of the principal probes of dark matter and dark energy in the universe. In this brief review we outline how weak lensing helps determine the structure of dark matter halos, measure the expansion rate of the universe, and distinguish between modified gravity and dark energy explanations for the acceleration of the universe. We also discuss requirements on the control of systematic errors so that the systematics do not appreciably degrade the power of weak lensing as a cosmological probe.Comment: Invited review article for the GRG special issue on gravitational lensing (P. Jetzer, Y. Mellier and V. Perlick Eds.). V3: subsection on three-point function and some references added. Matches the published versio

Design and Performance of the XENON10 Dark Matter Experiment

XENON10 is the first two-phase xenon time projection chamber (TPC) developed within the XENON dark matter search program. The TPC, with an active liquid xenon (LXe) mass of about 14 kg, was installed at the Gran Sasso underground laboratory (LNGS) in Italy, and operated for more than one year, with excellent stability and performance. Results from a dark matter search with XENON10 have been published elsewhere. In this paper, we summarize the design and performance of the detector and its subsystems, based on calibration data using sources of gamma-rays and neutrons as well as background and Monte Carlo simulations data. The results on the detector's energy threshold, energy and position resolution, and overall efficiency show a performance that exceeds design specifications, in view of the very low energy threshold achieved (<10 keVr) and the excellent energy resolution achieved by combining the ionization and scintillation signals, detected simultaneously

Prospective organisation of neonatal arm movements : a motor foundation of embodied agency, disrupted in premature birth

Prospective motor control moves the body into the future, from where one is to where one wants to be. It is a hallmark of intentionality. But its origins in development is uncertain. In this study, we tested whether or not the arm movements of newborn infants were prospectively controlled. We measured the spatiotemporal organisation of 480 neonatal arm movements and 384 arm movements of infants prematurely born at-risk for neurodevelopmental disorder. We found 75% of healthy term-birth neonatal movements and 68% of prematurely-born infant movements conformed to the tauG-coupling model of prospective sensorimotor control. Prospective coupling values were significantly reduced in the latter (p = .010, r = .087). In both cases prospectively controlled movements were tightly organised by fixed-duration units with a base duration of 218 ms and additional temporal units of 145 ms. Yet distances remained constant. Thus, we demonstrate for the first time a precise prospective spatiotemporal organisation of neonatal arm movements and demonstrate at-risk infants exhibit reduced sensorimotor control. Prospective motor control is a hallmark of primary sensorimotor intentionality and gives a strong embodied foundation to conscious motor agency

Relic Neutrino Absorption Spectroscopy

Resonant annihilation of extremely high-energy cosmic neutrinos on big-bang relic anti-neutrinos (and vice versa) into Z-bosons leads to sizable absorption dips in the neutrino flux to be observed at Earth. The high-energy edges of these dips are fixed, via the resonance energies, by the neutrino masses alone. Their depths are determined by the cosmic neutrino background density, by the cosmological parameters determining the expansion rate of the universe, and by the large redshift history of the cosmic neutrino sources. We investigate the possibility of determining the existence of the cosmic neutrino background within the next decade from a measurement of these absorption dips in the neutrino flux. As a by-product, we study the prospects to infer the absolute neutrino mass scale. We find that, with the presently planned neutrino detectors (ANITA, Auger, EUSO, OWL, RICE, and SalSA) operating in the relevant energy regime above 10^{21} eV, relic neutrino absorption spectroscopy becomes a realistic possibility. It requires, however, the existence of extremely powerful neutrino sources, which should be opaque to nucleons and high-energy photons to evade present constraints. Furthermore, the neutrino mass spectrum must be quasi-degenerate to optimize the dip, which implies m_{nu} >~ 0.1 eV for the lightest neutrino. With a second generation of neutrino detectors, these demanding requirements can be relaxed considerably.Comment: 19 pages, 26 figures, REVTeX