The impact of statistical adjustment on economic profiles of interventional cardiologists

AbstractOBJECTIVESThe objective of this study was to identify preprocedure patient factors associated with percutaneous intervention costs and to examine the impact of these patient factors on economic profiles of interventional cardiologists.BACKGROUNDThere is increasing demand for information about comparative resource use patterns of interventional cardiologists. Economic provider profiles, however, often fail to account for patient characteristics.METHODSData were obtained from Duke Medical Center cost and clinical information systems for 1,949 procedures performed by 13 providers between July 1, 1997, and December 31, 1998. Patient factors that influenced cost were identified using multiple regression analysis. After assessing interprovider variation in unadjusted cost, mixed linear models were used to examine how much cost variability was associated with the provider when patient characteristics were taken into account.RESULTSTotal hospital costs averaged $15,643 (median,$13,809), $6,515 of which represented catheterization laboratory costs. Disease severity, acuity, comorbid illness and lesion type influenced total costs (R2= 38%), whereas catheterization costs were affected by lesion type and acuity (R2= 32%). Patient characteristics varied significantly among providers. Unadjusted total costs were weakly associated with provider, and this association disappeared after accounting for patient factors. The provider influence on catheterization costs persisted after adjusting for patient characteristics. Furthermore, the pattern of variation changed: the adjusted analysis identified three new outliers, and two providers lost their outlier status. Only one provider was consistently identified as an outlier in the unadjusted and adjusted analyses.CONCLUSIONSEconomic profiles of interventional cardiologists may be misleading if they do not adequately adjust for patient characteristics before procedure

Gadolinium and nephrogenic systemic fibrosis: time to tighten practice

Nephrogenic systemic fibrosis (NSF) is a relatively new entity, first described in 1997. Few cases have been reported, but the disease has high morbidity and mortality. To date it has been seen exclusively in patients with renal dysfunction. There is an emerging link with intravenous injection of gadolinium contrast agents, which has been suggested as a main triggering factor, with a lag time of days to weeks. Risk factors include the severity of renal impairment, major surgery, vascular events and other proinflammatory conditions. There is no reason to believe that children have an altered risk compared to the adult population. It is important that the paediatric radiologist acknowledges emerging information on NSF but at the same time considers the risk:benefit ratio prior to embarking on alternative investigations, as children with chronic kidney disease require high-quality diagnostic imaging

Effector-Triggered Immune Response in Arabidopsis thaliana Is a Quantitative Trait

We identified loci responsible for natural variation in Arabidopsis thaliana (Arabidopsis) responses to a bacterial pathogen virulence factor, HopAM1. HopAM1 is a type III effector protein secreted by the virulent Pseudomonas syringae strain Pto DC3000. Delivery of HopAM1 from disarmed Pseudomonas strains leads to local cell death, meristem chlorosis, or both, with varying intensities in different Arabidopsis accessions. These phenotypes are not associated with differences in bacterial growth restriction. We treated the two phenotypes as quantitative traits to identify host loci controlling responses to HopAM1. Genome-wide association (GWA) of 64 Arabidopsis accessions identified independent variants highly correlated with response to each phenotype. Quantitative trait locus (QTL) mapping in a recombinant inbred population between Bur-0 and Col-0 accessions revealed genetic linkage to regions distinct from the top GWA hits. Two major QTL associated with HopAM1-induced cell death were also associated with HopAM1-induced chlorosis. HopAM1-induced changes in Arabidopsis gene expression showed that rapid HopAM1-dependent cell death in Bur-0 is correlated with effector-triggered immune responses. Studies of the effect of mutations in known plant immune system genes showed, surprisingly, that both cell death and chlorosis phenotypes are enhanced by loss of EDS1, a regulatory hub in the plant immune-signaling network. Our results reveal complex genetic architecture for response to this particular type III virulence effector, in contrast to the typical monogenic control of cell death and disease resistance triggered by most type III effectors

Fuel cycle modelling of open cycle thorium-fuelled nuclear energy systems

In this study, we have sought to determine the advantages, disadvantages, and viability of open cycle thorium–uranium-fuelled (Th–U-fuelled) nuclear energy systems. This has been done by assessing three such systems, each of which requires uranium enriched to ∼20% 235U, in comparison to a reference uranium-fuelled (U-fuelled) system over various performance indicators, spanning material flows, waste composition, economics, and proliferation resistance. The values of these indicators were determined using the UK National Nuclear Laboratory’s fuel cycle modelling code ORION. This code required the results of lattice-physics calculations to model the neutronics of each nuclear energy system, and these were obtained using various nuclear reactor physics codes and burn-up routines. In summary, all three Th–U-fuelled nuclear energy systems required more separative work capacity than the equivalent benchmark U-fuelled system, with larger levelised fuel cycle costs and larger levelised cost of electricity. Although a reduction of ∼6% in the required uranium ore per kWh was seen for one of the Th–U-fuelled systems compared to the reference U-fuelled system, the other two Th–U-fuelled systems required more uranium ore per kWh than the reference. Negligible advantages and disadvantages were observed for the amount and the properties of the spent nuclear fuel (SNF) generated by the systems considered. Two of the Th–U-fuelled systems showed some benefit in terms of proliferation resistance of the SNF generated. Overall, it appears that there is little merit in incorporating thorium into nuclear energy systems operating with open nuclear fuel cycles

Patterns and Predictors of Stress Testing Modality after Percutaneous Coronary Stenting: Retrospective Analysis using Data from the NCDR®

We evaluated temporal trends and geographic variation in choice of stress testing modality post-PCI, as well as associations between modality and procedure use after testing

Use of Stress Testing and Diagnostic Catheterization after Coronary Stenting: Association of Site-level Patterns with Patient Characteristics and Outcomes in 247,052 Medicare Beneficiaries

To determine diagnostic testing patterns after percutaneous coronary intervention (PCI)

Patterns of Stress Testing and Diagnostic Catheterization After Coronary Stenting in 250 350 Medicare Beneficiaries

Patterns of non-invasive stress test (ST) and invasive coronary angiography (CA) utilization after percutaneous coronary intervention (PCI) are not well described in older populations