Explaining Cost Overruns of Large-Scale Transportation Infrastructure Projects using a Signalling Game

Strategic behaviour is one of the main explanations for cost overruns. It can theoretically be supported by agency theory, in which strategic behaviour is the result of asymmetric information between the principal and agent. This paper gives a formal account of this relation by a signalling game. This is a game with incomplete information which considers the way in which parties anticipate upon other parties' behaviour in choosing a course of action. The game shows how cost overruns are the result of an inappropriate signal. This makes it impossible for the principal to distinguish between the types of agents, and hence, allows for strategic behaviour. It is illustrated how cost overruns can be avoided by means of two policy measures, e.g. an accountability structure and benchmarking

Inpatient glycemic variability and long-term mortality in hospitalized patients with type 2 diabetes

Aims/Hypothesis: To determine the association between inpatient glycemic variability and long-term mortality in patients with type 2 diabetes mellitus. Methods: Capillary blood glucose (CBG) of inpatients from 8 hospitals was analysed. 28,353 admissions identified were matched for age, duration of diabetes and admission and median and interquartile range of CBG. 6 year mortality was investigated for (i) those with CBG IQR in the top half of all IQR measurements (matched for all except IQR), vs those in the lower half and (ii) those with the lowest quartile median glucose (matched for all except median). Results: 1. Glycemic variability 3165 matched pairs were analysed. Mortality was greater in those with IQR in upper 50% (≥ 50.9 mg/dl) over follow-up from day 90 post-discharge to a maximum of 6 years (p<0.01, HR 1.17). 2. Median glucose 2.3755 matched pairs were analysed. Mortality was lower in those with a median glucose in upper 50% (≥ 148.5 mg/dl) over follow-up from day 90 post-discharge to a maximum of 6 years (p < 0.01, HR 0.87). Conclusion: Higher inpatient glycemic variability is associated with increased mortality on long-term follow up. When matched by IQR, we have demonstrated higher median CBG is associated with lower long-term mortality. CBG variability may increase cardiovascular morbidity by increasing exposure to hypoglycaemia or to variability per se. In hospitalized patients with diabetes, glycemic variability should be minimised and when greater CBG variability is unavoidable, a less stringent CBG target considered

An investigative study into the sensitivity of different partial discharge φ-q-n pattern resolution sizes on statistical neural network pattern classification

This paper investigates the sensitivity of statistical fingerprints to different phase resolution (PR) and amplitude bins (AB) sizes of partial discharge (PD) φ-q-n (phase-amplitude-number) patterns. In particular, this paper compares the capability of the ensemble neural network (ENN) and the single neural network (SNN) in recognizing and distinguishing different resolution sizes of φ-q-n discharge patterns. The training fingerprints for both the SNN and ENN comprise statistical fingerprints from different φ-q-n measurements. The result shows that there exists statistical distinction for different PR and AB sizes on some of the statistical fingerprints. Additionally, the ENN and SNN outputs change depending on training and testing with different PR and AB sizes. Furthermore, the ENN appears to be more sensitive in recognizing and discriminating the resolution changes when compared with the SNN. Finally, the results are assessed for practical implementation in the power industry and benefits to practitioners in the field are highlighted

A Longitudinal Perspective on User Uptake of an Electronic Personal Health Record for Diabetes, With Respect To Patient Demographics

INTRODUCTION: The growing prevalence of diabetes has increased the need for scalable technologies to improve outcomes. My Diabetes My Way (MDMW) is an electronic personal health record (ePHR) available to all people with diabetes in Scotland since 2010, associated with improved clinical outcomes among users. MDMW pulls data from a national clinician-facing informatics platform and provides self-management and educational information. This study aims to describe MDMW user demographics through time with respect to the national diabetes population, with a view to addressing potential health inequalities. METHODS: Aggregate data were obtained retrospectively from the MDMW database and annual Scottish Diabetes Survey (SDS) from 2010 to 2020. Variables included diabetes type, sex, age, socioeconomic status, ethnicity, and glycemic control. Prevalence of MDMW uptake was calculated using corresponding SDS data as denominators. Comparisons between years and demographic sub-groups were made using Chi- Squared tests. RESULTS: Overall uptake of MDMW has steadily increased since implementation. By 2020, of all people with T1D or T2D in Scotland, 13% were fully enrolled to MDMW (39,881/312,326). There was proportionately greater numbers of users in younger, more affluent demographic groups (with a clear social gradient) with better glycemic control. As uptake has increased through time, so too has the observed gaps between different demographic sub-groups. CONCLUSIONS: The large number of MDMW users is encouraging, but remains a minority of people with diabetes in Scotland. There is a risk that innovations like MDMW can widen health inequalities and it is incumbent upon healthcare providers to identify strategies to prevent this

Adherence to General Diabetes and Foot Care Processes, with Prompt Referral, Are Associated with Amputation-Free Survival in People with Type 2 Diabetes and Foot Ulcers:: A Scottish National Registry Analysis

AIMS: To compare different packages of care across care providers in Scotland on foot-related outcomes. METHODS: A retrospective cohort study with primary and secondary care electronic health records from the Scottish Diabetes Registry, including 6,845 people with type 2 diabetes and a first foot ulcer occurring between 2013 and 2017. We assessed the association between exposure to care processes and major lower extremity amputation and death. Proportional hazards were used for time-to-event univariate and multivariate analyses, adjusting for case-mix characteristics and care processes. Results were expressed in terms of hazard ratios with 95% confidence intervals. RESULTS: 2,243 (32.7%) subjects had a major amputation or death. Exposure to all nine care processes at all ages (HR = 0.63; 95% CI: 0.58-0.69; p 70 years (HR = 0.88; 0.78-0.99; p = .03) were associated with longer major amputation-free survival. Waiting time ≥ 12 weeks between ulceration and clinic attendance was associated with worse outcomes (HR = 1.59; 1.37-1.84; p 70 years, minor amputations were associated with improved major amputation-free survival (HR = 0.69; 0.52-0.92; p = .01). CONCLUSIONS: Strict adherence to a standardised package of general diabetes care before foot ulceration, timely foot care after ulceration, and specific treatment pathways were associated with longer major amputation-free survival among a large cohort of people with type 2 diabetes in Scotland, with a larger impact on older age groups

Decision Support for Diabetes in Scotland:Implementation and Evaluation of a Clinical Decision Support System

Background: Automated clinical decision support systems (CDSS) are associated with improvements in health care delivery to those with long-term conditions, including diabetes. A CDSS was introduced to two Scottish regions (combined diabetes population ~30 000) via a national diabetes electronic health record. This study aims to describe users’ reactions to the CDSS and to quantify impact on clinical processes and outcomes over two improvement cycles: December 2013 to February 2014 and August 2014 to November 2014. Methods: Feedback was sought via patient questionnaires, health care professional (HCP) focus groups, and questionnaires. Multivariable regression was used to analyze HCP SCI-Diabetes usage (with respect to CDSS message presence/absence) and case-control comparison of clinical processes/outcomes. Cases were patients whose HCP received a CDSS messages during the study period. Closely matched controls were selected from regions outside the study, following similar clinical practice (without CDSS). Clinical process measures were screening rates for diabetes-related complications. Clinical outcomes included HbA1c at 1 year. Results: The CDSS had no adverse impact on consultations. HCPs were generally positive toward CDSS and used it within normal clinical workflow. CDSS messages were generated for 5692 cases, matched to 10 667 controls. Following clinic, the probability of patients being appropriately screened for complications more than doubled for most measures. Mean HbA1c improved in cases and controls but more so in cases (–2.3 mmol/mol [–0.2%] versus –1.1 [–0.1%], P = .003). Discussion and Conclusions: The CDSS was well received; associated with improved efficiencies in working practices; and large improvements in guideline adherence. These evidence-based, early interventions can significantly reduce costly and devastating complications. </jats:sec