Scaling Up: Bringing the Transitional Care Model Into the Mainstream

Describes features of an innovative care management intervention to facilitate elderly, chronically ill patients' transitions among providers and settings; the adopting organization; and the external environment that affect its translation into practice

The Incentive Effects of No Fault Automobile Insurance

This paper presents a theoretical and empirical analysis of the effects of no fault automobile insurance on accident rates. As a mechanism for compensating the victims of automobile accidents, no fault has several important advantages over the tort system. However, by restricting access to tort, no fault may weaken incentives for careful driving, leading to higher accident rates. We conduct an empirical analysis of automobile accident fatality rates in all U.S. states over the period 1982-1994, controlling for the potential endogeneity of no fault laws. The results support the hypothesis that no fault is significantly associated with higher fatal accident rates than tort.

Applying Optimization to the Conservation Project Selection Process: A Case Study of Readiness and Environmental Protection Initiative

This study presents a thorough discussion of the efficiency and effectiveness improvement from optimization models (Binary Linear Programming and Goal Programming), as applied to the Department of Defense’s Readiness and Environmental Protection Initiative. The OM models can yield 21% and 19.1% higher benefit scores respectively, spending $13,013,473 and$31,463,473 less total acquisition costs. To achieve the same level of conservation benefits for the current rank based approach, the REPI would spend additional $20.1 million and approximate 50% of the budget. A counterpart of OM- the cost-effective analysis is observed to be inefficient when the problem becomes complex. In a real world of political environment of the conservation programs, we suggest a hybrid method of current rank based approach and the OM as well as the GP to address incompatible goals of interests groups.Environmental Economics and Policy, C6, Q24,

Aquatic Vegetation, Largemouth Bass and Water Quality Responses to Low-Dose Fluridone Two Years Post Treatment

Whole-lake techniques are increasingly being used to selectively remove exotic plants, including Eurasian watermilfoil ( Myriophyllum spicatum L.). Fluridone (1-methyl-3-phenyl- 5-[3-(trifluoromethyl)phenyl]-4(1 H )-pyridinone), a systemic whole-lake herbicide, is selective for Eurasian watermilfoil within a narrow low concentration range. Because fluridone applications have the potential for large effects on plant assemblages and lake food webs, they should be evaluated at the whole-lake scale. We examined effects of low-dose (5 to 8 ppb) fluridone applications by comparing submersed plant assemblages, water quality and largemouth bass ( Micropterus salmoides ) growth rates and diets between three reference lakes and three treatment lakes one- and two-years post treatment. In the treatment lakes, fluridone reduced Eurasian watermilfoil cover without reducing native plant cover, although the duration of Eurasian watermilfoil reduction varied among treatment lakes. (PDF has 11 pages.

First principles study of hBN-AlN short-period superlattice heterostructures

We report a theoretical study of the structural, electronic and optical properties of hBN-AlN superlattice heterostructures (SL) using a first-principles approach based on standard and hybrid Density Functional Theory. We consider short-period ($L<10$ nm) SL and find that their properties depend strongly on the AlN layer thickness $L_{AlN}$. For $L_{AlN}\lesssim1$ nm, AlN stabilizes into the hexagonal phase and SL display insulating behavior with type II interface band alignment and optical gaps as small as $5.2$ eV. The wurtzite phase forms for thicker AlN layers. In these cases built-in electric fields lead to formation of polarization compensating charges as well as two-dimensional conductive behavior for electronic transport along interfaces. We also find defect-like states localized at interfaces which are optically active in the visible range.Comment: 5 pages, 5 figures + Suppl. Mat., to appear in Appl. Phys. Let

Management of early pregnancy loss with mifepristone and misoprostol: clinical predictors of treatment success from a randomized trial.

BackgroundEarly pregnancy loss is a common event in the first trimester, occurring in 15%-20% of confirmed pregnancies. A common evidence-based medical regimen for early pregnancy loss uses misoprostol, a prostaglandin E1 analog, with a dosage of 800 μg, self-administered vaginally. The clinical utility of this regimen is limited by suboptimal effectiveness in patients with a closed cervical os, with 29% of patients experiencing early pregnancy loss requiring a second dose after 3 days and 16% of patients eventually requiring a uterine aspiration procedure.ObjectiveThis study aimed to evaluate clinical predictors associated with treatment success in patients receiving medical management with mifepristone-misoprostol or misoprostol alone for early pregnancy loss.Study designWe performed a planned secondary analysis of a randomized trial comparing mifepristone-misoprostol with misoprostol alone for management of early pregnancy loss. The published prediction model for treatment success of single-dose misoprostol administered vaginally included the following variables: active bleeding, type of early pregnancy loss (anembryonic pregnancy or embryonic and/or fetal demise), parity, gestational age, and treatment site; previous significant predictors were vaginal bleeding within the past 24 hours and parity of 0 or 1 vs &gt;1. To determine if these characteristics predicted differential proportions of patients with treatment success or failure, we performed bivariate analyses; given the small proportion of treatment failures in the combined treatment arm, both arms were combined for analysis. Thereafter, we performed a logistic regression analysis to assess the effect of these predictors collectively in each of the 2 treatment groups separately as well as in the full cohort as a proxy for the combined treatment arm. Finally, by using receiver operating characteristic curves, we tested the ability of these predictors in association with misoprostol treatment success to discriminate between treatment success and treatment failure. To quantify the ability of the score to discriminate between treatment success and treatment failure in each treatment arm as well as in the entire cohort, we calculated the area under the curve. Using multivariable logistic regression, we then assessed our study population for other predictors of treatment success in both treatment groups, with and without mifepristone pretreatment.ResultsOverall, 297 evaluable participants were included in the primary study, with 148 in the mifepristone-misoprostol combined treatment group and 149 in the misoprostol-alone treatment group. Among patients who had vaginal bleeding at the time of treatment, 15 of 17 (88%) in the mifepristone-misoprostol combined treatment group and 12 of 17 (71%) in the misoprostol-alone treatment group experienced expulsion of pregnancy tissue. Among patients with a parity of 0 or 1, 94 of 108 (87%) in the mifepristone-misoprostol treatment group and 66 of 95 (69%) in the misoprostol-alone treatment group experienced expulsion of pregnancy tissue. These clinical characteristics did not predict treatment success in the combined cohort alone (area under the curve=0.56; 95% confidence interval, 0.48-0.64). No other baseline clinical factors predicted treatment success in the misoprostol-alone treatment arm or mifepristone pretreatment arm. In the full cohort, the significant predictors of treatment success were pretreatment with mifepristone (adjusted odds ratio=2.51; 95% confidence interval, 1.43-4.43) and smoking (adjusted odds ratio=2.15; 95% confidence interval, 1.03-4.49).ConclusionNo baseline clinical factors predicted treatment success in women receiving medical management with misoprostol for early pregnancy loss. Adding mifepristone to the medical management regimen of early pregnancy loss improved treatment success; thus, mifepristone treatment should be considered for management of early pregnancy loss regardless of baseline clinical factors

Decision aids can support cancer clinical trials decisions: Results of a randomized trial

BACKGROUND. Cancer patients often do not make informed decisions regarding clinical trial participation. This study evaluated whether a web-based decision aid (DA) could support trial decisions compared with our cancer center’s website. METHODS. Adults diagnosed with cancer in the past 6 months who had not previously participated in a cancer clinical trial were eligible. Participants were randomized to view the DA or our cancer center’s website (enhanced usual care [UC]). Controlling for whether participants had heard of cancer clinical trials and educational attainment, multivariable linear regression examined group on knowledge, self-efficacy for finding trial information, decisional conflict (values clarity and uncertainty), intent to participate, decision readiness, and trial perceptions. RESULTS. Two hundred patients (86%) consented between May 2014 and April 2015. One hundred were randomized to each group. Surveys were completed by 87 in the DA group and 90 in the UC group. DA group participants reported clearer values regarding trial participation than UC group participants reported (least squares [LS] mean = 15.8 vs. 32, p < .0001) and less uncertainty (LS mean = 24.3 vs. 36.4, p = .025). The DA group had higher objective knowledge than the UC group’s (LS mean = 69.8 vs. 55.8, p < .0001). There were no differences between groups in intent to participate. CONCLUSIONS. Improvements on key decision outcomes including knowledge, self-efficacy, certainty about choice, and values clarity among participants who viewed the DA suggest web-based DAs can support informed decisions about trial participation among cancer patients facing this preference-sensitive choice. Although better informing patients before trial participation could improve retention, more work is needed to examine DA impact on enrollment and retention. IMPLICATIONS FOR PRACTICE: This paper describes evidence regarding a decision tool to support patients’ decisions about trial participation. By improving knowledge, helping patients clarify preferences for participation, and facilitating conversations about trials, decision aids could lead to decisions about participation that better match patients’ preferences, promoting patient-centered care and the ethical conduct of clinical research

A Review of Literature on Health-Related Quality of Life of Retinoblastoma Survivors.

Background: Retinoblastoma is a malignant tumor of the eye that typically presents in early childhood and occurs in approximately 1 in 20,000 births. While active treatment of the tumor is typically completed in childhood, survivors often suffer from long-term effects from treatment including visual impairment, facial deformities, and fear of recurrence or secondary cancer. However, little is known how these long-term effects affect their health-related quality of life (HRQOL). Purpose: To review the literature on HRQOL in retinoblastoma survivors. Method: We searched three electronic databases from January 2005 to December 2018 for original research articles reporting on HRQOL or individual domains such as function, cognition, and psychosocial outcomes in retinoblastoma survivors. Results: A total of 59 articles were reviewed and 15 were identified as eligible. Five of the studies reported worse HRQOL in retinoblastoma survivors than controls or general population norms. Parent-proxy ratings were worse than survivors' self-reports. Conclusion: Our findings confirm the need for further HRQOL research to assess the factors influencing long-term outcomes associated with treatment in adolescent and young adult retinoblastoma survivors. By identifying any potential deficits in specific domains of HRQOL, early interventions might be developed to improve HRQOL in retinoblastoma survivors

Forcing function control of Faraday wave instabilities in viscous shallow fluids

We investigate the relationship between the linear surface wave instabilities of a shallow viscous fluid layer and the shape of the periodic, parametric-forcing function (describing the vertical acceleration of the fluid container) that excites them. We find numerically that the envelope of the resonance tongues can only develop multiple minima when the forcing function has more than two local extrema per cycle. With this insight, we construct a multi-frequency forcing function that generates at onset a non-trivial harmonic instability which is distinct from a subharmonic response to any of its frequency components. We measure the corresponding surface patterns experimentally and verify that small changes in the forcing waveform cause a transition, through a bicritical point, from the predicted harmonic short-wavelength pattern to a much larger standard subharmonic pattern. Using a formulation valid in the lubrication regime (thin viscous fluid layer) and a WKB method to find its analytic solutions, we explore the origin of the observed relation between the forcing function shape and the resonance tongue structure. In particular, we show that for square and triangular forcing functions the envelope of these tongues has only one minimum, as in the usual sinusoidal case.Comment: 12 pages, 10 figure

Practice transformations to optimize the delivery of HIV primary care in community healthcare settings in the United States: A program implementation study.

BackgroundThe United States HIV care workforce is shrinking, which could complicate service delivery to people living with HIV (PLWH). In this study, we examined the impact of practice transformations, defined as efficiencies in structures and delivery of care, on demonstration project sites within the Workforce Capacity Building Initiative, a Health Resources and Services Administration (HRSA) Ryan White HIV/AIDS Program Special Projects of National Significance (SPNS).Methods and findingsData were collected at 14 demonstration project sites in 7 states and the District of Columbia. Organizational assessments were completed at sites once before and 4 times after implementation. They captured 3 transformation approaches: maximizing the HIV care workforce (efforts to increase the number of existing healthcare workforce members involved in the care of PLWH), share-the-care (team-based care giving more responsibility to midlevel providers and staff), and enhancing client engagement in primary HIV care to reduce emergency and inpatient care (e.g., care coordination). We also obtained Ryan White HIV/AIDS Program Services Reports (RSRs) from sites for calendar years (CYs) 2014-2016, corresponding to before, during, and after transformation. The RSR include data on client retention in HIV care, prescription of antiretroviral therapy (ART), and viral suppression. We used generalized estimating equation (GEE) models to analyze changes among sites implementing each practice transformation approach. The demonstration projects had a mean of 18.5 prescribing providers (SD = 23.5). They reported data on more than 13,500 clients per year (mean = 969/site, SD = 1,351). Demographic characteristics remained similar over time. In 2014, a majority of clients were male (71% versus 28% female and 0.2% transgender), with a mean age of 47 (interquartile range [IQR] 37-54). Racial/ethnic characteristics (48% African American, 31% Hispanic/Latino, 14% white) and HIV risk varied (31% men who have sex with men; 31% heterosexual men and women; 7% injection drug use). A substantial minority was on Medicaid (41%). Across sites, there was significant uptake in practices consistent with maximizing the HIV care workforce (18% increase, p &lt; 0.001), share-the-care (25% increase, p &lt; 0.001), and facilitating patient engagement in HIV primary care (13% increase, p &lt; 0.001). There were also significant improvements over time in retention in HIV care (adjusted odds ratio [aOR] = 1.03; 95% confidence interval [CI] 1.02-1.04; p &lt; 0.001), ART prescription levels (aOR = 1.01; 95% CI 1.00-1.01; p &lt; 0.001), and viral suppression (aOR = 1.03; 95% CI 1.02-1.04; p &lt; 0.001). All outcomes improved at sites that implemented transformations to maximize the HIV care workforce or improve client engagement. At sites that implemented share-the-care practices, only retention in care and viral suppression outcomes improved. Study limitations included use of demonstration project sites funded by the Ryan White HIV/AIDS Program (RWHAP), which tend to have better HIV outcomes than other US clinics; varying practice transformation designs; lack of a true control condition; and a potential Hawthorne effect because site teams were aware of the evaluation.ConclusionsIn this study, we found that practice transformations are a potential strategy for addressing anticipated workforce challenges among those providing care to PLWH. They hold the promise of optimizing the use of personnel and ensuring the delivery of care to all in need while potentially enhancing HIV care continuum outcomes