Hospital Readmissions: Measuring for Improvement, Accountability, and Patients

The Commonwealth Fund and the Institute for Healthcare Improvement convened 15 experts in May 2013 to help address the current controversy over the measurement of hospital readmissions. Experts agreed that Medicare should, through payment and other means, be encouraging greater coordination of care, improvement in care transitions, and mitigation of risks that leave patients vulnerable to readmission. While the current readmissions metric is undoubtedly an imperfect proxy for broader health system failures, it also provides a valuable foundation on which to build a better policy -- one that is useful for improvement, fair for accountability, and above all, relevant to patients

The role of cognitive functioning in predicting health outcomes of cardiac rehabilitation patients

Cardiovascular disease (CVD), characterized by a narrowing of arteries due to the build-up of plaque, is the most common cause of death worldwide, being responsible for an estimated 17.9 million death each year. Cardiac Rehabilitation (CR) is a multifaceted set of intervention services designed to afford CVD patients the opportunity to recover to the best of their capabilities and functioning. A variety of individual differences have been shown to effect CR patient outcomes including gender, socioeconomic status, and comorbid health conditions. However, the role that cognitive functioning plays in patient outcomes is poorly understood. This study investigates the role self-regulation and executive functioning play in predicting the physical and mental health status of patients attending Cardiac Rehabilitation. The Physical and Mental Health Status of 114 Phase 4 CR patients were assessed using the SF-12. Executive functioning was assessed using the Behavioural Assessment of Dysexecutive Syndrome (BADS), and the Self-Regulation Questionnaire (SFQ) and Cognitive Failures Questionnaire (CFQ) were used to measure self-regulation. Multiple linear regression analysis showed that increased physical health was predicted by an increase CFQ subscale of Distractibility. Mental health was not predicted by any of the cognitive measures. SRQ total scores correlated with both physical and mental health. Results have implications for CR research, policy, and practice. Incorporating an increased understanding of an individual differences into treatment regimens and recovery plans will help facilitate health improvements. Assimilation of knowledge regarding the role cognitions play in health outcomes would require policy change at various levels of rehabilitation implementation. In addition, further work is necessary to explore the precise nature of the relationships between various subcomponents of executive functioning/self-regulation and both health outcomes and behaviours

Analysis and Assessment of the Reimbursement Rates and Mechanisms for Kentucky’s Publicly Funded Ferries

The Kentucky Transportation Cabinet (KYTC) reimburses publicly operated ferries, including when they cease operations due to severe weather or unforeseen events. Reimbursement procedures are not codified in law and are largely based on historical practice. To determine how the Cabinet should handle reimbursement, funding, oversight of ferry services moving forward, the Kentucky Transportation Center (KTC) reviewed practices adopted by 10 other states and conducted a detailed analysis of Kentucky’s current approach. Of the states KTC examined, only Tennessee reimburses ferry operations for closures (at 50 percent of the normal hourly rate for a period up to 48 hours). Half of the states KTC examined make state funding available for ferry operations, others either devolve oversight to the local level or provide no funding assistance. In Kentucky, operating standards for ferry services are not consistent and no uniform method has been devised to calculate reimbursement rates. In light of these findings, KYTC should create detailed auditing guidelines to improve the consistency of ferry service financial statements; pursue funding sources it has not previously taken advantage of, and generate long-term forecasts of the state’s ferry operations. Lastly, the Cabinet should ask the General Assembly to revisit and modify several statutes pertaining to ferries which contain outdated language that has little relevance to the modern transportation system

Partnership work between Public Health and Health Psychology: introduction to a novel training programme

Background: Public health services implement individual, community and population level interventions to change health behaviours, improve healthy life expectancy and reduce health inequalities. Understanding and changing health behaviour is complex. Integrating behaviour change theory and evidence into interventions has the potential to improve services. Methods: Health Psychologists apply evidence and theories aimed at understanding and changing health behaviour. A Scottish programme is piloting the training of Health Psychologists within NHS contexts to address prominent public health challenges. Results: This article outlines the details of this novel programme. Two projects are examined to illustrate the potential of partnership working between public health and health psychology. Conclusion: In order to develop and improve behaviour change interventions and services, public health planners may want to consider developing and using the knowledge and skills of Health Psychologists. Supporting such training within public health contexts is a promising avenue to build critical NHS internal mass to tackle the major public health challenges ahead

Functional Amyloid Formation within Mammalian Tissue

Amyloid is a generally insoluble, fibrous cross-β sheet protein aggregate. The process of amyloidogenesis is associated with a variety of neurodegenerative diseases including Alzheimer, Parkinson, and Huntington disease. We report the discovery of an unprecedented functional mammalian amyloid structure generated by the protein Pmel17. This discovery demonstrates that amyloid is a fundamental nonpathological protein fold utilized by organisms from bacteria to humans. We have found that Pmel17 amyloid templates and accelerates the covalent polymerization of reactive small molecules into melanin—a critically important biopolymer that protects against a broad range of cytotoxic insults including UV and oxidative damage. Pmel17 amyloid also appears to play a role in mitigating the toxicity associated with melanin formation by sequestering and minimizing diffusion of highly reactive, toxic melanin precursors out of the melanosome. Intracellular Pmel17 amyloidogenesis is carefully orchestrated by the secretory pathway, utilizing membrane sequestration and proteolytic steps to protect the cell from amyloid and amyloidogenic intermediates that can be toxic. While functional and pathological amyloid share similar structural features, critical differences in packaging and kinetics of assembly enable the usage of Pmel17 amyloid for normal function. The discovery of native Pmel17 amyloid in mammals provides key insight into the molecular basis of both melanin formation and amyloid pathology, and demonstrates that native amyloid (amyloidin) may be an ancient, evolutionarily conserved protein quaternary structure underpinning diverse pathways contributing to normal cell and tissue physiology

Complete intracranial response to talimogene laherparepvec (T-Vec), pembrolizumab and whole brain radiotherapy in a patient with melanoma brain metastases refractory to dual checkpoint-inhibition

Background Immunotherapy, in particular checkpoint blockade, has changed the clinical landscape of metastatic melanoma. Nonetheless, the majority of patients will either be primary refractory or progress over follow up. Management of patients progressing on first-line immunotherapy remains challenging. Expanded treatment options with combination immunotherapy has demonstrated efficacy in patients previously unresponsive to single agent or alternative combination therapy. Case presentation We describe the case of a patient with diffusely metastatic melanoma, including brain metastases, who, despite being treated with stereotactic radiosurgery and dual CTLA-4/PD-1 blockade (ipilimumab/nivolumab), developed systemic disease progression and innumerable brain metastases. This patient achieved a complete CNS response and partial systemic response with standard whole brain radiation therapy (WBRT) combined with Talimogene laherparepvec (T-Vec) and pembrolizumab. Conclusion Patients who do not respond to one immunotherapy combination may respond during treatment with an alternate combination, even in the presence of multiple brain metastases. Biomarkers are needed to assist clinicians in evidence based clinical decision making after progression on first line immunotherapy to determine whether response can be achieved with second line immunotherapy

Leadership development through action learning sets: An evaluation study

This article examines the use of action learning sets in a leadership module delivered by a university in south east England. An evaluation research study was undertaking using survey method to evaluate student engagement with action learning sets, and their value, impact and sustainability. Data were collected through a questionnaire with a mix of Likert-style and open-ended questions and qualitative and quantitative data analysis was undertaken. Findings show that engagement in the action learning sets was very high. Action learning sets also had a positive impact on the development of leadership knowledge and skills and are highly valued by participants. It is likely that they would be sustainable as the majority would recommend action learning to colleagues and would consider taking another module that used action learning sets. When compared to existing literature on action learning, this study offers new insights as there is little empirical literature on student engagement with action learning sets and even less on value and sustainability

A multisite study of a breast density deep learning model for full-field digital mammography and synthetic mammography

PURPOSE: To develop a Breast Imaging Reporting and Data System (BI-RADS) breast density deep learning (DL) model in a multisite setting for synthetic two-dimensional mammographic (SM) images derived from digital breast tomosynthesis examinations by using full-field digital mammographic (FFDM) images and limited SM data. MATERIALS AND METHODS: A DL model was trained to predict BI-RADS breast density by using FFDM images acquired from 2008 to 2017 (site 1: 57 492 patients, 187 627 examinations, 750 752 images) for this retrospective study. The FFDM model was evaluated by using SM datasets from two institutions (site 1: 3842 patients, 3866 examinations, 14 472 images, acquired from 2016 to 2017; site 2: 7557 patients, 16 283 examinations, 63 973 images, 2015 to 2019). Each of the three datasets were then split into training, validation, and test. Adaptation methods were investigated to improve performance on the SM datasets, and the effect of dataset size on each adaptation method was considered. Statistical significance was assessed by using CIs, which were estimated by bootstrapping. RESULTS: Without adaptation, the model demonstrated substantial agreement with the original reporting radiologists for all three datasets (site 1 FFDM: linearly weighted Cohen κ [κ CONCLUSION: A BI-RADS breast density DL model demonstrated strong performance on FFDM and SM images from two institutions without training on SM images and improved by using few SM images

Monte Carlo Simulations of Star Clusters - VII. The globular cluster 47 Tuc

We describe Monte Carlo models for the dynamical evolution of the massive globular cluster 47 Tuc (NGC 104). The code includes treatments of two-body relaxation, most kinds of three- and four-body interactions involving primordial binaries and those formed dynamically, the Galactic tide, and the internal evolution of both single and binary stars. We arrive at a set of initial parameters for the cluster which, after 12Gyr of evolution, gives a model with a fairly satisfactory match to surface brightness and density profiles, the velocity dispersion profile, the luminosity function in two fields, and the acceleration of pulsars. Our models appear to require a relatively steep initial mass function for stars above about turnoff, with an index of about 2.8 (where the Salpeter mass function has an index of 2.35), and a relatively flat initial mass function (index about 0.4) for the lower main sequence. According to the model, the current mass is estimated at 0.9 million solar masses, of which about 34% consists of remnants. We find that primordial binaries are gradually taking over from mass loss by stellar evolution as the main dynamical driver of the core. Despite the high concentration of the cluster, core collapse will take at least another 20Gyr.Comment: 16 pages, 16 figures, revised version submitted to MNRA