Perspectives from deductible plan enrollees: plan knowledge and anticipated care-seeking changes

<p>Abstract</p> <p>Background</p> <p>Consumer directed health care proposes that patients will engage as informed consumers of health care services by sharing in more of their medical costs, often through deductibles. We examined knowledge of deductible plan details among new enrollees, as well as anticipated care-seeking changes in response to the deductible.</p> <p>Methods</p> <p>In a large integrated delivery system with a range of deductible-based health plans which varied in services included or exempted from deductible, we conducted a mixed-method, cross-sectional telephone interview study.</p> <p>Results</p> <p>Among 458 adults newly enrolled in a deductible plan (71% response rate), 51% knew they had a deductible, 26% knew the deductible amount, and 6% knew which medical services were included or exempted from their deductible. After adjusting for respondent characteristics, those with more deductible-applicable services and those with lower self-reported health status were significantly more likely to know they had a deductible. Among those who knew of their deductible, half anticipated that it would cause them to delay or avoid medical care, including avoiding doctor's office visits and medical tests, even services that they believed were medically necessary. Many expressed concern about their costs, anticipating the inability to afford care and expressing the desire to change plans.</p> <p>Conclusion</p> <p>Early in their experience with a deductible, patients had limited awareness of the deductible and little knowledge of the details. Many who knew of the deductible reported that it would cause them to delay or avoid seeking care and were concerned about their healthcare costs.</p

Neuere Faulkner-Literatur

Enth. Renzensionen von: Reed, Joseph W.: Faulkner's narrative. New Haven; London : Yale University Press, 1973. - XI, 303 S. Broughton, Panthea Reid: William Faulkner : the abstract and the actual. Baton Rouge : Lousiana State University Press, 1974. - XVIII, 222 S. Irwin, John T.: Doubling and incest : repetition and revange; a speculative reading of Faulkner. Baltimore : Johns Hopkins University Press, 1975. - 183 S. Levins, Lynn Gartrell: Faulkner's heroic design : the Yoknapatawpha novels. Athens : University of Georgia Press, 1976. - X, 202 S. Brooks, Cleanth: William Faulkner : toward Yoknapatawpha and beyond. New Haven : Yale University Press, 1978. - XVIII, 445 S

Differential phosphorylation of the N‐terminal extension regulates phytochrome B signaling

Phytochrome B (phyB) is an excellent light quality and quantity sensor that can detect subtle changes in the light environment. The relative amounts of the biologically active photoreceptor (phyB Pfr) are determined by the light conditions and light independent thermal relaxation of Pfr into the inactive phyB Pr, termed thermal reversion. Little is known about the regulation of thermal reversion and how it affects plants’ light sensitivity. In this study we identified several serine/threonine residues on the N-terminal extension (NTE) of Arabidopsis thaliana phyB that are differentially phosphorylated in response to light and temperature, and examined transgenic plants expressing nonphosphorylatable and phosphomimic phyB mutants. The NTE of phyB is essential for thermal stability of the Pfr form, and phosphorylation of S86 particularly enhances the thermal reversion rate of the phyB Pfr–Pr heterodimer in vivo. We demonstrate that S86 phosphorylation is especially critical for phyB signaling compared with phosphorylation of the more N-terminal residues. Interestingly, S86 phosphorylation is reduced in light, paralleled by a progressive Pfr stabilization under prolonged irradiation. By investigating other phytochromes (phyD and phyE) we provide evidence that acceleration of thermal reversion by phosphorylation represents a general mechanism for attenuating phytochrome signaling.Fil: Viczián, András. Institute of Plant Biology; HungríaFil: Ádám, Éva. Institute of Plant Biology; Hungría. University of Szeged; HungríaFil: Staudt, Anne Marie. Albert Ludwigs University of Freiburg; AlemaniaFil: Lambert, Dorothee. Albert Ludwigs University of Freiburg; AlemaniaFil: Klement, Eva. Biological Research Centre; HungríaFil: Romero Montepaone, Sofía Iara. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Instituto de Investigaciones Fisiológicas y Ecológicas Vinculadas a la Agricultura. Universidad de Buenos Aires. Facultad de Agronomía. Instituto de Investigaciones Fisiológicas y Ecológicas Vinculadas a la Agricultura; ArgentinaFil: Hiltbrunner, Andreas. Albert Ludwigs University of Freiburg; AlemaniaFil: Casal, Jorge José. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Instituto de Investigaciones Fisiológicas y Ecológicas Vinculadas a la Agricultura. Universidad de Buenos Aires. Facultad de Agronomía. Instituto de Investigaciones Fisiológicas y Ecológicas Vinculadas a la Agricultura; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Instituto de Investigaciones Bioquímicas de Buenos Aires. Fundación Instituto Leloir. Instituto de Investigaciones Bioquímicas de Buenos Aires; ArgentinaFil: Schäfer, Eberhard. Albert Ludwigs University of Freiburg; AlemaniaFil: Nagy, Ferenc. Institute of Plant Biology; HungríaFil: Klose, Cornelia. Albert Ludwigs University of Freiburg; Alemani

Avoiding overfitting of multilayer perceptrons by training derivatives

Resistance to overfitting is observed for neural networks trained with extended backpropagation algorithm. In addition to target values, its cost function uses derivatives of those up to the $4^{\mathrm{th}}$ order. For common applications of neural networks, high order derivatives are not readily available, so simpler cases are considered: training network to approximate analytical function inside 2D and 5D domains and solving Poisson equation inside a 2D circle. For function approximation, the cost is a sum of squared differences between output and target as well as their derivatives with respect to the input. Differential equations are usually solved by putting a multilayer perceptron in place of unknown function and training its weights, so that equation holds within some margin of error. Commonly used cost is the equation's residual squared. Added terms are squared derivatives of said residual with respect to the independent variables. To investigate overfitting, the cost is minimized for points of regular grids with various spacing, and its root mean is compared with its value on much denser test set. Fully connected perceptrons with six hidden layers and $2\cdot10^{4}$, $1\cdot10^{6}$ and $5\cdot10^{6}$ weights in total are trained with Rprop until cost changes by less than 10% for last 1000 epochs, or when the $10000^{\mathrm{th}}$ epoch is reached. Training the network with $5\cdot10^{6}$ weights to represent simple 2D function using 10 points with 8 extra derivatives in each produces cost test to train ratio of $1.5$, whereas for classical backpropagation in comparable conditions this ratio is $2\cdot10^{4}$

Manganese as a Probe of Fungal Degradation of Wood

Transition state metals, such as manganese (Mn) and iron (Fe), have been reported to be involved in fungal degradation of wood (Ellis, 1959; Shortl

Search algorithms as a framework for the optimization of drug combinations

Combination therapies are often needed for effective clinical outcomes in the management of complex diseases, but presently they are generally based on empirical clinical experience. Here we suggest a novel application of search algorithms, originally developed for digital communication, modified to optimize combinations of therapeutic interventions. In biological experiments measuring the restoration of the decline with age in heart function and exercise capacity in Drosophila melanogaster, we found that search algorithms correctly identified optimal combinations of four drugs with only one third of the tests performed in a fully factorial search. In experiments identifying combinations of three doses of up to six drugs for selective killing of human cancer cells, search algorithms resulted in a highly significant enrichment of selective combinations compared with random searches. In simulations using a network model of cell death, we found that the search algorithms identified the optimal combinations of 6-9 interventions in 80-90% of tests, compared with 15-30% for an equivalent random search. These findings suggest that modified search algorithms from information theory have the potential to enhance the discovery of novel therapeutic drug combinations. This report also helps to frame a biomedical problem that will benefit from an interdisciplinary effort and suggests a general strategy for its solution.Comment: 36 pages, 10 figures, revised versio

Process evaluation of appreciative inquiry to translate pain management evidence into pediatric nursing practice

Background Appreciative inquiry (AI) is an innovative knowledge translation (KT) intervention that is compatible with the Promoting Action on Research in Health Services (PARiHS) framework. This study explored the innovative use of AI as a theoretically based KT intervention applied to a clinical issue in an inpatient pediatric care setting. The implementation of AI was explored in terms of its acceptability, fidelity, and feasibility as a KT intervention in pain management. Methods A mixed-methods case study design was used. The case was a surgical unit in a pediatric academic-affiliated hospital. The sample consisted of nurses in leadership positions and staff nurses interested in the study. Data on the AI intervention implementation were collected by digitally recording the AI sessions, maintaining logs, and conducting individual semistructured interviews. Data were analysed using qualitative and quantitative content analyses and descriptive statistics. Findings were triangulated in the discussion. Results Three nurse leaders and nine staff members participated in the study. Participants were generally satisfied with the intervention, which consisted of four 3-hour, interactive AI sessions delivered over two weeks to promote change based on positive examples of pain management in the unit and staff implementation of an action plan. The AI sessions were delivered with high fidelity and 11 of 12 participants attended all four sessions, where they developed an action plan to enhance evidence-based pain assessment documentation. Participants labeled AI a 'refreshing approach to change' because it was positive, democratic, and built on existing practices. Several barriers affected their implementation of the action plan, including a context of change overload, logistics, busyness, and a lack of organised follow-up. Conclusions Results of this case study supported the acceptability, fidelity, and feasibility of AI as a KT intervention in pain management. The AI intervention requires minor refinements (e.g., incorporating continued follow-up meetings) to enhance its clinical utility and sustainability. The implementation process and effectiveness of the modified AI intervention require evaluation in a larger multisite study

Integrating a health-related-quality-of-life module within electronic health records: a comparative case study assessing value added

<p>Abstract</p> <p>Background</p> <p>Health information technology (HIT) applications that incorporate point-of-care use of health-related quality of life (HRQL) assessments are believed to promote patient-centered interactions between seriously ill patients and physicians. However, it is unclear how willing primary care providers are to use such HRQL HIT applications. The specific aim of this study was to explore factors that providers consider when assessing the value added of an HRQL application for their geriatric patients.</p> <p>Methods</p> <p>Three case studies were developed using the following data sources: baseline surveys with providers and staff, observations of staff and patients, audio recordings of patient-provider interactions, and semi-structured interviews with providers and staff.</p> <p>Results</p> <p>The primary factors providers considered when assessing value added were whether the HRQL information from the module was (1) duplicative of information gathered via other means during the encounter; (2) specific enough to be useful and/or acted upon, and; (3) useful for enough patients to warrant time spent reviewing it for all geriatric patients. Secondary considerations included level of integration of the HRQL and EHR, impact on nursing workflow, and patient reluctance to provide HRQL information.</p> <p>Conclusions</p> <p>Health-related quality of life modules within electronic health record systems offer the potential benefit of improving patient centeredness and quality of care. However, the modules must provide benefits that are substantial and prominent in order for physicians to decide that they are worthwhile and sustainable. Implications of this study for future research include the identification of perceived "costs" as well as a foundation for operationalizing the concept of "usefulness" in the context of such modules. Finally, developers of these modules may need to make their products customizable for practices to account for variation in EHR capabilities and practice workflows.</p