Do Patients Bypass Rural Hospitals? Determinants of Inpatient Hospital Choice in Rural California

Rural hospitals play a crucial role in providing healthcare to rural Americans, a vulnerable and underserved population; however, rural hospitals have faced threats to their financial viability and many have closed as a result. This paper examines the hospital characteristics that are associated with patients choosing rural hospitals, and sheds light on the types of patients who depend on rural hospitals for care and, hence, may be the most impaired by the closure of rural hospitals. Using data from California hospitals, the paper shows that patients were more likely to choose nearby hospitals, larger hospitals, and hospitals that offered more services and technologies. However, even after adjusting for these factors, patients had a propensity to bypass rural hospitals in favor of large urban hospitals. Offering additional services and technologies would increase the share of rural residents choosing rural hospitals only slightly.Rural hospitals, hospital choice, rural health

Education as a Complex System: Conceptual and Methodological Implications

Education is a complex system, which has conceptual and methodological implications for education research and policy. In this article, an overview is first provided of the Complex Systems Conceptual Framework for Learning (CSCFL), which consists of a set of conceptual perspectives that are generally shared by educational complex systems, organized into two focus areas: collective behaviors of a system, and behaviors of individual agents in a system. Complexity and research methodologies for education are then considered, and it is observed that commonly used quantitative and qualitative techniques are generally appropriate for studying linear dynamics of educational systems. However, it is proposed that computational modeling approaches, being extensively used for studying nonlinear characteristics of complex systems in other fields, can provide a methodological complement to quantitative and qualitative education research approaches. Two research case studies of this approach are discussed. We conclude with a consideration of how viewing education as a complex system using complex systems’ conceptual and methodological tools can help advance education research and also inform policy

Data-Oblivious Stream Productivity

We are concerned with demonstrating productivity of specifications of infinite streams of data, based on orthogonal rewrite rules. In general, this property is undecidable, but for restricted formats computable sufficient conditions can be obtained. The usual analysis disregards the identity of data, thus leading to approaches that we call data-oblivious. We present a method that is provably optimal among all such data-oblivious approaches. This means that in order to improve on the algorithm in this paper one has to proceed in a data-aware fashion

Comparison of analgesic effects and patient tolerability of nabilone and dihydrocodeine for chronic neuropathic pain: randomised, crossover, double blind study

<b>Objective</b>: To compare the analgesic efficacy and side effects of the synthetic cannabinoid nabilone with those of the weak opioid dihydrocodeine for chronic neuropathic pain. <b>Design</b>: Randomised, double blind, crossover trial of 14 weeks’ duration comparing dihydrocodeine and nabilone. <b>Setting</b>: Outpatient units of three hospitals in the United Kingdom. <b>Participants</b>: 96 patients with chronic neuropathic pain, aged 23-84 years. <b>Main outcome measures</b>: The primary outcome was difference between nabilone and dihydrocodeine in pain, as measured by the mean visual analogue score computed over the last 2 weeks of each treatment period. Secondary outcomes were changes in mood, quality of life, sleep, and psychometric function. Side effects were measured by a questionnaire. <b>Intervention</b>: Patients received a maximum daily dose of 240 mg dihydrocodeine or 2 mg nabilone at the end of each escalating treatment period of 6 weeks. Treatment periods were separated by a 2 week washout period. <b>Results</b>: Mean baseline visual analogue score was 69.6 mm (range 29.4-95.2) on a 0-100 mm scale. 73 patients were included in the available case analysis and 64 patients in the per protocol analysis. The mean score was 6.0 mm longer for nabilone than for dihydrocodeine (95% confidence interval 1.4 to 10.5) in the available case analysis and 5.6 mm (10.3 to 0.8) in the per protocol analysis. Side effects were more frequent with nabilone. <b>Conclusion</b>: Dihydrocodeine provided better pain relief than the synthetic cannabinoid nabilone and had slightly fewer side effects, although no major adverse events occurred for either drug

Where Do the Sick Go? Health Insurance and Employment in Small and Large Firms

Small firms that offer health insurance to their employees may face variable premiums if the firm hires an employee with high-expected health costs. To avoid expensive premium variability, a small firm may attempt to maintain a workforce with low-expected health costs. In addition, workers with high-expected health costs may prefer employment in larger firms with health insurance rather than in smaller firms. This results in employment distortions. We examine the magnitude of these employment distortions in hiring, employment, and separations, using the Medical Expenditure Panel Survey from 1996 to 2001. Furthermore, we examine the effect of state small group health insurance reforms that restrict insurers’ ability to deny coverage and restrict premium variability on employment distortions in small firms relative to large firms. We find that workers with high-expected health cost are less likely to be new hires in small firms that offer health insurance, and are less likely to be employed in insured small firms. However, we find no evidence that state small group health insurance reforms have reduced the extent of these distortions. Estimating the magnitude of employment distortions in insured small firms is essential in refining reforms to the small group health insurance market. The difficulties that small firms face in obtaining and maintaining health insurance for their employees have been widely documented (Brown, Hamilton and Medoff, 1990; McLaughlin,1992; Fronstin and Helman, 2000). Only 45% of firms with fewer than 50 employees offer health insurance compared to 97% of firms with 50 or more employees (AHRQ, 2002). This low proportion has been attributed, in part, to the high administrative cost of health insurance for small firms, the low demand for insurance among workers in these firms, and the unwillingness of insurers to take on small firm risks (McLaughlin, 1992, Fronstin and Helman, 2000, Monheit and Vistnes, 1999). In recent decades, small firms that provide health insurance to their employees were in a precarious position. Their premiums were calculated yearly, based on the expected value of their health care utilization. Hence, a single high cost employee could lead to a substantial surcharge on the premiums for the firm (Zellers, McLaughlin, and Frick, 1992). In a survey of small employers that did not offer health insurance, 75 percent claimed that an important reason for not offering insurance was high premium variability (Morrisey, Jensen and Morlock, 1994). Concerns about these problems fueled the passage of numerous state small group health insurance reforms in the 1990s that implemented premium rating reforms and restrictions on pre-existing condition exclusions. While a few states have implemented premium rating reform that has severely restricted small group insurers’ ability to use health status to set premiums, in most states, these reforms have been moderate. Assuming that firms are unable to perfectly tailor individual wages to individual health insurance costs, unexpectedly high premiums may impose a large burden on small firms. Paying high premiums, possibly financed by borrowing at high interest rates, may increase the risk of bankruptcy. If small firms choose not to pay high premiums, and instead drop insurance coverage, they renege on the implicit compensation contract with workers. Employers may opt to raise employee contributions to cover higher costs but large increases may lead to healthier employees dropping coverage. Faced with this predicament, small firms may choose to prevent expensive premium variability by maintaining a work force that has a low-expected utilization of health care services. Thus, the link between employment and health insurance in small firms may result in a welfare loss if it prevents individuals with high-expected health costs from being employed in small firm jobs in which they may have high match specific productivity. Employers may obtain information about employees’ medical conditions in several ways. Before the passage of the 1990 Americans with Disabilities Act (ADA), half of all employers conducted pre-employment medical examinations (U.S. Congress, 1988). Most small group employers required the completion of a family health questionnaire for insurance coverage (Zellers et al., 1992, Cutler 1994). While ADA now restricts employer inquiries on employee health, it does not apply to firms with under 15 employees. In addition, employer compliance with the ADA may be hindered because its stipulations about pre-employment health inquiries are vague. Medical inquires are allowed if they pertain to the applicant’s ability to perform the job. In addition, medical information is explicitly allowed in the use of medical underwriting for insurance (Epstein, 1996). The media continues to report cases where employers easily obtain employee medical records (Rubin, 1998), or employees have been laid-off because of high health costs (O’Connor, 1996), or employee premiums have been adjusted to reflect the employee’s claims experience (Kolata, 1992). The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes a nondiscrimination provision that bars a group health plan or issuer from discriminating in eligibility or contributions on the basis of a health status-related factor. However, HIPAA allows medical underwriting and allows insurers to rate groups of employees based on health status as long as the premium rate for all employees is blended. This stipulation prevents employers from requiring higher cost employees to contribute a higher premium share, but does not shield employers from bearing the costs for a sick worker. Economists have typically believed that health insurance is an attribute of “good jobs” and workers do not choose jobs based on whether or not the job provides health insurance. In fact, this precept is behind the notion that employment is a mechanism for minimizing adverse selection in the market for health insurance (see, for example, Gruber and Levitt, 2000). However, a number of recent studies have suggested that worker demand for health insurance may play an important role in employment decisions. Workers with high-expected family costs may prefer jobs that offer health insurance, and conversely, workers with low preferences for health insurance may sort into jobs that lack health insurance. (Monheit and Vistnes, 1999, Monheit and Vistnes, 2006, Royalty and Abraham, 2005, Bundorf and Pauly, 2004). In this paper, we use the Medical Expenditure Panel Survey (MEPS) from 1996 to 2001 to examine the magnitude of employment distortions for workers with high-expected health costs. Since health insurance and employment are linked, health insurance may be an important determinant of employment outcomes. High-expected health costs may reduce the probability that workers are employed in firms where they have the highest match specific productivity. We estimate the magnitude of distortions in hiring, employment, and separations. Furthermore, we examine the effect of state small group health insurance reforms that restrict insurers’ ability to deny coverage and restrict premium variability on employment distortions in small firms relative to large firms. Estimating the magnitude of employment distortions in insured small firms and understanding the effect of small group regulation on these distortions is essential in deciding optimal public policy towards the small group health insurance market.

Guided Unfoldings for Finding Loops in Standard Term Rewriting

In this paper, we reconsider the unfolding-based technique that we have introduced previously for detecting loops in standard term rewriting. We improve it by guiding the unfolding process, using distinguished positions in the rewrite rules. This results in a depth-first computation of the unfoldings, whereas the original technique was breadth-first. We have implemented this new approach in our tool NTI and compared it to the previous one on a bunch of rewrite systems. The results we get are promising (better times, more successful proofs).Comment: Pre-proceedings paper presented at the 28th International Symposium on Logic-Based Program Synthesis and Transformation (LOPSTR 2018), Frankfurt am Main, Germany, 4-6 September 2018 (arXiv:1808.03326

Longitudinal EEG power in the first postnatal year differentiates autism outcomes

An aim of autism spectrum disorder (ASD) research is to identify early biomarkers that inform ASD pathophysiology and expedite detection. Brain oscillations captured in electroencephalography (EEG) are thought to be disrupted as core ASD pathophysiology. We leverage longitudinal EEG power measurements from 3 to 36 months of age in infants at low- and high-risk for ASD to test how and when power distinguishes ASD risk and diagnosis by age 3-years. Power trajectories across the first year, second year, or first three years postnatally were submitted to data-driven modeling to differentiate ASD outcomes. Power dynamics during the first postnatal year best differentiate ASD diagnoses. Delta and gamma frequency power trajectories consistently distinguish infants with ASD diagnoses from others. There is also a developmental shift across timescales towards including higher-frequency power to differentiate outcomes. These findings reveal the importance of developmental timing and trajectory in understanding pathophysiology and classifying ASD outcomes.R01 DC010290 - NIDCD NIH HHS; T32 MH112510 - NIMH NIH HHS; U54 HD090255 - NICHD NIH HHSPublished versio

Flexible copper-indium-diselenide films and devices for space applications

With the ever increasing demands on space power systems, it is imperative that low cost, lightweight, reliable photovoltaics be developed. One avenue of pursuit for future space power applications is the use of low cost, lightweight flexible PV cells and arrays. Most work in this area assumes the use of flexible amorphous silicon (a-Si), despite its inherent instability and low efficiencies. However, polycrystalline thin film PV such as copper-indium-diselenide (CIS) are inherently more stable and exhibit better performance than a-Si. Furthermore, preliminary data indicate that CIS also offers exciting properties with respect to space applications. However, CIS has only heretofore only produced on rigid substrates. The implications of flexible CIS upon present and future space power platforms was explored. Results indicate that space qualified CIS can dramatically reduce the cost of PV, and in most cases, can be substituted for silicon (Si) based on end-of-life (EOL) estimations. Furthermore, where cost is a prime consideration, CIS can become cost effective than gallium arsenide (GaAs) in some applications. Second, investigations into thin film deposition on flexible substrates were made, and data from these tests indicate that fabrication of flexible CIS devices is feasible. Finally, data is also presented on preliminary TCO/CdS/CuInSe2/Mo devices