Bending the Curve: Options for Achieving Savings and Improving Value in Health Spending

Analyzes the potential of fifteen federal health policy options to lower spending over the next ten years and yield higher value on investments in health care

Effects of Aging in Pointing to Visible and Remembered Targets

Most studies that have compared pointing to visible versus remembered targets have involved situations when both the limb and target are present (closed loop-target present), or when both the limb and target are occluded (open loop-target absent). This comparison confounds vision of the target with vision of the hand. In order to dissociate these two sources of visual information in pointing, it is necessary to examine conditions in which only one of these sources of information is occluded, that is, when only vision of the hand (open loop-target present) or vision of the target (closed loop-target absent) is occluded. Some studies have compared subsets of these four conditions to examine, for example, the role of vision of the hand in pointing where the target is present throughout the movement but vision of the hand is occluded (open loop) or not (closed loop). Very few studies to date have compared all of these conditions to examine the relative contribution of these two sources of information in pointing. The purpose of this study was to make these comparisons and to examine whether aging had an effect on how these sources of information were used in pointing. To address this, we asked young (N=10, mean age = 21.8 years, 6 females, 4 males) and older (N=9, mean age = 73.8 years, 4 females, 5 males) right-handed adults to point to each of three targets: one situated at the midline and one each at 45 degrees to the left (contralateral) and right (ipsilateral) of the midline, while manipulating whether participants had vision of their pointing limb, the target, or both. In target-absent trials, the time between target occlusion and movement initiation was also manipulated (movement initiation immediately after occlusion or following a delay of 2 seconds) to examine the time course of the representation of target information in memory. All conditions were randomized between each participant. Results showed vision of the limb significantly affects the movement in a positive manner, such that endpoint error and variability were less than conditions in which the limb was not available during movement. This was true for both target present and absent actions, suggesting limb vision provides crucial visual and proprioceptive information to result in a much more precise and consistent movement to targets. This information may also be more important to the participant than target presence, in terms of accuracy and variability, as there tended to be little differences between target present and target absence trials. Where target presence made a difference was during the decelerative phase of movement time (after peak velocity has been reached), where relatively more time was allotted in this period when the target was visible throughout the movement. Because this time is indicative of online feedback processing, this suggests that vision of the target was contributing some type of information to the movement. Interestingly, there was no significant main effect of age group in this study. However, age did play a role in the way participants moved to the targets. In the directional (x) axis, young adults were more likely to aim to targets that were biased further from their body, whereas elderly adult participants displayed the opposite bias: their accuracy data show they tend to aim closer to their body

Hospital ownership and financial performance: a quantitative research review

We apply meta-analytic methods to conduct a quantitative review of the empirical literature since 1999 comparing financial performance of US for-profit, not-for-profit, and government-owned general acute hospitals. We find that tthe diverse results in the hospital ownership literature can be explained largely by differences in authors' underlying theoretical frameworks, assumptions about the functional form of the dependent variables, and model specifications. Weaker methods and functional forms tend to predict larger differences in financial performance between not-for-profits and for-profits. The combined estimates across studies suggest little difference in cost among all three types of hospital ownership, and that for-profit hospitals generate more revenue and greater profits than not-for-prorfits hospitals, alhough the difference is only of modest economic significance. There is little difference in revenue or profits between government and not-for-profit hospitals

Multistage quadratic stochastic programming

Multistage stochastic programming is an important tool in medium to long term planning where there are uncertainties in the data. In this thesis, we consider a special case of multistage stochastic programming in which each subprogram is a convex quadratic program. The results are also applicable if the quadratic objectives are replaced by convex piecewise quadratic functions. Convex piecewise quadratic functions have important application in financial planning problems as they can be used as very flexible risk measures. The stochastic programming problems can be used as multi-period portfolio planning problems tailored to the need of individual investors. Using techniques from convex analysis and sensitivity analysis, we show that each subproblem of a multistage quadratic stochastic program is a polyhedral piecewise quadratic program with convex Lipschitz objective. The objective of any subproblem is differentiable with Lipschitz gradient if all its descendent problems have unique dual variables, which can be guaranteed if the linear independence constraint qualification is satisfied. Expression for arbitrary elements of the subdifferential and generalized Hessian at a point can be calculated for quadratic pieces that are active at the point. Generalized Newton methods with linesearch are proposed for solving multistage quadratic stochastic programs. The algorithms converge globally. If the piecewise quadratic objective is differentiable and strictly convex at the solution, then convergence is also finite. A generalized Newton algorithm is implemented in Matlab. Numerical experiments have been carried out to demonstrate its effectiveness. The algorithm is tested on random data with 3, 4 and 5 stages with a maximum of 315 scenarios. The algorithm has also been successfully applied to two sets of test data from a capacity expansion problem and a portfolio management problem. Various strategies have been implemented to improve the efficiency of the proposed algorithm. We experimented with trust region methods with different parameters, using an advanced solution from a smaller version of the original problem and sorting the stochastic right hand sides to encourage faster convergence. The numerical results show that the proposed generalized Newton method is a highly accurate and effective method for multistage quadratic stochastic programs. For problems with the same number of stages, solution times increase linearly with the number of scenarios

Hospital ownership and quality of care: what explains the different results?

Does quality of care systematically differ among government-owned, private not-for-profit, and for-profit hospitals? A large empirical literature provides conflicting evidance. Through quantitative review of 46 studies since 1990, we find that several study features that can explain divergent results: analytic methods, disease studied, and data sources. For unprofitable care, how studies handle market competition and regional differences account for substantial variation. Policymakers should be aware that differences in results appear to arise predominately from differences between studies' analytic methods. Moreover, conventional methods of meta-analysis synthesis should be applied with great caution given the considerable overlap among studied hospitals

Variación interanual en la tasa de crecimiento de pichones de Pingüino de Humboldt (Spheniscus Humboldti, Meyen 1834) en punta San Juan-Ica periodo 2000-2019

El desarrollo de los pichones durante la época de guardia parental puede reflejar las adaptaciones que tienen las especies a efectos adversos durante el ciclo reproductivo y/o las adaptaciones que pueden haber adquirido con el tiempo. El pingüino de Humboldt es un depredador tope endémico del Sistema de la Corriente de Humboldt, un lugar sujeto a fluctuaciones climáticas que condicionan la abundancia de alimento disponible para esta especie. En la presente investigación se estimó y comparó la tasa de crecimiento de los pichones de Spheniscus humboldti interanualmente y se determinó si existe relación con las anomalías de la temperatura superficial del mar entre 2000-2019. Se analizaron aproximadamente 16000 registros de datos morfométricos durante los 20 años de estudio; éstos fueron ajustados a regresiones no lineales de la familia de las curvas logísticas. Se visualizó el aumento de peso y el crecimiento de las medidas morfométricas cada año para evaluar la variación interanual. Posterior al ajuste se analizó la tasa de aumento de peso diario y se correlacionó con la anomalía de la temperatura superficial del mar de las estaciones de verano y otoño. De las medidas morfométricas evaluadas, los apéndices óseos muestran un desarrollo constante y con poca variación interanual durante el periodo de estudio, mientras que el peso fluctúa interanualmente. Se observa una correlación negativa no significativa con la anomalía de la temperatura superficial del mar, lo que implica que hay más factores externos que afectan al crecimiento

Pairing status and stimulus type predict responses to audio playbacks in female titi monkeys

Some paired primates use complex, coordinated vocal signals to communicate within and between family groups. The information encoded within those signals is not well understood, nor is the intricacy of individuals’ behavioral and physiological responses to these signals. Considering the conspicuous nature of these vocal signals, it is a priority to better understand paired primates’ responses to conspecific calls. Pair-bonded titi monkeys (Plecturocebus cupreus) sing duets comprised of the male and female’s long call. Here, we use a playback study to assess female titi monkeys’ responses to different vocal stimuli based on the subject’s pairing status. Six adult female titi monkeys participated in the study at two timepoints—pre-pairing and post-pairing. At each timepoint, subjects underwent three distinct playbacks—control recording, male solo vocalization, and pair duet. Behaviors such as locomotion and vocalizations were scored during and after the playback, and cortisol and androgen values were assessed via a plasma blood sample. Female titi monkeys attended more to social signals compared to the control, regardless of pairing status. However, in the time immediately following any playback type, female titi monkeys trilled more and spent a greater proportion of time locomoting during pre-pairing timepoints (compared to post-pairing). Female titi monkeys’ behavioral responses to social audio stimuli, combined with subjects’ increases in cortisol and androgens as paired individuals, imply female titi monkeys attend and respond to social signals territorially

Cultural respect encompassing simulation training: being heard about health through broadband

BACKGROUND: Cultural Respect Encompassing Simulation Training (CREST) is a learning program that uses simulation to provide health professional students and practitioners with strategies to communicate sensitively with culturally and linguistically diverse (CALD) patients. It consists of training modules with a cultural competency evaluation framework and CALD simulated patients to interact with trainees in immersive simulation scenarios. The aim of this study was to test the feasibility of expanding the delivery of CREST to rural Australia using live video streaming; and to investigate the fidelity of cultural sensitivity - defined within the process of cultural competency which includes awareness, knowledge, skills, encounters and desire - of the streamed simulations. DESIGN AND METHODS: In this mixed-methods evaluative study, health professional trainees were recruited at three rural academic campuses and one rural hospital to pilot CREST sessions via live video streaming and simulation from the city campus in 2014. Cultural competency, teaching and learning evaluations were conducted. RESULTS: Forty-five participants rated 26 reliable items before and after each session and reported statistically significant improvement in 4 of 5 cultural competency domains, particularly in cultural skills (P<0.05). Qualitative data indicated an overall acknowledgement amongst participants of the importance of communication training and the quality of the simulation training provided remotely by CREST. CONCLUSIONS: Cultural sensitivity education using live video-streaming and simulation can contribute to health professionals\u27 learning and is effective in improving cultural competency. CREST has the potential to be embedded within health professional curricula across Australian universities to address issues of health inequalities arising from a lack of cultural sensitivity training. Significance for public healthThere are significant health inequalities for migrant populations. They commonly have poorer access to health services and poorer health outcomes than the Australian-born population. The factors are multiple, complex and include language and cultural barriers. To address these disparities, culturally competent patient-centred care is increasingly recognised to be critical to improving care quality, patient satisfaction, patient compliance and patient outcomes. Yet there is a lack of quality in the teaching and learning of cultural competence in healthcare education curricula, particularly in rural settings where qualified trainers and resources can be limited. The Cultural Respect Encompassing Simulation Training (CREST) program offers opportunities to health professional students and practitioners to learn and develop communication skills with professionally trained culturally and linguistically diverse simulated patients who contribute their experiences and health perspectives. It has already been shown to contribute to health professionals\u27 learning and is effective in improving cultural competency in urban settings. This study demonstrates that CREST when delivered via live video-streaming and simulation can achieve similar results in rural settings

Cultural respect encompassing simulation training: being heard about health through broadband

Background. Cultural Respect Encompassing Simulation Training (CREST) is a learning program that uses simulation to provide health professional students and practitioners with strategies to communicate sensitively with culturally and linguistically diverse (CALD) patients. It consists of training modules with a cultural competency evaluation framework and CALD simulated patients to interact with trainees in immersive simulation scenarios. The aim of this study was to test the feasibility of expanding the delivery of CREST to rural Australia using live video streaming; and to investigate the fidelity of cultural sensitivity – defined within the process of cultural competency which includes awareness, knowledge, skills, encounters and desire – of the streamed simulations. Design and Methods. In this mixed-methods evaluative study, health professional trainees were recruited at three rural academic campuses and one rural hospital to pilot CREST sessions via live video streaming and simulation from the city campus in 2014. Cultural competency, teaching and learning evaluations were conducted. Results. Forty-five participants rated 26 reliable items before and after each session and reported statistically significant improvement in 4 of 5 cultural competency domains, particularly in cultural skills (P<0.05). Qualitative data indicated an overall acknowledgement amongst participants of the importance of communication training and the quality of the simulation training provided remotely by CREST. Conclusions. Cultural sensitivity education using live video-streaming and simulation can contribute to health professionals’ learning and is effective in improving cultural competency. CREST has the potential to be embedded within health professional curricula across Australian universities to address issues of health inequalities arising from a lack of cultural sensitivity training