Effect of Testing and Treatment on Emergency Department Length of Stay Using a National Database

Objectives:  Testing and treatment are essential aspects of the delivery of emergency care. Recognition of the effects of these activities on emergency department (ED) length of stay (LOS) has implications for administrators planning efficient operations, providers, and patients regarding expectations for length of visit; researchers in creating better models to predict LOS; and policy‐makers concerned about ED crowding. Methods:  A secondary analysis was performed using years 2006 through 2008 of the National Hospital Ambulatory Medical Care Survey (NHAMCS), a nationwide study of ED services. In univariate and bivariate analyses, the authors assessed ED LOS and frequency of testing (blood test, urinalysis, electrocardiogram [ECG], radiograph, ultrasound, computed tomography [CT], or magnetic resonance imaging [MRI]) and treatment (providing a medication or performance of a procedure) according to disposition (discharged or admitted status). Two sets of multivariable models were developed to assess the contribution of testing and treatment to LOS, also stratified by disposition. The first was a series of logistic regression models to provide an overview of how testing and treatment activity affects three dichotomized LOS cutoffs at 2, 4, and 6 hours. The second was a generalized linear model (GLM) with a log‐link function and gamma distribution to fit skewed LOS data, which provided time costs associated with tests and treatment. Results:  Among 360 million weighted ED visits included in this analysis, 227 million (63%) involved testing, 304 million (85%) involved treatment, and 201 million (56%) involved both. Overall, visits with any testing were associated with longer LOS (median = 196 minutes; interquartile range [IQR] = 125 to 305 minutes) than those with any treatment (median = 159 minutes; IQR = 91 to 262 minutes). This difference was more pronounced among discharged patients than admitted patients. Obtaining a test was associated with an adjusted odds ratio (OR) of 2.29 (95% confidence interval [CI] = 1.86 to 2.83) for experiencing a more than 4‐hour LOS, while performing a treatment had no effect (adjusted OR = 0.84; 95% CI = 0.68 to 1.03). The most time‐costly testing modalities included blood test (adjusted marginal effects on LOS = +72 minutes; 95% CI = 66 to 78 minutes), MRI (+64 minutes; 95% CI = 36 to 93 minutes), CT (+59 minutes; 95% CI = 54 to 65 minutes), and ultrasound (US; +56 minutes; 95% CI = 45 to 67 minutes). Treatment time costs were less substantial: performing a procedure (+24 minutes; 95% CI = 20 to 28 minutes) and providing a medication (+15 minutes; 95% CI = 8 to 21 minutes). Conclusions:  Testing and less substantially treatment were associated with prolonged LOS in the ED, particularly for blood testing and advanced imaging. This knowledge may better direct efforts at streamlining delivery of care for the most time‐costly diagnostic modalities or suggest areas for future research into improving processes of care. Developing systems to improve efficient utilization of these services in the ED may improve patient and provider satisfaction. Such practice improvements could then be examined to determine their effects on ED crowding.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/92123/1/j.1553-2712.2012.01353.x.pd

A latent variable approach to potential outcomes for emergency department admission decisions

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/151329/1/sim8210.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151329/2/sim8210_am.pd

Targeting FGFR signaling to disrupt cellular cross-talk in pancreatic cancer

PhD Thesi

Social preferences, accountability, and wage bargaining

We assess the extent of preferences for employment in a collective wage bargaining situation with heterogeneous workers. We vary the size of the union and introduce a treatment mechanism transforming the voting game into an individual allocation task. Our results show that highly productive workers do not take employment of low productive workers into account when making wage proposals, regardless of whether insiders determine the wage or all workers. The level of pro-social preferences is small in the voting game, while it increases as the game is transformed into an individual allocation task. We interpret this as an accountability effect

Monitoring and Pay: An Experiment on Employee Performance under Endogenous Supervision

We present an experimental test of a shirking model where monitoring intensity is endogenous and effort a continuous variable. Wage level, monitoring intensity and consequently the desired enforceable effort level are jointly determined by the maximization problem of the firm. As a result, monitoring and pay should be complements. In our experiment, between and within treatment variation is qualitatively in line with the normative predictions of the model under standard assumptions. Yet, we also find evidence for reciprocal behavior. Our data analysis shows, however, that it does not pay for the employer to solely rely on the reciprocity of employees

Centrosome amplification mediates small extracellular vesicles secretion via lysosome disruption

PreprintSummary Bidirectional communication between cells and their surrounding environment is critical in both normal and pathological settings. Extracellular vesicles (EVs), which facilitate the horizontal transfer of molecules between cells, are recognized as an important constituent of cell-cell communication. In cancer, alterations in EV secretion contribute to the growth and metastasis of tumor cells. However, the mechanisms underlying these changes remain largely unknown. Here, we show that centrosome amplification is associated with and sufficient to promote small extracellular vesicle ( S EV) secretion in pancreatic cancer cells. This is a direct result due of lysosomal dysfunction, caused by increased reactive oxygen species (ROS) downstream of extra centrosomes. Defects in lysosome function promotes multivesicular body fusion with the plasma membrane, thereby enhancing S EV secretion. Furthermore, we find that S EVs secreted in response to amplified centrosomes are functionally distinct and activate pancreatic stellate cells (PSCs). These activated PSCs promote the invasion of pancreatic cancer cells in heterotypic 3-D cultures. We propose that S EVs secreted by cancer cells with amplified centrosomes influence the bidirectional communication between the tumor cells and the surrounding stroma to promote malignancy

On the automatic construction of indistinguishable operations

An increasingly important design constraint for software running on ubiquitous computing devices is security, particularly against physical methods such as side-channel attack. One well studied methodology for defending against such attacks is the concept of indistinguishable functions which leak no information about program control flow since all execution paths are computationally identical. However, constructing such functions by hand becomes laborious and error prone as their complexity increases. We investigate techniques for automating this process and find that effective solutions can be constructed with only minor amounts of computational effort.Fundação para a Ciência e Tecnologia - SFRH/BPD/20528/2004

Other People’S Money: A Visual Technology for Teaching Corporate Restructuring Cross-Functionally

This article presents a detailed plan for using the movie Other People's Money as an integrative technology to teach organizational behavior and finance concepts crossfunctionally. The movie depicts corporate restructuring issues in a comic manner, while still conveying a message. It incorporates topics such as differing organizational models and perpectives, leadership, managerial goals, and stakeholder needs/wants. It also helps students learn about mergers and acquisitions including topics like takeovers, tender offers, and greenmail while stimulating thinking aout complex ethical issues. This teaching tool can be incorporated in undergraduate or graduate business classes, or as a module for management education in corporate settings. The teaching notes include a vocabulary list, suggested stopping points with discussion questions, and a set of postmovie questions to reinforce related concepts and motivate further study.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/68685/2/10.1177_105256299902300106.pd

The OPERA experiment Target Tracker

The main task of the Target Tracker detector of the long baseline neutrino oscillation OPERA experiment is to locate in which of the target elementary constituents, the lead/emulsion bricks, the neutrino interactions have occurred and also to give calorimetric information about each event. The technology used consists in walls of two planes of plastic scintillator strips, one per transverse direction. Wavelength shifting fibres collect the light signal emitted by the scintillator strips and guide it to both ends where it is read by multi-anode photomultiplier tubes. All the elements used in the construction of this detector and its main characteristics are described.Comment: 25 pages, submitted to Nuclear Instrument and Method