1,657 research outputs found
Team Effect on Variation in Laboratory Utilization on Subspecialty Services
Background: The objective was to determine whether variation in laboratory utilization exists and whether physicians were responsible for a portion of this variation.
Method: Variation in laboratory test ordering was collected on subspecialty services: the Medical Intensive Care Unit (MICU) and the Oncology Service. Ordinary least-squares regression was used to determine the effect of interns, residents, and attendings on the variation observed.
Results: Variation in laboratory utilization attributable to physicians exists. Housestaff explain a proportion of this variation on each subspecialty service.
Conclusions: Housestaff explain a large proportion of laboratory utilization attributable to physicians. This may represent an opportunity for education on systems-based practice and practice-based learning.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/65005/1/09.Dine.Bellini.I.Acad.Med.pd
The Impact of Residents, Interns, and Attendings on Inpatient Laboratory Ordering Patterns: A Report From One University's Hospitalist Service
Purpose: To examine the laboratory test ordering patterns of interns to determine the effects of more senior residents' and attendings' supervision on trainees' patterns and residents' perceptions of control in test ordering.
Method: In a 2007 cohort study of 2,066 patients cared for by 85 interns, 56 residents, and 27 attendings on the University of Pennsylvania general medical hospitalist service, the authors studied variation in laboratory test utilization and costs in 10,908 patient-days. Ordinary least squares regression was used to partition variance among supervised and supervising physicians. Interns and residents were surveyed about their perceived control over lab test ordering.
Results: Forty-five percent (95% confidence interval [CI]: 39–53) of the variation in laboratory test utilization was attributable to interns' ordering, 26% (95% CI: 21–34) to residents, and 9% (95% CI: 7–16) to attendings; 20% (95% CI: 6–25) could not be uniquely attributed to a particular level of the care team. Similar results were obtained for variation in laboratory costs. Interns underestimated their control over laboratory test utilization, residents overestimated their control, and both groups had inaccurate assessments of their utilization relative to peers.
Conclusions: Attending faculty had relatively little impact on laboratory ordering patterns. This may reflect a consistent baseline impact of attending physicians on laboratory use, but it may also represent a missed opportunity to reduce practice variation and improve patient care. Observing variation in trainee practice patterns in the face of different supervisors represents a new approach to measuring the supervision in clinical settings.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78540/1/11.Acad.Med.Intern.Resident.Faculty.Variation.lab.Ordering.pd
Teaching Hospital Five-Year Mortality Trends in the Wake of Duty Hour Reforms
Background
The Accreditation Council for Graduate Medical Education (ACGME) implemented duty hour regulations for residents in 2003 and again in 2011. While previous studies showed no systematic impacts in the first 2 years post-reform, the impact on mortality in subsequent years has not been examined. OBJECTIVE
To determine whether duty hour regulations were associated with changes in mortality among Medicare patients in hospitals of different teaching intensity after the first 2 years post-reform. DESIGN
Observational study using interrupted time series analysis with data from July 1, 2000 to June 30, 2008. Logistic regression was used to examine the change in mortality for patients in more versus less teaching-intensive hospitals before (2000–2003) and after (2003–2008) duty hour reform, adjusting for patient comorbidities, time trends, and hospital site. PATIENTS
Medicare patients (n = 13,678,956) admitted to short-term acute care non-federal hospitals with principal diagnoses of acute myocardial infarction (AMI), gastrointestinal bleeding, or congestive heart failure (CHF); or a diagnosis-related group (DRG) classification of general, orthopedic, or vascular surgery. MAIN MEASURE
All-location mortality within 30 days of hospital admission. KEY RESULTS
In medical and surgical patients, there were no consistent changes in the odds of mortality at more vs. less teaching intensive hospitals in post-reform years 1–3. However, there were significant relative improvements in mortality for medical patients in the fourth and fifth years post-reform: Post4 (OR 0.88, 95 % CI [0.93–0.94]); Post5 (OR 0.87, [0.82–0.92]) and for surgical patients in the fifth year post-reform: Post5 (OR 0.91, [0.85–0.96]). CONCLUSIONS
Duty hour reform was associated with no significant change in mortality in the early years after implementation, and with a trend toward improved mortality among medical patients in the fourth and fifth years. It is unclear whether improvements in outcomes long after implementation can be attributed to the reform, but concerns about worsening outcomes seem unfounded
A Randomized Trial of Nighttime Physician Staffing in an Intensive Care Unit
Background
Increasing numbers of intensive care units (ICUs) are adopting the practice of nighttime intensivist staffing despite the lack of experimental evidence of its effectiveness.
Methods
We conducted a 1-year randomized trial in an academic medical ICU of the effects of nighttime staffing with in-hospital intensivists (intervention) as compared with nighttime coverage by daytime intensivists who were available for consultation by telephone (control). We randomly assigned blocks of 7 consecutive nights to the intervention or the control strategy. The primary outcome was patients’ length of stay in the ICU. Secondary outcomes were patients’ length of stay in the hospital, ICU and in-hospital mortality, discharge disposition, and rates of readmission to the ICU. For length-of-stay outcomes, we performed time-to-event analyses, with data censored at the time of a patient’s death or transfer to another ICU.
Results
A total of 1598 patients were included in the analyses. The median Acute Physiology and Chronic Health Evaluation (APACHE) III score (in which scores range from 0 to 299, with higher scores indicating more severe illness) was 67 (interquartile range, 47 to 91), the median length of stay in the ICU was 52.7 hours (interquartile range, 29.0 to 113.4), and mortality in the ICU was 18%. Patients who were admitted on intervention days were exposed to nighttime intensivists on more nights than were patients admitted on control days (median, 100% of nights [interquartile range, 67 to 100] vs. median, 0% [interquartile range, 0 to 33]; P\u3c0.001). Nonetheless, intensivist staffing on the night of admission did not have a significant effect on the length of stay in the ICU (rate ratio for the time to ICU discharge, 0.98; 95% confidence interval [CI], 0.88 to 1.09; P=0.72), ICU mortality (relative risk, 1.07; 95% CI, 0.90 to 1.28), or any other end point. Analyses restricted to patients who were admitted at night showed similar results, as did sensitivity analyses that used different definitions of exposure and outcome.
Conclusions
In an academic medical ICU in the United States, nighttime in-hospital intensivist staffing did not improve patient outcomes. (Funded by University of Pennsylvania Health System and others; ClinicalTrials.gov number, NCT01434823.
Scalar perturbation spectra from warm inflation
We present a numerical integration of the cosmological scalar perturbation
equations in warm inflation. The initial conditions are provided by a
discussion of the thermal fluctuations of an inflaton field and thermal
radiation using a combination of thermal field theory and thermodynamics. The
perturbation equations include the effects of a damping coefficient
and a thermodynamic potential . We give an analytic expression for the
spectral index of scalar fluctuations in terms of a new slow-roll parameter
constructed from . A series of toy models, inspired by spontaneous
symmetry breaking and a known form of the damping coefficient, lead to a
spectrum with on large scales and on small scales.Comment: 12 pages, 5 figures, RevTeX 4, revised with extra figure
Resonant decay of gravitational waves into dark energy
We study the decay of gravitational waves into dark energy fluctuations \u3c0, taking into account the large occupation numbers. We describe dark energy using the effective field theory approach, in the context of generalized scalar-tensor theories. When the m33 (cubic Horndeski) and 3c m42 (beyond Horndeski) operators are present, the gravitational wave acts as a classical background for \u3c0 and modifies its dynamics. In particular, \u3c0 fluctuations are described by a Mathieu equation and feature instability bands that grow exponentially. Focusing on the regime of small gravitational-wave amplitude, corresponding to narrow resonance, we calculate analytically the produced \u3c0, its energy and the change of the gravitational-wave signal. The resonance is affected by \u3c0 self-interactions in a way that we cannot describe analytically. This effect is very relevant for the operator m33 and it limits the instability. In the case of the 3c m42 operator self-interactions can be neglected, at least in some regimes. The modification of the gravitational-wave signal is observable for 3
7 10-20 64 \u3b1H 64 10-17 with a LIGO/Virgo-like interferometer and for 10-16 64 \u3b1H 64 10-10 with a LISA-like one
Multi-particle azimuthal correlations in p-Pb and Pb-Pb collisions at the CERN Large Hadron Collider
Measurements of multi-particle azimuthal correlations (cumulants) for charged
particles in p-Pb and Pb-Pb collisions are presented. They help address the
question of whether there is evidence for global, flow-like, azimuthal
correlations in the p-Pb system. Comparisons are made to measurements from the
larger Pb-Pb system, where such evidence is established. In particular, the
second harmonic two-particle cumulants are found to decrease with multiplicity,
characteristic of a dominance of few-particle correlations in p-Pb collisions.
However, when a gap is placed to suppress such correlations,
the two-particle cumulants begin to rise at high-multiplicity, indicating the
presence of global azimuthal correlations. The Pb-Pb values are higher than the
p-Pb values at similar multiplicities. In both systems, the second harmonic
four-particle cumulants exhibit a transition from positive to negative values
when the multiplicity increases. The negative values allow for a measurement of
to be made, which is found to be higher in Pb-Pb collisions at
similar multiplicities. The second harmonic six-particle cumulants are also
found to be higher in Pb-Pb collisions. In Pb-Pb collisions, we generally find
which is indicative of a Bessel-Gaussian
function for the distribution. For very high-multiplicity Pb-Pb
collisions, we observe that the four- and six-particle cumulants become
consistent with 0. Finally, third harmonic two-particle cumulants in p-Pb and
Pb-Pb are measured. These are found to be similar for overlapping
multiplicities, when a gap is placed.Comment: 25 pages, 11 captioned figures, 3 tables, authors from page 20,
published version, figures at http://aliceinfo.cern.ch/ArtSubmission/node/87
Multiplicity dependence of jet-like two-particle correlations in p-Pb collisions at = 5.02 TeV
Two-particle angular correlations between unidentified charged trigger and
associated particles are measured by the ALICE detector in p-Pb collisions at a
nucleon-nucleon centre-of-mass energy of 5.02 TeV. The transverse-momentum
range 0.7 5.0 GeV/ is examined,
to include correlations induced by jets originating from low
momen\-tum-transfer scatterings (minijets). The correlations expressed as
associated yield per trigger particle are obtained in the pseudorapidity range
. The near-side long-range pseudorapidity correlations observed in
high-multiplicity p-Pb collisions are subtracted from both near-side
short-range and away-side correlations in order to remove the non-jet-like
components. The yields in the jet-like peaks are found to be invariant with
event multiplicity with the exception of events with low multiplicity. This
invariance is consistent with the particles being produced via the incoherent
fragmentation of multiple parton--parton scatterings, while the yield related
to the previously observed ridge structures is not jet-related. The number of
uncorrelated sources of particle production is found to increase linearly with
multiplicity, suggesting no saturation of the number of multi-parton
interactions even in the highest multiplicity p-Pb collisions. Further, the
number scales in the intermediate multiplicity region with the number of binary
nucleon-nucleon collisions estimated with a Glauber Monte-Carlo simulation.Comment: 23 pages, 6 captioned figures, 1 table, authors from page 17,
published version, figures at
http://aliceinfo.cern.ch/ArtSubmission/node/161
Charge separation relative to the reaction plane in Pb-Pb collisions at TeV
Measurements of charge dependent azimuthal correlations with the ALICE
detector at the LHC are reported for Pb-Pb collisions at TeV. Two- and three-particle charge-dependent azimuthal correlations in
the pseudo-rapidity range are presented as a function of the
collision centrality, particle separation in pseudo-rapidity, and transverse
momentum. A clear signal compatible with a charge-dependent separation relative
to the reaction plane is observed, which shows little or no collision energy
dependence when compared to measurements at RHIC energies. This provides a new
insight for understanding the nature of the charge dependent azimuthal
correlations observed at RHIC and LHC energies.Comment: 12 pages, 3 captioned figures, authors from page 2 to 6, published
version, figures at http://aliceinfo.cern.ch/ArtSubmission/node/286
A note on comonotonicity and positivity of the control components of decoupled quadratic FBSDE
In this small note we are concerned with the solution of Forward-Backward
Stochastic Differential Equations (FBSDE) with drivers that grow quadratically
in the control component (quadratic growth FBSDE or qgFBSDE). The main theorem
is a comparison result that allows comparing componentwise the signs of the
control processes of two different qgFBSDE. As a byproduct one obtains
conditions that allow establishing the positivity of the control process.Comment: accepted for publicatio
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