Brief Announcement: Simple Majority Consensus in Networks with Unreliable Communication

In this work, we consider a synchronous model of n faultless agents, with a complete communication graph and messages that are lost with some constant probability q ? (0,1). In this model we show that there exists a protocol, called the Simple Majority Protocol, that solves consensus in 3 communication rounds with probability of agreement converging to 1 as n ? ?. We also prove that 3 communication rounds are necessary for the SMP to achieve consensus, with high probability

Multicultural Transitions: Caregiver Presence and Language-Concordance at Discharge

Introduction: Patients with low health literacy (HL) and minority patients encounter many challenges during hospital to community transitions. We assessed care transitions of minority patients with various HL levels and tested whether presence of caregivers and provision of language-concordant care are associated with better care transitions. Methods: A prospective cohort study of 598 internal medicine patients, Hebrew, Russian, or Arabic native speakers, at a tertiary medical center in central Israel, from 2013 to 2014. HL was assessed at baseline with the Brief Health Literacy Screen. A follow-up telephone survey was used to administer the Care Transition Measure [CTM] and to assess, caregiver presence and patient–provider language-concordance at discharge. Results: Patients with low HL and without language-concordance or caregiver presence had the lowest CTM scores (33.1, range 0–100). When language-concordance and caregivers were available, CTM scores did not differ between the medium-high and low HL groups (68.7 and 66.9, respectively, p = 0.118). The adjusted analysis, showed that language-concordance and caregiver presence during discharge moderate the relationship between HL and patients’ care transition experience ('p' < 0.001). Conclusions: Language-concordance care and caregiver presence are associated with higher patients’ ratings of the transitional-care experience among patients with low HL levels and among minorities

Assessing socioeconomic health care utilization inequity in Israel: impact of alternative approaches to morbidity adjustment

<p/> <p>Background</p> <p>The ability to accurately detect differential resource use between persons of different socioeconomic status relies on the accuracy of health-needs adjustment measures. This study tests different approaches to morbidity adjustment in explanation of health care utilization inequity.</p> <p>Methods</p> <p>A representative sample was selected of 10 percent (~270,000) adult enrolees of Clalit Health Services, Israel's largest health care organization. The Johns-Hopkins University Adjusted Clinical Groups^®were used to assess each person's overall morbidity burden based on one year's (2009) diagnostic information. The odds of above average health care resource use (primary care visits, specialty visits, diagnostic tests, or hospitalizations) were tested using multivariate logistic regression models, separately adjusting for levels of health-need using data on age and gender, comorbidity (using the Charlson Comorbidity Index), or morbidity burden (using the Adjusted Clinical Groups). Model fit was assessed using tests of the Area Under the Receiver Operating Characteristics Curve and the Akaike Information Criteria.</p> <p>Results</p> <p>Low socioeconomic status was associated with higher morbidity burden (1.5-fold difference). Adjusting for health needs using age and gender or the Charlson index, persons of low socioeconomic status had greater odds of above average resource use for all types of services examined (primary care and specialist visits, diagnostic tests, or hospitalizations). In contrast, after adjustment for overall morbidity burden (using Adjusted Clinical Groups), low socioeconomic status was no longer associated with greater odds of specialty care or diagnostic tests (OR: 0.95, CI: 0.94-0.99; and OR: 0.91, CI: 0.86-0.96, for specialty visits and diagnostic respectively). Tests of model fit showed that adjustment using the comprehensive morbidity burden measure provided a better fit than age and gender or the Charlson Index.</p> <p>Conclusions</p> <p>Identification of socioeconomic differences in health care utilization is an important step in disparity reduction efforts. Adjustment for health-needs using a comprehensive morbidity burden diagnoses-based measure, this study showed relative underutilization in use of specialist and diagnostic services, and thus allowed for identification of inequity in health resources use, which could not be detected with less comprehensive forms of health-needs adjustments.</p

Simple Majority Consensus in Networks with Unreliable Communication

In this work, we analyze the performance of a simple majority-rule protocol solving a fundamental coordination problem in distributed systems—binary majority consensus— in the presence of probabilistic message loss. Using probabilistic analysis for a large-scale, fully-connected, network of 2n agents, we prove that the Simple Majority Protocol (SMP) reaches consensus in only three communication rounds, with probability approaching 1 as n grows to infinity. Moreover, if the difference between the numbers of agents that hold different opinions grows at a rate of√n, then the SMP with only two communication rounds attains consensus on the majority opinion of the network, and if this difference grows faster than√n, then the SMP reaches consensus on the majority opinion of the network in a single round, with probability converging to 1 as exponentially fast as n → ∞. We also provide some converse results, showing that these requirements are not only sufficient, but also necessary.ISSN:1099-430

Impact of a nurse-based intervention on medication outcomes in vulnerable older adults

Abstract Background Medication-related problems are common in older adults with multiple chronic conditions. We evaluated the impact of a nurse-based primary care intervention, based on the Guided Care model of care, on patient-centered aspects of medication use. Methods Controlled clinical trial of the Comprehensive Care for Multimorbid Adults Project (CC-MAP), conducted among 1218 participants in 7 intervention clinics and 6 control (usual care) clinics. Inclusion criteria included age 45–94, presence of ≥3 chronic conditions, and Adjusted Clinical Groups (ACG) score > 0.19. The co-primary outcomes were number of changes to the medication regimen between baseline and 9 month followup, and number of changes to symptom-focused medications, markers of attentiveness to medication-related issues. Results Mean age in the intervention group was 72 years, 59% were women, and participants used a mean of 6.6 medications at baseline. The control group was slightly older (73 years) and used more medications (mean 7.1). Between baseline and 9 months, intervention subjects had more changes to their medication regimen than control subjects (mean 4.04 vs. 3.62 medication changes; adjusted difference 0.55, p = 0.001). Similarly, intervention subjects had more changes to their symptomatic medications (mean 1.38 vs. 1.26 changes, adjusted difference 0.20, p = 0.003). The total number of medications in use remained stable between baseline and follow-up in both groups (p > 0.18). Conclusion This nurse-based, primary care intervention resulted in substantially more changes to patients’ medication regimens than usual care, without increasing the total number of medications used. This enhanced rate of change likely reflects greater attentiveness to the medication-related needs of patients. Trial registration This trial is registered at https://clinicaltrials.gov, trial number NCT01811173

Epidemic Use of Benzodiazepines among Older Adults in Israel: Epidemiology and Leverage Points for Improvement

BackgroundBenzodiazepines and benzodiazepine-receptor agonists (BDZRAs, often known as "Z-drugs") are commonly used in older adults despite well-documented harms.ObjectiveTo evaluate patterns of benzodiazepine and BDZRA use in Israel, focusing on potential leverage points where quality improvement initiatives might effectively curtail new use or the transition from intermittent to chronic use.Design and participantsWe used national electronic medical data to assess a 10% random sample of adults receiving care in Clalit Health Services, which serves half of Israel's population. The sample included 267,221 adults, of whom 56,808 (21%) were age 65 and older.Main measuresMedication use from 2013 to 2015 was ascertained using pharmacy dispensing data.ResultsIn 2014, 7% of adults age 21-64 and 32% of adults age 65 and older received at least one benzodiazepine/BDZRA, including 49% of adults age 85 and older (P&nbsp;&lt;&nbsp;0.001). The majority of older users (59%) were long-term users of the drugs, and 21% of older adults who were short-term users in 2014 transitioned to medium- or long-term use in 2015. Older Arab Israelis were much less likely to receive benzodiazepine/BDZRAs than older Jewish Israelis (adjusted OR 0.28, 95% 0.25-0.31), but within each community there was no major variation in prescribing rates across clinics. Depression diagnosis was associated with particularly high rates of benzodiazepine/BDZRA use: 17% of older adults with depression received a benzodiazepine/BDZRA but no antidepressant, and 42% received both. Recent hospitalization increased the risk of new benzodiazepine/BDZRA use (adjusted OR 1.41, 95% CI 1.01-1.96), but the absolute risk increase was only 3%.ConclusionsBenzodiazepines/BDZRAs are used at exceptionally high rates by older Israeli adults, especially the oldest old. Important leverage points for quality improvement efforts include curtailing the transition from short-term to long-term use, reducing use in older adults with depression, and identifying reasons that explain large differences in benzodiazepine/BDZRA prescribing between different ethnic groups

Evaluating an organization-wide disparity reduction program: Understanding what works for whom and why

Background: Disparity-reduction programs have been shown to vary in the degree to which they achieve their goal; yet the causes of these variations is rarely studied. We investigated a broad-scale program in Israel’s largest health plan, aimed at reducing disparities in socially disadvantaged groups using a composite measure of seven health and health care indicators. Methods: A realistic evaluation was conducted to evaluate the program in 26 clinics and their associated managerial levels. First, we performed interviews with key stakeholders and an ethnographic observation of a regional meeting to derive the underlying program theory. Next, semi-structured interviews with 109 clinic teams, subregional headquarters, and regional headquarters personnel were conducted. Social network analysis was performed to derive measures of team interrelations. Perceived team effectiveness (TE) and clinic characteristics were assessed to elicit contextual characteristics. Interventions implemented by clinics were identified from interviews and coded according to the mechanisms each clinic employed. Assessment of each clinic’s performance on the seven-indicator composite measure was conducted at baseline and after 3 years. Finally, we reviewed different context-mechanism-outcome (CMO) configurations to understand what works to reduce disparity, and under what circumstances. Results: Clinics’ inner contextual characteristics varied in both network density and perceived TE. Successful CMO configurations included 1) highly dense clinic teams having high perceived TE, only a small gap to minimize, and employing a wide range of interventions; (2) clinics with a large gap to minimize with high clinic density and high perceived TE, focusing efforts on tailoring services to their enrollees; and (3) clinics having medium to low density and perceived TE, and strong middle-management support. Conclusions: Clinics that achieved disparity reduction had high clinic density, close ties with middle management, and tailored interventions to the unique needs of the populations they serve.</p

Journal officiel de la République française. Lois et décrets

03 février 18861886/02/03 (A18,N33).Appartient à l’ensemble documentaire : MAEDIGen0Appartient à l’ensemble documentaire : MAEDI008Appartient à l’ensemble documentaire : MAEDI012Appartient à l’ensemble documentaire : MAEDI006Appartient à l’ensemble documentaire : MAEDI00