Doctor Behaviour Under a Pay for Performance Contract: Further Evidence from the Quality and Outcomes Framework

Since 2003, 25% of UK general practitioners’ income has been determined by the quality of their care. The 65 clinical quality indicators in this scheme (the Quality and Outcomes Framework) are in the form of ratios, with financial reward increasing linearly with the ratio between a lower and upper threshold. The numerator is the number of patients for whom an indicator is achieved and the denominator is the number of patients the practices declare are suitable for the indicator. The number declared suitable is the number of patients with the relevant condition less the number exception reported by the practice for a specified range of reasons. Exception reporting is designed to avoid harmful treatment resulting from the application of quality targets to patients for whom they were not intended. However, exception reporting also gives GPs the opportunity to exclude patients who should in fact be treated in order to achieve higher financial rewards. This is inappropriate use of exception reporting or ‘gaming’. Practices can also increase income if they are below the upper threshold by reducing the number of patients declared with a condition (prevalence), or by increasing reported prevalence if they were above the upper threshold. This study examines the factors affecting delivered quality (the proportion of prevalent patients for indicators were achieved) and tests for gaming of exceptions and for prevalence reporting being responsive to financial incentives.Quality. Incentives. Gaming. Pay for performance.

Doctor Behaviour Under a Pay for Performance Contract: Evidence from the Quality and Outcomes Framework

Since 2003, 25% of UK general practitioners’ income has been determined by the quality of their care. The 65 clinical quality indicators in this scheme (the Quality and Outcomes Framework) are in the form of ratios, with financial reward increasing linearly with the ratio between a lower and upper threshold. The numerator is the number of patients for whom an indicator is achieved and the denominator is the number of patients the practices declares are suitable for the indicator. The number declared suitable is the number of patients with the relevant condition less the number exception reported by the practice for a specified range of reasons. Exception reporting is designed to avoid harmful treatment resulting from the application of quality targets to patients for whom they were not intended. However, exception reporting also gives GPs the opportunity to exclude patients who should in fact be treated in order to achieve higher financial rewards. This is inappropriate use of exception reporting or ‘gaming’. Practices can also increase income if they are below the upper threshold by reducing the number of patients declared with a condition (prevalence), or by increasing reported prevalence if they were above the upper threshold. This study examines the factors affecting delivered quality (the proportion of prevalent patients for indicators were achieved) and tests for gaming of exceptions and for prevalence reporting being responsive to financial incentives.Quality. Incentives. Gaming. Pay for performance.

Alkaline air: changing perspectives on nitrogen and air pollution in an ammonia-rich world

Ammonia and ammonium have received less attention than other forms of air pollution, with limited progress in controlling emissions at UK, European and global scales. By contrast, these compounds have been of significant past interest to science and society, the recollection of which can inform future strategies. Sal ammoniac (nūshādir, nao sha) is found to have been extremely valuable in long-distance trade (ca AD 600–1150) from Egypt and China, where 6–8 kg N could purchase a human life, while air pollution associated with nūshādir collection was attributed to this nitrogen form. Ammonia was one of the keys to alchemy—seen as an early experimental mesocosm to understand the world—and later became of interest as ‘alkaline air’ within the eighteenth century development of pneumatic chemistry. The same economic, chemical and environmental properties are found to make ammonia and ammonium of huge relevance today. Successful control of acidifying SO2 and NOx emissions leaves atmospheric NH3 in excess in many areas, contributing to particulate matter (PM2.5) formation, while leading to a new significance of alkaline air, with adverse impacts on natural ecosystems. Investigations of epiphytic lichens and bog ecosystems show how the alkalinity effect of NH3 may explain its having three to five times the adverse effect of ammonium and nitrate, respectively. It is concluded that future air pollution policy should no longer neglect ammonia. Progress is likely to be mobilized by emphasizing the lost economic value of global N emissions ($200 billion yr−1), as part of developing the circular economy for sustainable nitrogen management

Determinants of General Practitioners' Wages in England

We analyse the determinants of annual net income and wages (annual net income/hours) of general practitioners (GPs) using a unique, anonymised, non-disclosive dataset derived from tax returns for 21,657 GPs in England for the financial year 2002/3. The average GP had a gross income of £189,300, incurred expenses of £115,600, and earned an annual net income of £73,700. The mean wage was £35 per hour. Net income and wages depended on gender, experience, list size, partnership size, whether or not the GP worked in a dispensing practice, whether or not they worked in a Primary Medical Service (PMS) practice, and the characteristics of the local population (limiting long term illness rate, proportion from ethnic minorities, population density, Index of Multiple Deprivation 2000). The findings have implications for discrimination by GP gender and country of qualification, economies of scale by practice size, incentives for competition for patients, compensating differentials for local population characteristics, and the attractiveness of PMS versus General Medical Services contracts.Physician, family. General practitioner. Income. Wages. Contract.

Prioritized Sweeping Neural DynaQ with Multiple Predecessors, and Hippocampal Replays

During sleep and awake rest, the hippocampus replays sequences of place cells that have been activated during prior experiences. These have been interpreted as a memory consolidation process, but recent results suggest a possible interpretation in terms of reinforcement learning. The Dyna reinforcement learning algorithms use off-line replays to improve learning. Under limited replay budget, a prioritized sweeping approach, which requires a model of the transitions to the predecessors, can be used to improve performance. We investigate whether such algorithms can explain the experimentally observed replays. We propose a neural network version of prioritized sweeping Q-learning, for which we developed a growing multiple expert algorithm, able to cope with multiple predecessors. The resulting architecture is able to improve the learning of simulated agents confronted to a navigation task. We predict that, in animals, learning the world model should occur during rest periods, and that the corresponding replays should be shuffled.Comment: Living Machines 2018 (Paris, France

A Mixed-Mode I/II Fracture Criterion and Its Application in Crack Growth Predictions

A crack tip opening displacement (CTOD)-based, mixed mode fracture criterion is developed for predicting the onset and direction of crack growth. The criterion postulates that crack growth occurs in either the Mode I or Mode II direction, depending on whether the maximum in either the opening or the shear component of CTOD, measured at a specified distance behind the crack tip, attains a critical value. For crack growth direction prediction, the proposed CTOD criterion is shown to be equivalent to seven commonly used crack growth criteria under linearly elastic and asymptotic conditions. Under elastic-plastic conditions the CTOD criterion's prediction of the dependence of the crack growth direction on the crack-up mode mixity is in excellent agreement with the Arcan test results. Furthermore, the CTOD criterion correctly predicts the existence of a crack growth transition from mode I to mode II as the mode mixity approaches the mode II loading condition. The proposed CTOD criterion has been implemented in finite element crack growth simulation codes Z1P2DL and FRANC2DL to predict the crack growth paths in (a) a modified Arcan test specimen and fixture made of AL 2024-T34 and (b) a double cantilever beam (DCB) specimen made of AL 7050. A series of crack growth simulations have been carried out for the crack growth tests in the Arcan and DCB specimens and the results further demonstrate the applicability of the mixed mode CTOD fracture criterion crack growth predictions and residual strength analyses for airframe materials

Analysis of consultants' NHS and private incomes in England in 2003/4

This article has been made available through the Brunel Open Access Publishing Fund and is available from the specified link - Copyright @ 2008 Royal Society of Medicine PressConsultants employed by the NHS in England are allowed to undertake private practice to supplement their NHS income. Until the introduction of a new contract from October 2003, those employed on full-time contracts were allowed to earn private incomes no greater than 10% of their NHS income. In this paper we investigate the magnitude and determinants of consultants' NHS and private incomes

Doctor behaviour under a pay for performance contract : Further evidence from the quality and outcomes framework

Since 2003, 25% of UK general practitioners’ income has been determined by the quality of their care. The 65 clinical quality indicators in this scheme (the Quality and Outcomes Framework) are in the form of ratios, with financial reward increasing linearly with the ratio between a lower and upper threshold. The numerator is the number of patients for whom an indicator is achieved and the denominator is the number of patients the practices declare are suitable for the indicator. The number declared suitable is the number of patients with the relevant condition less the number exception reported by the practice for a specified range of reasons. Exception reporting is designed to avoid harmful treatment resulting from the application of quality targets to patients for whom they were not intended. However, exception reporting also gives GPs the opportunity to exclude patients who should in fact be treated in order to achieve higher financial rewards. This is inappropriate use of exception reporting or ‘gaming’. Practices can also increase income if they are below the upper threshold by reducing the number of patients declared with a condition (prevalence), or by increasing reported prevalence if they were above the upper threshold. This study examines the factors affecting delivered quality (the proportion of prevalent patients for indicators were achieved) and tests for gaming of exceptions and for prevalence reporting being responsive to financial incentives

Sigma Meson Cloud and Proton's Light Flavor Sea Quarks

We take into account the sigma meson cloud effect in the meson cloud model to calculate the distributions of light flavor sea quarks in the proton. Our calculation gives a better description of the data for $\bar{d}(x)/\bar{u}(x)$. We also provide a picture that the probability of finding a physical proton in a Fock state $|N\omega>$ is reasonable small with a smaller cutoff $\Lambda_{\omega}$.Comment: 10 latex pages, 4 figures. Version to appear in PL

Predictors of willingness to participate in HIV vaccine trials among African Americans

African Americans in the United States (U.S.) are disproportionately affected by HIV. Developing an HIV vaccine is an important part of the HIV prevention and treatment toolkit and may help contribute to ending the HIV epidemic. To date, HIV vaccine trials have not engaged representative numbers of African Americans. We evaluated the willingness of African Americans to participate in HIV vaccine trials and identified correlates of willingness to participate (WTP) by surveying African Americans at low- and high-risk of HIV infection in a multi-site, cross-sectional study. We enrolled 1,452 participants; 59% heterosexual women; 21% heterosexual men; 20% men who have sex with men (MSM). Over half of participants (58%) expressed some level of WTP in HIV vaccine trials. Multivariable analyses revealed several variables were positively related to WTP: HIV risk behavior, knowing someone with HIV/AIDS, social support for trial participation, high perception of risk, perceived protection if in a trial, altruism, and greater tolerance for the ambiguous nature of trials (p\u3c0.01). Emphasis on contextual factors related to personal HIV experiences, including knowledge of someone with HIV, and community support for research, may provide effective strategies for engaging African Americans in future HIV vaccine trials