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.

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

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

Case study on using the user-centric-backhaul scheme to unlock the realistic backhaul

The fifth generation of mobile networks (5G) is maturing fast and the target year 2020 is around the corner. However, the realistic backhaul network may not be ready for 5G arrival as it is likely to converge to 5G requirements at a slower pace than the radio counterpart. In this work, we develop a method that identifies pertinent backhaul upgrade stages that are ranked based on their associated cost. First, the User-centric- backhaul (UCB) scheme is employed to reveal the bottlenecks of the incumbent backhaul network, as perceived by users and holistic network. A multi- hop hybrid backhaul modelling framework is then employed to quantify possible rectifications that would deliver the highest improvement at the lowest cost. These are implemented and the results are verified following another usage of UCB. A case study is presented that demonstrates the strength of this method in enabling an effective and cost efficient evolution road map towards the 5G backhaul

Testing the meson cloud in the nucleon in Drell-Yan processes

We discuss the present status of the \bar u-\bar d asymmetry in the nucleon and analize the quantities which are best suited to verify the asymmetry. We find that the Drell-Yan asymmetry is the quantity insensitive to the valence quark distributions and very sensitive to the flavour asymmetry of the sea. We compare the prediction of the meson cloud model with different experimental data including the Fermilab E772 data and recent data of the NA51 Collaboration at CERN and make predictions for the planned Drell-Yan experiments.Comment: written in ReVTeX, 26 pages + 10 PS-figure

Learning and innovative elements of strategy adoption rules expand cooperative network topologies

Cooperation plays a key role in the evolution of complex systems. However, the level of cooperation extensively varies with the topology of agent networks in the widely used models of repeated games. Here we show that cooperation remains rather stable by applying the reinforcement learning strategy adoption rule, Q-learning on a variety of random, regular, small-word, scale-free and modular network models in repeated, multi-agent Prisoners Dilemma and Hawk-Dove games. Furthermore, we found that using the above model systems other long-term learning strategy adoption rules also promote cooperation, while introducing a low level of noise (as a model of innovation) to the strategy adoption rules makes the level of cooperation less dependent on the actual network topology. Our results demonstrate that long-term learning and random elements in the strategy adoption rules, when acting together, extend the range of network topologies enabling the development of cooperation at a wider range of costs and temptations. These results suggest that a balanced duo of learning and innovation may help to preserve cooperation during the re-organization of real-world networks, and may play a prominent role in the evolution of self-organizing, complex systems.Comment: 14 pages, 3 Figures + a Supplementary Material with 25 pages, 3 Tables, 12 Figures and 116 reference

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

Evaluation of the performance of different atmospheric chemical transport models and inter-comparison of nitrogen and sulphur deposition estimates for the UK

An evaluation has been made of a number of contrasting atmospheric chemical transport models, of varying complexity, applied to estimate sulphur and nitrogen deposition in the UK. The models were evaluated by comparison with annually averaged measurements of gas, aerosol and precipitation concentrations from the national monitoring networks. The models were evaluated in relation to performance criteria. They were generally able to satisfy a criterion of ‘fitness for purpose’ that at least 50% of modelled concentrations should be within a factor of two of measured values. The second criterion, that the magnitude of the normalised mean bias should be less than 20%, was not always satisfied. Considering known uncertainties in measurement techniques, this criterion may be too strict. Overall, simpler models were able to give a good representation of measured gas concentrations whilst the use of dynamic meteorology, and complex photo-chemical reactions resulted in a generally better representation of measured aerosol and precipitation concentrations by more complex models. The models were compared graphically by plotting maps and cross-country transects of wet and dry deposition as well as calculating budgets of total wet and dry deposition to the UK for sulphur, oxidised nitrogen and reduced nitrogen. The total deposition to the UK varied by ±22–36% amongst the different models depending on the deposition component. At a local scale estimates of both dry and wet deposition for individual 5 km × 5 km model grid squares were found to vary between the different models by up to a factor of 4.This work was funded by the Department for the Environment, Food and Rural Affairs. Additional support was provided by the Joint Environmental Program, the Natural Environment Research Council and the Environment Agency.This is the final version of the article. It first appeared from Elsevier via http://dx.doi.org/10.1016/j.atmosenv.2015.08.00