Statistical Issues in Assessing Hospital Performance

From the Preface: The Centers for Medicare and Medicaid Services (CMS), through a subcontract with Yale New Haven Health Services Corporation, Center for Outcomes Research and Evaluation (YNHHSC/CORE), is supporting a committee appointed by the Committee of Presidents of Statistical Societies (COPSS) to address statistical issues identified by the CMS and stakeholders about CMS’s approach to modeling hospital quality based on outcomes. In the spring of 2011, with the direct support of YNHHSC/ CORE, COPSS formed a committee comprised of one member from each of its constituent societies, a chair, and a staff member from the American Statistical Association, and held a preliminary meeting in April. In June, YNHHSC/CORE executed a subcontract with COPSS under its CMS contract to support the development of a White Paper on statistical modeling. Specifically, YNHHSC/CORE contracted with COPSS to “provide guidance on statistical approaches . . .when estimating performance metrics,” and “consider and discuss concerns commonly raised by stakeholders (hospitals, consumer, and insurers) about the use of “hierarchical generalized linear models in profiling hospital quality. The committee convened in June and August of 2011, and exchanged a wide variety of materials. To ensure the committee’s independence, YNHHSC/CORE did not comment on the white paper findings, and CMS pre-cleared COPSS’ publication of an academic manuscript based on the White Paper

Emergence of qualia from brain activity or from an interaction of proto-consciousness with the brain: which one is the weirder? Available evidence and a research agenda

This contribution to the science of consciousness aims at comparing how two different theories can explain the emergence of different qualia experiences, meta-awareness, meta-cognition, the placebo effect, out-of-body experiences, cognitive therapy and meditation-induced brain changes, etc. The first theory postulates that qualia experiences derive from specific neural patterns, the second one, that qualia experiences derive from the interaction of a proto-consciousness with the brain\u2019s neural activity. From this comparison it will be possible to judge which one seems to better explain the different qualia experiences and to offer a more promising research agenda

Does Alendronate reduce the risk of fracture in men? A meta-analysis incorporating prior knowledge of anti-fracture efficacy in women

BACKGROUND: Alendronate has been found to reduce the risk of fractures in postmenopausal women as demonstrated in multiple randomized controlled trials enrolling thousands of women. Yet there is a paucity of such randomized controlled trials in osteoporotic men. Our objective was to systematically review the anti-fracture efficacy of alendronate in men with low bone mass or with a history of prevalent fracture(s) and incorporate prior knowledge of alendronate efficacy in women in the analysis. METHODS: We examined randomized controlled trials in men comparing the anti-fracture efficacy of alendronate to placebo or calcium or vitamin D, or any combination of these. Studies of men with secondary causes of osteoporosis other than hypogonadism were excluded. We searched the following electronic databases (without language restrictions) for potentially relevant citations: Medline, Medline in Process (1966-May 24/2004), and Embase (1996–2004). We also contacted the manufacturer of the drug in search of other relevant trials. Two reviewers independently identified two trials (including 375 men), which met all inclusion criteria. Data were abstracted by one reviewer and checked by another. Results of the male trials were pooled using Bayesian random effects models, incorporating prior information of anti-fracture efficacy from meta-analyses of women. RESULTS: The odds ratios of incident fractures in men (with 95% credibility intervals) with alendronate (10 mg daily) were: vertebral fractures, 0.44 (0.23, 0.83) and non-vertebral fractures, 0.60 (0.29, 1.44). CONCLUSION: In conclusion, alendronate decreases the risk of vertebral fractures in men at risk. There is currently insufficient evidence of a statistically significant reduction of non-vertebral fractures, but the paucity of trials in men limit the statistical power to detect such an effect

Airway and Esophageal Stenting in Patients with Advanced Esophageal Cancer and Pulmonary Involvement

BACKGROUND: Most inoperable patients with esophageal-advanced cancer (EGC) have a poor prognosis. Esophageal stenting, as part of a palliative therapy management has dramatically improved the quality of live of EGC patients. Airway stenting is generally proposed in case of esophageal stent complication, with a high failure rate. The study was conducted to assess the efficacy and safety of scheduled and non-scheduled airway stenting in case of indicated esophageal stenting for EGC. METHODS AND FINDINGS: The study is an observational study conducted in pulmonary and gastroenterology endoscopy units. Consecutive patients with EGC were referred to endoscopy units. We analyzed the outcome of airway stenting in patients with esophageal stent indication admitted in emergency or with a scheduled intervention. Forty-four patients (58+/-\-8 years of age) with esophageal stenting indication were investigated. Seven patients (group 1) were admitted in emergency due to esophageal stent complication in the airway (4 fistulas, 3 cases with malignant infiltration and compression). Airway stenting failed for 5 patients. Thirty-seven remaining patients had a scheduled stenting procedure (group 2): stent was inserted for 13 patients with tracheal or bronchial malignant infiltration, 12 patients with fistulas, and 12 patients with airway extrinsic compression (preventive indication). Stenting the airway was well tolerated. Life-threatening complications were related to group 1. Overall mean survival was 26+/-10 weeks and was significantly shorter in group 1 (6+/-7.6 weeks) than in group 2 (28+/-11 weeks), p<0.001). Scheduled double stenting significantly improved symptoms (95% at day 7) with a low complication rate (13%), and achieved a specific cancer treatment (84%) in most cases. CONCLUSION: Stenting the airway should always be considered in case of esophageal stent indication. A multidisciplinary approach with initial airway evaluation improved prognosis and decreased airways complications related to esophageal stent. Emergency procedures were rarely efficient in our experience

The Political Consequences of Outsider Labour Market Status in the United States: A Micro-level Study

This paper contributes to recent research that seeks to understand the political consequences of ‘outsider’ labour market status. There is an emerging consensus that labour market outsiders have systematically different policy preferences and display systematically different political behavior to securely employed ‘insiders’ in Europe. Yet the political consequences of outsider status in the United States are less clear. They may be expected to differ from those that have been documented in the European context, because 1) the US is characterized by low employment protection of insiders, and 2) there is evidence that Americans are more reluctant than Europeans to hold governments responsible for personal economic hardship. We therefore use the General Social Survey to examine how outsider labour market status is related to voting behavior and to social policy preferences in the United States. We find that the concept of ‘labour market outsider’ - as conventionally operationalized - holds little explanatory power in the American context. Disaggregating the outsider category, our results suggest that the political consequences of outsider labour market status may be contingent on individual beliefs about government responsibility