Optimal initiation of a GLWB in a variable annuity: no arbitrage approach

This paper offers a financial economic perspective on the optimal time (and age) at which the owner of a Variable Annuity (VA) policy with a Guaranteed Living Withdrawal Benefit (GLWB) rider should initiate guaranteed lifetime income payments. We abstract from utility, bequest and consumption preference issues by treating the VA as liquid and tradable. This allows us to use an American option pricing framework to derive a so-called optimal initiation region. Our main practical finding is that given current design parameters in which volatility (asset allocation) is restricted to less than 20%, while guaranteed payout rates (GPR) as well as bonus (roll-up) rates are less than 5%, GLWBs that are in-the-money should be turned on by the late 50s and certainly the early 60s. The exception to the rule is when a non-constant GPR is about to increase (soon) to a higher age band, in which case the optimal policy is to wait until the new GPR is hit and then initiate immediately. Also, to offer a different perspective, we invert the model and solve for the bonus (roll-up) rate that is required to justify delaying initiation at any age. We find that the required bonus is quite high and more than what is currently promised by existing products. Our methodology and results should be of interest to researchers as well as to the individuals that collectively have over \$1 USD trillion in aggregate invested in these products. We conclude by suggesting that much of the non-initiation at older age is irrational (which obviously benefits the insurance industry.

Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework

This is the final version. Available on open access from BMJ Publishing Group via the DOI in this recordData sharing: Technical appendix and statistical code available from the corresponding author ([email protected]). The dataset was derived from the General Practice Research Database and is not available from the authors, but it can be derived on application to GPRD.OBJECTIVE: To investigate whether the incentive scheme for UK general practitioners led them to neglect activities not included in the scheme. DESIGN: Longitudinal analysis of achievement rates for 42 activities (23 included in incentive scheme, 19 not included) selected from 428 identified indicators of quality of care. SETTING: 148 general practices in England (653 500 patients). MAIN OUTCOME MEASURES: Achievement rates projected from trends in the pre-incentive period (2000-1 to 2002-3) and actual rates in the first three years of the scheme (2004-5 to 2006-7). RESULTS: Achievement rates improved for most indicators in the pre-incentive period. There were significant increases in the rate of improvement in the first year of the incentive scheme (2004-5) for 22 of the 23 incentivised indicators. Achievement for these indicators reached a plateau after 2004-5, but quality of care in 2006-7 remained higher than that predicted by pre-incentive trends for 14 incentivised indicators. There was no overall effect on the rate of improvement for non-incentivised indicators in the first year of the scheme, but by 2006-7 achievement rates were significantly below those predicted by pre-incentive trends. CONCLUSIONS: There were substantial improvements in quality for all indicators between 2001 and 2007. Improvements associated with financial incentives seem to have been achieved at the expense of small detrimental effects on aspects of care that were not incentivised.There was no direct funding for this study, but the National Primary Care Research and Development Centre receives core funding from the UK Department of Health

LEND ME YOUR EAAR: ENHANCING THE AFTER ACTION REVIEW TO INCREASE TACTICAL LEARNING

Leaders need more opportunities to train with their units to hone their skills. Leaders use After Action Reviews to improve themselves and their units. The After Action Review has existed since the 1970s and has not substantially changed in that time. New technological advancements in the last several years offer the opportunity to enhance the efficacy of the After Action Review for future leaders and units. One of these new technologies is virtual reality. Virtual reality presents trainers the ability to control all aspects of the training environment. It also enables thorough data collection and the ability to rapidly run through a scenario again. This project sought to identify the information gaps in live training and determine whether virtual reality enables tactical learning at the individual level. Using surveys and experimentation, the team concluded that virtual reality scenarios in concert with After Action Reviews can be used for tactical learning at the individual level. Through the course of the experiment, the team also discovered that servicemembers take advantage of opportunities to improve themselves regardless of their performance.Major, United States ArmyMajor, United States ArmyCaptain, United States ArmyMajor, United States ArmyMajor, United States ArmyApproved for public release. Distribution is unlimited

A trick for passing degenerate points in Ashtekar formulation

We examine one of the advantages of Ashtekar's formulation of general relativity: a tractability of degenerate points from the point of view of following the dynamics of classical spacetime. Assuming that all dynamical variables are finite, we conclude that an essential trick for such a continuous evolution is in complexifying variables. In order to restrict the complex region locally, we propose some `reality recovering' conditions on spacetime. Using a degenerate solution derived by pull-back technique, and integrating the dynamical equations numerically, we show that this idea works in an actual dynamical problem. We also discuss some features of these applications.Comment: 9 pages by RevTeX or 16 pages by LaTeX, 3 eps figures and epsf-style file are include

The Development and Feasibility of a Ward-Based Physiotherapy and Nutritional Rehabilitation Package for People Experiencing Critical Illness

Lisa Salisbury - ORCID: 0000-0002-1400-3224 https://orcid.org/0000-0002-1400-3224Item is not available in this repository.Objective: To investigate ward-based rehabilitation after critical illness and undertake a pilot study exploring the feasibility of delivering enhanced physiotherapy and nutritional rehabilitation. Design: Service evaluation (part A) and pilot feasibility randomized controlled trial (part B). Setting: Hospital inpatient wards following discharge from intensive care. Participants: Part A involved 24 people with an intensive care stay of four days or more. Part B involved 16 participants randomized into a control (n = 8) or intervention (n = 8) group. Interventions: Part A defined the current ‘standard’ physiotherapy and nutritional interventions. In part B the control group received this ‘standard’ service while the intervention group received this ‘standard’ service plus enhanced rehabilitation. Main measures: Part A collected process outcomes of current interventions and outcomes that included calorie and protein intake and the Rivermead Mobility Index. In part B process outcomes determined differences between groups. Outcomes included those undertaken in part A plus an incremental shuttle test, handgrip dynamometry and visual analogue scales. Results: Part A found low levels of ward-based physiotherapy (walking and transfer practice once per week) and dietetic input (0.8 visits per week). Part B found an increased frequency of both physiotherapy (P = 0.002) and dietetic (P = 0.001) visits in the intervention group. Physical and nutritional outcomes were suitable for use after critical illness, but no statistically significant differences were found between groups. Power calculations indicated 100 participants per group would be required for a definitive study. Conclusions: This feasibility pilot work has informed the design of a larger study to evaluate enhanced rehabilitation following critical illness.https://doi.org/10.1177/026921550936063924pubpub

A video life-world approach to consultation practice: The relevance of a socio-phenomenological approach

This article discusses the [development and] use of a video life-world schema to explore alternative orientations to the shared health consultation. It is anticipated that this schema can be used by practitioners and consumers alike to understand the dynamics of videoed health consultations, the role of the participants within it and the potential to consciously alter the outcome by altering behaviour during the process of interaction. The study examines health consultation participation and develops an interpretative method of analysis that includes image elicitation (via videos), phenomenology (to identify the components of the analytic framework), narrative (to depict the stories of interactions) and a reflexive mode (to develop shared meaning through a conceptual framework for analysis). The analytic framework is derived from a life-world conception of human mutual shared interaction which is presented here as a novel approach to understanding patient-centred care. The video materials used in this study were derived from consultations in a Walk-in Centre (WiC) in East London. The conceptual framework produced through the process of video analysis is comprised of different combinations of movement, knowledge and emotional conversations that are used to classify objective or engaged WiC health care interactions. The videoed interactions organise along an active or passive, facilitative or directive typical situation continuum illustrating different kinds of textual approaches to practice that are in tension or harmony. The schema demonstrates how practitioners and consumers interact to produce these outcomes and indicates the potential for both consumers and practitioners to be educated to develop practice dynamics that support patient-centred care and impact on health outcomes

Psychosocial resilience among left-behind adolescents in rural Thailand: A qualitative exploration

When parents migrate, they often leave children behind with relatives. Despite being at higher risk of socio-emotional problems, many left-behind children have good health and social outcomes, suggesting their resilience. We sought to understand how adolescents with internal and international migrant parents build resilience in Thailand. We conducted qualitative interviews with 24 adolescents aged 10–19, and six caregivers, parents and community leaders. Interviews were transcribed, translated and analysed, drawing on techniques from grounded theory. We found that resilience was built in a context where for many families, migration was a financial necessity and the parent–child relationship was mainly phone-based. Adolescents built resilience using three key ‘resources’: warmth (love and understanding), financial support and guidance. Adolescents with insecure parent or caregiver relationships, or with caring responsibilities for relatives, were less likely to have access to these resources. These adolescents sought emotional and financial independence, prioritised friendships and identified role models to obtain key resources and build resilience. The findings indicate practical and psychosocial barriers to building resilience among left-behind adolescents in Thailand. Further work could explore pathways to mental illness in this population, interventions that build peer networks and caregiver–child relationships and the use of technology to support remote parenting

Increasing Short-Stay Unplanned Hospital Admissions among Children in England; Time Trends Analysis '97-'06

BACKGROUND: Timely care by general practitioners in the community keeps children out of hospital and provides better continuity of care. Yet in the UK, access to primary care has diminished since 2004 when changes in general practitioners' contracts enabled them to 'opt out' of providing out-of-hours care and since then unplanned pediatric hospital admission rates have escalated, particularly through emergency departments. We hypothesised that any increase in isolated short stay admissions for childhood illness might reflect failure to manage these cases in the community over a 10 year period spanning these changes. METHODS AND FINDINGS: We conducted a population based time trends study of major causes of hospital admission in children 2 days. By 2006, 67.3% of all unplanned admissions were isolated short stays <2 days. The increases in admission rates were greater for common non-infectious than infectious causes of admissions. CONCLUSIONS: Short stay unplanned hospital admission rates in young children in England have increased substantially in recent years and are not accounted for by reductions in length of in-hospital stay. The majority are isolated short stay admissions for minor illness episodes that could be better managed by primary care in the community and may be evidence of a failure of primary care services

Mutuality as a method: advancing a social paradigm for global mental health through mutual learning.

PURPOSE: Calls for "mutuality" in global mental health (GMH) aim to produce knowledge more equitably across epistemic and power differences. With funding, convening, and publishing power still concentrated in institutions in the global North, efforts to decolonize GMH emphasize the need for mutual learning instead of unidirectional knowledge transfers. This article reflects on mutuality as a concept and practice that engenders sustainable relations, conceptual innovation, and queries how epistemic power can be shared. METHODS: We draw on insights from an online mutual learning process over 8 months between 39 community-based and academic collaborators working in 24 countries. They came together to advance the shift towards a social paradigm in GMH. RESULTS: Our theorization of mutuality emphasizes that the processes and outcomes of knowledge production are inextricable. Mutual learning required an open-ended, iterative, and slower paced process that prioritized trust and remained responsive to all collaborators' needs and critiques. This resulted in a social paradigm that calls for GMH to (1) move from a deficit to a strength-based view of community mental health, (2) include local and experiential knowledge in scaling processes, (3) direct funding to community organizations, and (4) challenge concepts, such as trauma and resilience, through the lens of lived experience of communities in the global South. CONCLUSION: Under the current institutional arrangements in GMH, mutuality can only be imperfectly achieved. We present key ingredients of our partial success at mutual learning and conclude that challenging existing structural constraints is crucial to prevent a tokenistic use of the concept