Identifying and characterizing COPD patients in US managed care. A retrospective, cross-sectional analysis of administrative claims data

<p>Abstract</p> <p>Background</p> <p>Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death among US adults and is projected to be the third by 2020. In anticipation of the increasing burden imposed on healthcare systems and payers by patients with COPD, a means of identifying COPD patients who incur higher healthcare utilization and costs is needed.</p> <p>Methods</p> <p>This retrospective, cross-sectional analysis of US managed care administrative claims data describes a practical way to identify COPD patients. We analyze 7.79 million members for potential inclusion in the COPD cohort, who were continuously eligible during a 1-year study period. A younger commercial population (7.7 million) is compared with an older Medicare population (0.115 million). We outline a novel approach to stratifying COPD patients using "complexity" of illness, based on occurrence of claims for given comorbid conditions. Additionally, a unique algorithm was developed to identify and stratify COPD exacerbations using claims data.</p> <p>Results</p> <p>A total of 42,565 commercial (median age 56 years; 51.4% female) and 8507 Medicare patients (median 75 years; 53.1% female) were identified as having COPD. Important differences were observed in comorbidities between the younger commercial versus the older Medicare population. Stratifying by complexity, 45.0%, 33.6%, and 21.4% of commercial patients and 36.6%, 35.8%, and 27.6% of older patients were low, moderate, and high, respectively. A higher proportion of patients with high complexity disease experienced multiple (≥2) exacerbations (61.7% commercial; 49.0% Medicare) than patients with moderate- (56.9%; 41.6%), or low-complexity disease (33.4%; 20.5%). Utilization of healthcare services also increased with an increase in complexity.</p> <p>Conclusion</p> <p>In patients with COPD identified from Medicare or commercial claims data, there is a relationship between complexity as determined by pulmonary and non-pulmonary comorbid conditions and the prevalence of exacerbations and utilization of healthcare services. Identification of COPD patients at highest risk of exacerbations using complexity stratification may facilitate improved disease management by targeting those most in need of treatment.</p

Medical Student Professionalism Narratives: A Thematic Analysis and Interdisciplinary Comparative Investigation

<p>Abstract</p> <p>Background</p> <p>Professionalism development is influenced by the informal and hidden curriculum. The primary objective of this study was to better understand this experiential learning in the setting of the Emergency Department (ED). Secondarily, the study aimed to explore differences in the informal curriculum between Emergency Medicine (EM) and Internal Medicine (IM) clerkships.</p> <p>Methods</p> <p>A thematic analysis was conducted on 377 professionalism narratives from medical students completing a required EM clerkship from July 2008 through May 2010. The narratives were analyzed using established thematic categories from prior research as well as basic descriptive characteristics. Chi-square analysis was used to compare the frequency of thematic categories to prior research in IM. Finally, emerging themes not fully appreciated in the established thematic categories were created using grounded theory.</p> <p>Results</p> <p>Observations involving interactions between attending physician and patient were most abundant. The narratives were coded as positive 198 times, negative 128 times, and hybrid 37 times. The two most abundant narrative themes involved <it>manifesting respect </it>(36.9%) and <it>spending time </it>(23.7%). Both of these themes were statistically more likely to be noted by students on EM clerkships compared to IM clerkships. Finally, one new theme regarding <it>cynicism </it>emerged during analysis.</p> <p>Conclusions</p> <p>This analysis describes an informal curriculum that is diverse in themes. Student narratives suggest their clinical experiences to be influential on professionalism development. Medical students focus on different aspects of professionalism depending on clerkship specialty.</p

Modelling Hot Spots of Soil Loss by Wind Erosion (SoLoWind) in Western Saxony, Germany

Land Degradation and Development published by John Wiley & Sons, Ltd. While it needs yet to be assessed whether or not wind erosion in Western Saxony is a major point of concern regarding land degradation and fertility, it has already been recognized that considerable off-site effects of wind erosion in the adjacent regions of Saxony-Anhalt and Brandenburg are connected to the spread of herbicides, pesticides and dust. So far, no wind erosion assessment for Western Saxony, Germany, exists. The wind erosion model previously applied for Germany (DIN standard 19706) is considering neither changes in wind direction over time nor influences of field size. This study aims to provide a first assessment of wind erosion for Western Saxony by extending the existing DIN model to a multidirectional model on soil loss by wind (SoLoWind) with new controlling factors (changing wind directions, soil cover, mean field length and mean protection zone) combined by fuzzy logic. SoLoWind is used for a local off-site effect evaluation in combination with high-resolution wind speed and wind direction data at a section of the highway A72. The model attributes 3·6% of the arable fields in Western Saxony to the very-high-wind erosion risk class. A relationship between larger fields (greater than 116 ha) and higher proportions (51·7%) of very-high-wind erosion risk can be observed. Sections of the highway A72 might be under high risk according to the modelled off-site effects of wind erosion. The presented applications showed the potential of SoLoWind to support and consult management for protection measures on a regional scale. © 2016 The Authors. Land Degradation and Development published by John Wiley & Sons, Ltd.The authors would like to thank Jürgen Heinrich and Gudrun Mayer for the technical revision of the model conception and the German Weather Service, the Saxon State Office for the Environment, Agriculture and Geology, the Saxon State Office for Road Construction and Traffic, the Saxon State Ministry of the Environment and Agriculture, the Saxon State Spatial Data and Land Survey Corporation, the Saxon Road Maintenance Depots, OpenStreetMap and the National Aeronautics and Space Administration for providing the datasets. We would also like to thank three anonymous reviewers for helpful comments.info:eu-repo/semantics/publishedVersio

Cell-Autonomous Requirement for Rx Function in the Mammalian Retina and Posterior Pituitary

Rx is a paired-like homeobox gene that is required for vertebrate eye formation. Mice lacking Rx function do not develop eyes or the posterior pituitary. To determine whether Rx is required cell autonomously in these tissues, we generated embryonic chimeras consisting of wild type and Rx−/− cells. We found that in the eye, Rx-deficient cells cannot participate in the formation of the neuroretina, retina pigment epithelium and the distal part of the optic stalk. In addition, in the ventral forebrain, Rx function is required cell autonomously for the formation of the posterior pituitary. Interestingly, Rx−/− and wild type cells segregate before the morphogenesis of these two tissues begins. Our observations suggest that Rx function is not only required for the morphogenesis of the retina and posterior pituitary, but also prior to morphogenesis, for the sorting out of cells to form distinct fields of retinal/pituitary cells

Experimental Investigation and Large-Eddy Simulation of the Turbulent Flow past a Smooth and Rigid Hemisphere

Computations carried out on the German Federal Top-Level Computer SuperMUC at LRZ Munich under the contract number pr84na.International audienceThe objective of the present paper is to provide a detailed experimental and numerical investigation on the turbulent flow past a hemispherical obstacle (diameter D). For this purpose, the bluff body is exposed to a thick turbulent boundary layer of the thickness δ = D/2 at Re = 50,000. In the experiment this boundary layer thickness is achieved by specific fences placed in the upstream region of the wind tunnel. A detailed measurement of the upstream flow conditions by laser-Doppler and hot-film probes allows to mimic the inflow conditions for the complementary large-eddy simulation of the flow field using a synthetic turbulence inflow generator. These clearly defined boundary and operating conditions are the prerequisites for a combined experimental and numerical investigation of the flow field relying on the laser-Doppler anemometry and a finite-volume Navier-Stokes solver for block-structured curvilinear grids. The results comprise an analysis on the unsteady flow features observed in the vicinity of the hemisphere as well as a detailed discussion of the time-averaged flow field. The latter includes the mean velocity field as well as the Reynolds stresses. Owing to the proper description of the oncoming flow and supplementary numerical studies guaranteeing the choice of an appropriate grid and subgrid-scale model, the results of the measurements and the prediction are found to be in close agreement