24 research outputs found

    Wrong Place, Right Time

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    Mazor recounts working in the three distinctly different environments during her first year of teaching: sixth-grade math, pre-school social studies, and first-grade reading. Each of these experiences taught her specific skills that she later applied to assignments; additionally, each experience helped her develop her own style as a teacher

    It takes patience and persistence to get negative feedback about patients’ experiences: a secondary analysis of national inpatient survey data

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    Background: Patient experience surveys are increasingly used to gain information about the quality of healthcare. This paper investigates whether patients who respond before and after reminders to a large national survey of inpatient experience differ in systematic ways in how they evaluate the care they received. Methods: The English national inpatient survey of 2009 obtained data from just under 70,000 patients. We used ordinal logistic regression to analyse their evaluations of the quality of their care in relation to whether or not they had received a reminder before they responded. Results: 33% of patients responded after the first questionnaire, a further 9% after the first reminder, and a further 10% after the second reminder. Evaluations were less positive among people who responded only after a reminder and lower still among those who needed a second reminder. Conclusions: Quality improvement efforts depend on having accurate data and negative evaluations of care received in healthcare settings are particularly valuable. This study shows that there is a relationship between the time taken to respond and patients’ evaluations of the care they received, with early responders being more likely to give positive evaluations. This suggests that bias towards positive evaluations could be introduced if the time allowed for patients to respond is truncated or if reminders are omitted

    Synaptic and circuit mechanisms promoting broadband transmission of olfactory stimulus dynamics

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    Sensory stimuli fluctuate on many timescales. However, short-term plasticity causes synapses to act as temporal filters, limiting the range of frequencies they can transmit. How synapses in vivo might transmit a range of frequencies in spite of short-term plasticity is poorly understood. The first synapse in the Drosophila olfactory system exhibits short-term depression, and yet can transmit broadband signals. Here we describe two mechanisms that broaden the frequency characteristics of this synapse. First, two distinct excitatory postsynaptic currents transmit signals on different timescales. Second, presynaptic inhibition dynamically updates synaptic properties to promote accurate transmission of signals across a wide range of frequencies. Inhibition is transient but grows slowly, and simulations show that these two features of inhibition promote broadband synaptic transmission. Dynamic inhibition is often thought to restrict the temporal patterns that a neuron responds to, but our results illustrate a different idea: inhibition can expand the bandwidth of neural coding

    Access and Reimbursement for Cancer-Related Pharmacogenetic Tests and Medications

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    Background: Genomic tests are the fastest growing sector of medicine and medical science, yet there is a dearth of research on access to cancer-related pharmacogenetic tests and medications. The objective of this study is to explore views of clinicians about access to pharmacogenetic tests using qualitative methods. Methods: We conducted semi-structured interviews with a purposeful sample of clinicians who had prescribed medications that should be guided by pharmacogenetic testing. The purpose of the interviews was to explore knowledge of insurance cost-sharing for test, experienced or perceived barriers to access, and strategies used for managing costs. Interviews were recorded and transcribed verbatim. Using directed qualitative content analysis, two members of the research team performed iterative open coding of the transcripts. Each interview transcript was independently read and coded by two members of the study team. Results: Ten interviews were conducted (8 oncologists, 1 nurse practitioner, 1 nurse). Of the 10 clinicians, 6 practiced in an academic hospital setting and 4 practiced in a community setting. Clinicians described logistical and insurance issues relating to ordering genetic tests and medications. They also reported that they ordered pharmacogenetic tests based on medical need with little communication about insurance with patients; they had few perceived and experienced barriers in access to tests but had limited awareness of coverage of tests. The process of ordering tests is variable. In comparison, clinicians were much more aware of financial and administrative barriers to access cancer therapies related to pharmacogenetic testing, including burdensome and lengthy insurance approval and reimbursement processes for both patients and providers and substantial out-of-pocket costs. Conclusion: Currently, ordering pharmacogenetic tests is less complex than ordering cancer therapies, but this is likely to change in the near future as administrative barriers are introduced to manage volume. Better understanding of the implementation of pharmacogenetic tests into community and clinical settings will help inform future implementation strategies for other more complex genomic technologies to improve patient outcomes

    Payer Decision-Making for Pharmacogenetic Tests: Preliminary Results

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    Background: Genetic tests are the fastest growing sector of medicine and medical science, yet there is a dearth of research on access to cancer-related pharmacogenetic tests. The objective is to explore payers’ views about management strategies for pharmacogenetic tests and to describe criteria for coverage decisions, policy challenges and strategies used to overcome these challenges. Methods: We conducted semi-structured interviews with representatives of U.S. private payers. Interviews were recorded and transcribed verbatim. Using a directed qualitative content analysis, two members of the research team performed open coding of the transcripts in an iterative process, building a provisional code book as coding progressed. Each interview transcript was independently read and coded by two members of the study team. Results: Payers may not have established coverage policies for single gene tests, but even without a policy in place, these are generally accessible on a case-by-case basis. For coverage decision-making for pharmacogenetic tests, payers generally followed coverage decision-making processes originally established for pharmaceuticals. Some realize that the evidence requirements, which are established for pharmaceuticals, are not applicable to pharmacogenetic tests, particularly because the field is advancing rapidly. “Outcomes-based” risk sharing agreements with diagnostic companies are recognized as a possible option to collect evidence and limiting coverage. Some payers are introducing prior authorization requirements for pharmacogenetic tests to better manage utilization because an established coding system for tests is lacking. Another key challenge from payers’ perspective is managing the use of and payment for gene panels. Laboratories provide different combination of genes in their panel tests, thus knowing which genes are tested is a challenge. Some payers do not pay for large gene panels. Conclusion: Single pharmacogenetic tests are generally readily accessible. However, as we move from single gene tests to gene panels, payers have identified challenges and ways of overcoming those challenges as the field evolves

    The Implementation Process for Pharmacogenomic Testing for Cancer-Targeted Therapies

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    Recent advances in genomic medicine have led to the availability of genomic tests that have the potential to improve population health, yet the process for obtaining these tests and getting them reimbursed by insurers has not been described. The objective of this study was to describe the process of ordering pharmacogenomic tests by interviewing providers, patients, and laboratories about cancer-related pharmacogenomic tests. We interviewed patients who were prescribed, providers who prescribed medications that should be guided by pharmacogenomic testing, and individuals from diagnostic laboratories. A total of 10 providers, 16 patients, and eight diagnostic laboratories described logistical and insurance issues relating to ordering and receiving pharmacogenomic tests and medications. We found that the process of ordering pharmacogenomic tests is time-consuming, expensive, and complex. Ordering pharmacogenomic tests is quite different across institutions. Even in the same institution, multiple providers can order the test. Once the provider places the order for the pharmacogenomic test, the laboratory receives the request and usually begins testing without knowing how the test will be paid for. Next, the laboratory completes the pharmacogenomic testing and the results of the tests are reported to providers, patients, or placed directly in the medical record. In conclusion, processes related to ordering and obtaining insurance coverage for pharmacogenomic tests varies greatly across institutions and is time-consuming

    Access to Guideline-Recommended Pharmacogenomic Tests for Cancer Treatments: Experience of Providers and Patients

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    Genomic tests are the fastest growing sector in medicine and medical science, yet there remains a dearth of research on access to pharmacogenomic tests and medications. The objective of this study is to explore providers’ and patients’ experiences and views on test access as well as strategies used for gaining access. We interviewed clinicians who prescribed medications that should be guided by pharmacogenomic testing and patients who received those prescriptions. We organized the themes into the four dimensions suggested by the World Health Organization framework on access to medications and health technologies. Guideline-recommended pharmacogenomic tests for cancer care are generally available, although the timeliness of return of test results is sometimes suboptimal. Accessibility of pharmacogenomic tests is made challenging by the process of ordering pharmacogenomic tests, which is time-consuming. Affordability is a barrier to some patients as expressed by both providers and patients, who noted that the cost of pharmacogenomic tests and medications is high. Acceptability of the tests is high as both providers and patients view the tests positively. Understanding challenges to accessing pharmacogenomic tests will allow policymakers to develop policies that streamline access to genomics-based technologies to improve population health

    Oscillations and sparsening of odor representations in the mushroom body

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    In the insect olfactory system, oscillatory synchronization is functionally relevant and reflects the coherent activation of dynamic neural assemblies. We examined the role of such oscillatory synchronization in information transfer between networks in this system. The antennal lobe is the obligatory relay for olfactory afferent signals and generates oscillatory output. The mushroom body is responsible for formation and retrieval of olfactory and other memories. The format of odor representations differs significantly across these structures. Whereas representations are dense, dynamic, and seemingly redundant in the antennal lobe, they are sparse and carried by more selective neurons in the mushroom body. This transformation relies on a combination of oscillatory dynamics and intrinsic and circuit properties that act together to selectively filter and synthesize the output from the antennal lobe. These results provide direct support for the functional relevance of correlation codes and shed some light on the role of oscillatory synchronization in sensory networks. Electroencephalogram and local field potentia

    Classifying Streamflow Duration: The Scientific Basis and an Operational Framework for Method Development

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    Streamflow duration is used to differentiate reaches into discrete classes (e.g., perennial, intermittent, and ephemeral) for water resource management. Because the depiction of the extent and flow duration of streams via existing maps, remote sensing, and gauging is constrained, field-based tools are needed for use by practitioners and to validate hydrography and modeling advances. Streamflow Duration Assessment Methods (SDAMs) are rapid, reach-scale indices or models that use physical and biological indicators to predict flow duration class. We review the scientific basis for indicators and present conceptual and operational frameworks for SDAM development. Indicators can be responses to or controls of flow duration. Aquatic and terrestrial responses can be integrated into SDAMs, reflecting concurrent increases and decreases along the flow duration gradient. The conceptual framework for data-driven SDAM development shows interrelationships among the key components: study reaches, hydrologic data, and indicators. We present a generalized operational framework for SDAM development that integrates the data-driven components through five process steps: preparation, data collection, data analysis, evaluation, and implementation. We highlight priorities for the advancement of SDAMs, including expansion of gauging of nonperennial reaches, use of citizen science data, adjusting for stressor gradients, and statistical and monitoring advances to improve indicator effectiveness
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