Risk adjustment of health-care performance measures in a multinational register-based study: A pragmatic approach to a complicated topic

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Tron Anders Moger

2014-03-01

Full Text Available Objectives: Health-care performance comparisons across countries are gaining popularity. In such comparisons, the risk adjustment methodology plays a key role for meaningful comparisons. However, comparisons may be complicated by the fact that not all participating countries are allowed to share their data across borders, meaning that only simple methods are easily used for the risk adjustment. In this study, we develop a pragmatic approach using patient-level register data from Finland, Hungary, Italy, Norway, and Sweden. Methods: Data on acute myocardial infarction patients were gathered from health-care registers in several countries. In addition to unadjusted estimates, we studied the effects of adjusting for age, gender, and a number of comorbidities. The stability of estimates for 90-day mortality and length of stay of the first hospital episode following diagnosis of acute myocardial infarction is studied graphically, using different choices of reference data. Logistic regression models are used for mortality, and negative binomial models are used for length of stay. Results: Results from the sensitivity analysis show that the various models of risk adjustment give similar results for the countries, with some exceptions for Hungary and Italy. Based on the results, in Finland and Hungary, the 90-day mortality after acute myocardial infarction is higher than in Italy, Norway, and Sweden. Conclusion: Health-care registers give encouraging possibilities to performance measurement and enable the comparison of entire patient populations between countries. Risk adjustment methodology is affected by the availability of data, and thus, the building of risk adjustment methodology must be transparent, especially when doing multinational comparative research. In that case, even basic methods of risk adjustment may still be valuable.

Risk adjustment and the fear of markets: the case of Belgium.

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Schokkaert, E; Van de Voorde, C

2000-02-01

In Belgium the management and administration of the compulsory and universal health insurance is left to a limited number of non-governmental non-profit sickness funds. Since 1995 these sickness funds are partially financed in a prospective way. The risk adjustment scheme is based on a regression model to explain medical expenditures for different social groups. Medical supply is taken out of the formula to construct risk-adjusted capitation payments. The risk-adjustment formula still leaves scope for risk selection. At the same time, the sickness funds were not given the instruments to exert a real influence on expenditures and the health insurance market has not been opened for new entrants. As a consequence, Belgium runs the danger of ending up in a situation with little incentives for efficiency and considerable profits from cream skimming.

INSTITUTIONAL OWNERSHIP LEVEL AND RISK-ADJUSTED RETURN

OpenAIRE

Isaiah, Chioma; Li, Meng (Emma)

2017-01-01

This paper examines the relationship between the level of institutional ownership andrisk-adjusted return on stocks. We find a significant positive relationship between the level ofinstitutional ownership on a stock and its risk-adjusted return. This result holds both in the longrun and in shorter time periods. Our findings suggest that all things being equal, it is possible toobtain risk-adjusted return by going short on the stocks with low institutional ownership andgoing long on those with...

Spatial implications of covariate adjustment on patterns of risk

DEFF Research Database (Denmark)

Sabel, Clive Eric; Wilson, Jeff Gaines; Kingham, Simon

2007-01-01

Epidemiological studies that examine the relationship between environmental exposures and health often address other determinants of health that may influence the relationship being studied by adjusting for these factors as covariates. While disease surveillance methods routinely control...... for covariates such as deprivation, there has been limited investigative work on the spatial movement of risk at the intraurban scale due to the adjustment. It is important that the nature of any spatial relocation be well understood as a relocation to areas of increased risk may also introduce additional...... localised factors that influence the exposure-response relationship. This paper examines the spatial patterns of relative risk and clusters of hospitalisations based on an illustrative small-area example from Christchurch, New Zealand. A four-stage test of the spatial relocation effects of covariate...

The risk-adjusted performance of companies with female directors: A South African case

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Mkhethwa Mkhize

2013-04-01

Full Text Available The objective of this research was to examine the effects of female directors on the risk-adjusted performance of firms listed on the JSE Securities Exchange of South Africa (the JSE. The theoretical underpinning for the relationship between representation of female directors and the risk-adjusted performance of companies was based on institutional theory. The hypothesis that there is no difference between the risk-adjusted performance of companies with female directors and that of companies without female directors was rejected. Implications of the results are discussed and suggestions for future research presented.

Risk-adjusted capitation: recent experiences in The Netherlands.

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van de Ven, W P; van Vliet, R C; van Barneveld, E M; Lamers, L M

1994-01-01

The market-oriented health care reforms taking place in the Netherlands show a clear resemblance to the proposals for managed competition in U.S. health care. In both countries good risk adjustment mechanisms that prevent cream skimming--that is, that prevent plans from selecting the best health risks--are critical to the success of the reforms. In this paper we present an overview of the Dutch reforms and of our research concerning risk-adjusted capitation payments. Although we are optimistic about the technical possibilities for solving the problem of cream skimming, the implementation of good risk-adjusted capitation is a long-term challenge.

Portfolio balancing and risk adjusted values under constrained budget conditions

International Nuclear Information System (INIS)

MacKay, J.A.; Lerche, I.

1996-01-01

For a given hydrocarbon exploration opportunity, the influences of value, cost, success probability and corporate risk tolerance provide an optimal working interest that should be taken in the opportunity in order to maximize the risk adjusted value. When several opportunities are available, but when the total budget is insufficient to take optimal working interest in each, an analytic procedure is given for optimizing the risk adjusted value of the total portfolio; the relevant working interests are also derived based on a cost exposure constraint. Several numerical illustrations are provided to exhibit the use of the method under different budget conditions, and with different numbers of available opportunities. When value, cost, success probability, and risk tolerance are uncertain for each and every opportunity, the procedure is generalized to allow determination of probable optimal risk adjusted value for the total portfolio and, at the same time, the range of probable working interest that should be taken in each opportunity is also provided. The result is that the computations of portfolio balancing can be done quickly in either deterministic or probabilistic manners on a small calculator, thereby providing rapid assessments of opportunities and their worth to a corporation. (Author)

Competition Leverage : How the Demand Side Affects Optimal Risk Adjustment

NARCIS (Netherlands)

Bijlsma, M.; Boone, J.; Zwart, Gijsbert

2011-01-01

We study optimal risk adjustment in imperfectly competitive health insurance markets when high-risk consumers are less likely to switch insurer than low-risk consumers. First, we find that insurers still have an incentive to select even if risk adjustment perfectly corrects for cost differences

The risk-adjusted vision beyond casemix (DRG) funding in Australia. International lessons in high complexity and capitation.

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Antioch, Kathryn M; Walsh, Michael K

2004-06-01

Hospitals throughout the world using funding based on diagnosis-related groups (DRG) have incurred substantial budgetary deficits, despite high efficiency. We identify the limitations of DRG funding that lack risk (severity) adjustment for State-wide referral services. Methods to risk adjust DRGs are instructive. The average price in casemix funding in the Australian State of Victoria is policy based, not benchmarked. Average cost weights are too low for high-complexity DRGs relating to State-wide referral services such as heart and lung transplantation and trauma. Risk-adjusted specified grants (RASG) are required for five high-complexity respiratory, cardiology and stroke DRGs incurring annual deficits of $3.6 million due to high casemix complexity and government under-funding despite high efficiency. Five stepwise linear regressions for each DRG excluded non-significant variables and assessed heteroskedasticity and multicollinearlity. Cost per patient was the dependent variable. Significant independent variables were age, length-of-stay outliers, number of disease types, diagnoses, procedures and emergency status. Diagnosis and procedure severity markers were identified. The methodology and the work of the State-wide Risk Adjustment Working Group can facilitate risk adjustment of DRGs State-wide and for Treasury negotiations for expenditure growth. The Alfred Hospital previously negotiated RASG of $14 million over 5 years for three trauma and chronic DRGs. Some chronic diseases require risk-adjusted capitation funding models for Australian Health Maintenance Organizations as an alternative to casemix funding. The use of Diagnostic Cost Groups can facilitate State and Federal government reform via new population-based risk adjusted funding models that measure health need.

Introducing risk adjustment and free health plan choice in employer-based health insurance: Evidence from Germany.

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Pilny, Adam; Wübker, Ansgar; Ziebarth, Nicolas R

2017-12-01

To equalize differences in health plan premiums due to differences in risk pools, the German legislature introduced a simple Risk Adjustment Scheme (RAS) based on age, gender and disability status in 1994. In addition, effective 1996, consumers gained the freedom to choose among hundreds of existing health plans, across employers and state-borders. This paper (a) estimates RAS pass-through rates on premiums, financial reserves, and expenditures and assesses the overall RAS impact on market price dispersion. Moreover, it (b) characterizes health plan switchers and investigates their annual and cumulative switching rates over time. Our main findings are based on representative enrollee panel data linked to administrative RAS and health plan data. We show that sickness funds with bad risk pools and high pre-RAS premiums lowered their total premiums by 42 cents per additional euro allocated by the RAS. Consequently, post-RAS, health plan prices converged but not fully. Because switchers are more likely to be white collar, young and healthy, the new consumer choice resulted in more risk segregation and the amount of money redistributed by the RAS increased over time. Copyright © 2017 Elsevier B.V. All rights reserved.

A simple signaling rule for variable life-adjusted display derived from an equivalent risk-adjusted CUSUM chart.

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Wittenberg, Philipp; Gan, Fah Fatt; Knoth, Sven

2018-04-17

The variable life-adjusted display (VLAD) is the first risk-adjusted graphical procedure proposed in the literature for monitoring the performance of a surgeon. It displays the cumulative sum of expected minus observed deaths. It has since become highly popular because the statistic plotted is easy to understand. But it is also easy to misinterpret a surgeon's performance by utilizing the VLAD, potentially leading to grave consequences. The problem of misinterpretation is essentially caused by the variance of the VLAD's statistic that increases with sample size. In order for the VLAD to be truly useful, a simple signaling rule is desperately needed. Various forms of signaling rules have been developed, but they are usually quite complicated. Without signaling rules, making inferences using the VLAD alone is difficult if not misleading. In this paper, we establish an equivalence between a VLAD with V-mask and a risk-adjusted cumulative sum (RA-CUSUM) chart based on the difference between the estimated probability of death and surgical outcome. Average run length analysis based on simulation shows that this particular RA-CUSUM chart has similar performance as compared to the established RA-CUSUM chart based on the log-likelihood ratio statistic obtained by testing the odds ratio of death. We provide a simple design procedure for determining the V-mask parameters based on a resampling approach. Resampling from a real data set ensures that these parameters can be estimated appropriately. Finally, we illustrate the monitoring of a real surgeon's performance using VLAD with V-mask. Copyright © 2018 John Wiley & Sons, Ltd.

Health plans and selection: formal risk adjustment vs. market design and contracts.

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Frank, R G; Rosenthal, M B

2001-01-01

In this paper, we explore the demand for risk adjustment by health plans that contract with private employers by considering the conditions under which plans might value risk adjustment. Three factors reduce the value of risk adjustment from the plans' point of view. First, only a relatively small segment of privately insured Americans face a choice of competing health plans. Second, health plans share much of their insurance risk with payers, providers, and reinsurers. Third, de facto experience rating that occurs during the premium negotiation process and management of coverage appear to substitute for risk adjustment. While the current environment has not generated much demand for risk adjustment, we reflect on its future potential.

Evidence that Risk Adjustment is Unnecessary in Estimates of the User Cost of Money

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Diego A. Restrepo-Tobón

2015-12-01

Full Text Available Investors value the  special attributes of monetary assets (e.g.,  exchangeability, liquidity, and safety  and pay a premium for holding them in the form of a lower return rate. The user cost of holding monetary assets can be measured approximately by the difference between the  returns on illiquid risky assets and  those of safer liquid assets. A more appropriate measure should adjust this difference by the  differential risk of the  assets in question. We investigate the  impact that time  non-separable preferences has on the  estimation of the  risk-adjusted user cost of money. Using U.K. data from 1965Q1 to 2011Q1, we estimate a habit-based asset pricing model  with money  in the utility function and  find that the  risk  adjustment for risky monetary assets is negligible. Thus, researchers can dispense with risk adjusting the  user cost of money  in constructing monetary aggregate indexes.

Risk-adjusted Outcomes of Clinically Relevant Pancreatic Fistula Following Pancreatoduodenectomy: A Model for Performance Evaluation.

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McMillan, Matthew T; Soi, Sameer; Asbun, Horacio J; Ball, Chad G; Bassi, Claudio; Beane, Joal D; Behrman, Stephen W; Berger, Adam C; Bloomston, Mark; Callery, Mark P; Christein, John D; Dixon, Elijah; Drebin, Jeffrey A; Castillo, Carlos Fernandez-Del; Fisher, William E; Fong, Zhi Ven; House, Michael G; Hughes, Steven J; Kent, Tara S; Kunstman, John W; Malleo, Giuseppe; Miller, Benjamin C; Salem, Ronald R; Soares, Kevin; Valero, Vicente; Wolfgang, Christopher L; Vollmer, Charles M

2016-08-01

To evaluate surgical performance in pancreatoduodenectomy using clinically relevant postoperative pancreatic fistula (CR-POPF) occurrence as a quality indicator. Accurate assessment of surgeon and institutional performance requires (1) standardized definitions for the outcome of interest and (2) a comprehensive risk-adjustment process to control for differences in patient risk. This multinational, retrospective study of 4301 pancreatoduodenectomies involved 55 surgeons at 15 institutions. Risk for CR-POPF was assessed using the previously validated Fistula Risk Score, and pancreatic fistulas were stratified by International Study Group criteria. CR-POPF variability was evaluated and hierarchical regression analysis assessed individual surgeon and institutional performance. There was considerable variability in both CR-POPF risk and occurrence. Factors increasing the risk for CR-POPF development included increasing Fistula Risk Score (odds ratio 1.49 per point, P ratio 3.30, P performance outliers were identified at the surgeon and institutional levels. Of the top 10 surgeons (≥15 cases) for nonrisk-adjusted performance, only 6 remained in this high-performing category following risk adjustment. This analysis of pancreatic fistulas following pancreatoduodenectomy demonstrates considerable variability in both the risk and occurrence of CR-POPF among surgeons and institutions. Disparities in patient risk between providers reinforce the need for comprehensive, risk-adjusted modeling when assessing performance based on procedure-specific complications. Furthermore, beyond inherent patient risk factors, surgical decision-making influences fistula outcomes.

Ensemble of trees approaches to risk adjustment for evaluating a hospital's performance.

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Liu, Yang; Traskin, Mikhail; Lorch, Scott A; George, Edward I; Small, Dylan

2015-03-01

A commonly used method for evaluating a hospital's performance on an outcome is to compare the hospital's observed outcome rate to the hospital's expected outcome rate given its patient (case) mix and service. The process of calculating the hospital's expected outcome rate given its patient mix and service is called risk adjustment (Iezzoni 1997). Risk adjustment is critical for accurately evaluating and comparing hospitals' performances since we would not want to unfairly penalize a hospital just because it treats sicker patients. The key to risk adjustment is accurately estimating the probability of an Outcome given patient characteristics. For cases with binary outcomes, the method that is commonly used in risk adjustment is logistic regression. In this paper, we consider ensemble of trees methods as alternatives for risk adjustment, including random forests and Bayesian additive regression trees (BART). Both random forests and BART are modern machine learning methods that have been shown recently to have excellent performance for prediction of outcomes in many settings. We apply these methods to carry out risk adjustment for the performance of neonatal intensive care units (NICU). We show that these ensemble of trees methods outperform logistic regression in predicting mortality among babies treated in NICU, and provide a superior method of risk adjustment compared to logistic regression.

PACE and the Medicare+Choice risk-adjusted payment model.

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Temkin-Greener, H; Meiners, M R; Gruenberg, L

2001-01-01

This paper investigates the impact of the Medicare principal inpatient diagnostic cost group (PIP-DCG) payment model on the Program of All-Inclusive Care for the Elderly (PACE). Currently, more than 6,000 Medicare beneficiaries who are nursing home certifiable receive care from PACE, a program poised for expansion under the Balanced Budget Act of 1997. Overall, our analysis suggests that the application of the PIP-DCG model to the PACE program would reduce Medicare payments to PACE, on average, by 38%. The PIP-DCG payment model bases its risk adjustment on inpatient diagnoses and does not capture adequately the risk of caring for a population with functional impairments.

Underwriters' view of risk - An adjuster's perspective

International Nuclear Information System (INIS)

Smith, M.

1992-01-01

This paper reviews how a risk assessment is performed by an insurance adjuster to determine rates and insurability of a client. It provides a historical perspective on insurance and how information systems are used to monitor past claims to determine future risk. Although this paper does not specifically address the oil and gas industry, it is informative in identifying how insurance rates are determined and risk assessments for various oil and gas operations are performed

Suboptimal decision making by children with ADHD in the face of risk: Poor risk adjustment and delay aversion rather than general proneness to taking risks.

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Sørensen, Lin; Sonuga-Barke, Edmund; Eichele, Heike; van Wageningen, Heidi; Wollschlaeger, Daniel; Plessen, Kerstin Jessica

2017-02-01

Suboptimal decision making in the face of risk (DMR) in children with attention-deficit hyperactivity disorder (ADHD) may be mediated by deficits in a number of different neuropsychological processes. We investigated DMR in children with ADHD using the Cambridge Gambling Task (CGT) to distinguish difficulties in adjusting to changing probabilities of choice outcomes (so-called risk adjustment) from general risk proneness, and to distinguish these 2 processes from delay aversion (the tendency to choose the least delayed option) and impairments in the ability to reflect on choice options. Based on previous research, we predicted that suboptimal performance on this task in children with ADHD would be primarily relate to problems with risk adjustment and delay aversion rather than general risk proneness. Drug naïve children with ADHD (n = 36), 8 to 12 years, and an age-matched group of typically developing children (n = 34) performed the CGT. As predicted, children with ADHD were not more prone to making risky choices (i.e., risk proneness). However, they had difficulty adjusting to changing risk levels and were more delay aversive-with these 2 effects being correlated. Our findings add to the growing body of evidence that children with ADHD do not favor risk taking per se when performing gambling tasks, but rather may lack the cognitive skills or motivational style to appraise changing patterns of risk effectively. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

12 CFR Appendix B to Part 3 - Risk-Based Capital Guidelines; Market Risk Adjustment

Science.gov (United States)

2010-01-01

...) The bank must have a risk control unit that reports directly to senior management and is independent... management systems at least annually. (c) Market risk factors. The bank's internal model must use risk.... Section 4. Internal Models (a) General. For risk-based capital purposes, a bank subject to this appendix...

Use of risk-adjusted CUSUM charts to monitor 30-day mortality in Danish hospitals

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Rasmussen TB

2018-04-01

Full Text Available Thomas Bøjer Rasmussen, Sinna Pilgaard Ulrichsen, Mette Nørgaard Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus N, Denmark Background: Monitoring hospital outcomes and clinical processes as a measure of clinical performance is an integral part of modern health care. The risk-adjusted cumulative sum (CUSUM chart is a frequently used sequential analysis technique that can be implemented to monitor a wide range of different types of outcomes.Objective: The aim of this study was to describe how risk-adjusted CUSUM charts based on population-based nationwide medical registers were used to monitor 30-day mortality in Danish hospitals and to give an example on how alarms of increased hospital mortality from the charts can guide further in-depth analyses.Materials and methods: We used routinely collected administrative data from the Danish National Patient Registry and the Danish Civil Registration System to create risk-adjusted CUSUM charts. We monitored 30-day mortality after hospital admission with one of 77 selected diagnoses in 24 hospital units in Denmark in 2015. The charts were set to detect a 50% increase in 30-day mortality, and control limits were determined by simulations.Results: Among 1,085,576 hospital admissions, 441,352 admissions had one of the 77 selected diagnoses as their primary diagnosis and were included in the risk-adjusted CUSUM charts. The charts yielded a total of eight alarms of increased mortality. The median of the hospitals’ estimated average time to detect a 50% increase in 30-day mortality was 50 days (interquartile interval, 43;54. In the selected example of an alarm, descriptive analyses indicated performance problems with 30-day mortality following hip fracture surgery and diagnosis of chronic obstructive pulmonary disease.Conclusion: The presented implementation of risk-adjusted CUSUM charts can detect significant increases in 30-day mortality within 2 months, on average, in most

Risk-adjusted antibiotic consumption in 34 public acute hospitals in Ireland, 2006 to 2014

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Oza, Ajay; Donohue, Fionnuala; Johnson, Howard; Cunney, Robert

2016-01-01

As antibiotic consumption rates between hospitals can vary depending on the characteristics of the patients treated, risk-adjustment that compensates for the patient-based variation is required to assess the impact of any stewardship measures. The aim of this study was to investigate the usefulness of patient-based administrative data variables for adjusting aggregate hospital antibiotic consumption rates. Data on total inpatient antibiotics and six broad subclasses were sourced from 34 acute hospitals from 2006 to 2014. Aggregate annual patient administration data were divided into explanatory variables, including major diagnostic categories, for each hospital. Multivariable regression models were used to identify factors affecting antibiotic consumption. Coefficient of variation of the root mean squared errors (CV-RMSE) for the total antibiotic usage model was very good (11%), however, the value for two of the models was poor (> 30%). The overall inpatient antibiotic consumption increased from 82.5 defined daily doses (DDD)/100 bed-days used in 2006 to 89.2 DDD/100 bed-days used in 2014; the increase was not significant after risk-adjustment. During the same period, consumption of carbapenems increased significantly, while usage of fluoroquinolones decreased. In conclusion, patient-based administrative data variables are useful for adjusting hospital antibiotic consumption rates, although additional variables should also be employed. PMID:27541730

Latino risk-adjusted mortality in the men screened for the Multiple Risk Factor Intervention Trial.

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Thomas, Avis J; Eberly, Lynn E; Neaton, James D; Smith, George Davey

2005-09-15

Latinos are now the largest minority in the United States, but their distinctive health needs and mortality patterns remain poorly understood. Proportional hazards regressions were used to compare Latino versus White risk- and income-adjusted mortality over 25 years' follow-up from 5,846 Latino and 300,647 White men screened for the Multiple Risk Factor Intervention Trial. Men were aged 35-57 years and residing in 14 states when screened in 1973-1975. Data on coronary heart disease risk factors, self-reported race/ethnicity, and home addresses were obtained at baseline; income was estimated by linking addresses to census data. Mortality follow-up through 1999 was obtained using the National Death Index. The fully adjusted Latino/White hazard ratio for all-cause mortality was 0.82 (95% confidence interval (CI): 0.77, 0.87), based on 1,085 Latino and 73,807 White deaths; this pattern prevailed over time and across states (thus, likely across Latino subgroups). Hazard ratios were significantly greater than one for stroke (hazard ratio = 1.30, 95% CI: 1.01, 1.68), liver cancer (hazard ratio = 2.02, 95% CI: 1.21, 3.37), and infection (hazard ratio = 1.69, 95% CI: 1.24, 2.32). A substudy found only minor racial/ethnic differences in the quality of Social Security numbers, birth dates, soundex-adjusted names, and National Death Index searches. Results were not likely an artifact of return migration or incomplete mortality data.

Performance evaluation of inpatient service in Beijing: a horizontal comparison with risk adjustment based on Diagnosis Related Groups.

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Jian, Weiyan; Huang, Yinmin; Hu, Mu; Zhang, Xiumei

2009-04-30

The medical performance evaluation, which provides a basis for rational decision-making, is an important part of medical service research. Current progress with health services reform in China is far from satisfactory, without sufficient regulation. To achieve better progress, an effective tool for evaluating medical performance needs to be established. In view of this, this study attempted to develop such a tool appropriate for the Chinese context. Data was collected from the front pages of medical records (FPMR) of all large general public hospitals (21 hospitals) in the third and fourth quarter of 2007. Locally developed Diagnosis Related Groups (DRGs) were introduced as a tool for risk adjustment and performance evaluation indicators were established: Charge Efficiency Index (CEI), Time Efficiency Index (TEI) and inpatient mortality of low-risk group cases (IMLRG), to reflect respectively work efficiency and medical service quality. Using these indicators, the inpatient services' performance was horizontally compared among hospitals. Case-mix Index (CMI) was used to adjust efficiency indices and then produce adjusted CEI (aCEI) and adjusted TEI (aTEI). Poisson distribution analysis was used to test the statistical significance of the IMLRG differences between different hospitals. Using the aCEI, aTEI and IMLRG scores for the 21 hospitals, Hospital A and C had relatively good overall performance because their medical charges were lower, LOS shorter and IMLRG smaller. The performance of Hospital P and Q was the worst due to their relatively high charge level, long LOS and high IMLRG. Various performance problems also existed in the other hospitals. It is possible to develop an accurate and easy to run performance evaluation system using Case-Mix as the tool for risk adjustment, choosing indicators close to consumers and managers, and utilizing routine report forms as the basic information source. To keep such a system running effectively, it is necessary to

Public Reporting of Primary Care Clinic Quality: Accounting for Sociodemographic Factors in Risk Adjustment and Performance Comparison.

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Wholey, Douglas R; Finch, Michael; Kreiger, Rob; Reeves, David

2018-01-03

Performance measurement and public reporting are increasingly being used to compare clinic performance. Intended consequences include quality improvement, value-based payment, and consumer choice. Unintended consequences include reducing access for riskier patients and inappropriately labeling some clinics as poor performers, resulting in tampering with stable care processes. Two analytic steps are used to maximize intended and minimize unintended consequences. First, risk adjustment is used to reduce the impact of factors outside providers' control. Second, performance categorization is used to compare clinic performance using risk-adjusted measures. This paper examines the effects of methodological choices, such as risk adjusting for sociodemographic factors in risk adjustment and accounting for patients clustering by clinics in performance categorization, on clinic performance comparison for diabetes care, vascular care, asthma, and colorectal cancer screening. The population includes all patients with commercial and public insurance served by clinics in Minnesota. Although risk adjusting for sociodemographic factors has a significant effect on quality, it does not explain much of the variation in quality. In contrast, taking into account the nesting of patients within clinics in performance categorization has a substantial effect on performance comparison.

Monitoring risk-adjusted outcomes in congenital heart surgery: does the appropriateness of a risk model change with time?

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Tsang, Victor T; Brown, Katherine L; Synnergren, Mats Johanssen; Kang, Nicholas; de Leval, Marc R; Gallivan, Steve; Utley, Martin

2009-02-01

Risk adjustment of outcomes in pediatric congenital heart surgery is challenging due to the great diversity in diagnoses and procedures. We have previously shown that variable life-adjusted display (VLAD) charts provide an effective graphic display of risk-adjusted outcomes in this specialty. A question arises as to whether the risk model used remains appropriate over time. We used a recently developed graphic technique to evaluate the performance of an existing risk model among those patients at a single center during 2000 to 2003 originally used in model development. We then compared the distribution of predicted risk among these patients with that among patients in 2004 to 2006. Finally, we constructed a VLAD chart of risk-adjusted outcomes for the latter period. Among 1083 patients between April 2000 and March 2003, the risk model performed well at predicted risks above 3%, underestimated mortality at 2% to 3% predicted risk, and overestimated mortality below 2% predicted risk. There was little difference in the distribution of predicted risk among these patients and among 903 patients between June 2004 and October 2006. Outcomes for the more recent period were appreciably better than those expected according to the risk model. This finding cannot be explained by any apparent bias in the risk model combined with changes in case-mix. Risk models can, and hopefully do, become out of date. There is scope for complacency in the risk-adjusted audit if the risk model used is not regularly recalibrated to reflect changing standards and expectations.

Sperm competition risk drives rapid ejaculate adjustments mediated by seminal fluid.

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Bartlett, Michael J; Steeves, Tammy E; Gemmell, Neil J; Rosengrave, Patrice C

2017-10-31

In many species, males can make rapid adjustments to ejaculate performance in response to sperm competition risk; however, the mechanisms behind these changes are not understood. Here, we manipulate male social status in an externally fertilising fish, chinook salmon ( Oncorhynchus tshawytscha ), and find that in less than 48 hr, males can upregulate sperm velocity when faced with an increased risk of sperm competition. Using a series of in vitro sperm manipulation and competition experiments, we show that rapid changes in sperm velocity are mediated by seminal fluid and the effect of seminal fluid on sperm velocity directly impacts paternity share and therefore reproductive success. These combined findings, completely consistent with sperm competition theory, provide unequivocal evidence that sperm competition risk drives plastic adjustment of ejaculate quality, that seminal fluid harbours the mechanism for the rapid adjustment of sperm velocity and that fitness benefits accrue to males from such adjustment.

Risk adjustment models for short-term outcomes after surgical resection for oesophagogastric cancer.

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Fischer, C; Lingsma, H; Hardwick, R; Cromwell, D A; Steyerberg, E; Groene, O

2016-01-01

Outcomes for oesophagogastric cancer surgery are compared with the aim of benchmarking quality of care. Adjusting for patient characteristics is crucial to avoid biased comparisons between providers. The study objective was to develop a case-mix adjustment model for comparing 30- and 90-day mortality and anastomotic leakage rates after oesophagogastric cancer resections. The study reviewed existing models, considered expert opinion and examined audit data in order to select predictors that were consequently used to develop a case-mix adjustment model for the National Oesophago-Gastric Cancer Audit, covering England and Wales. Models were developed on patients undergoing surgical resection between April 2011 and March 2013 using logistic regression. Model calibration and discrimination was quantified using a bootstrap procedure. Most existing risk models for oesophagogastric resections were methodologically weak, outdated or based on detailed laboratory data that are not generally available. In 4882 patients with oesophagogastric cancer used for model development, 30- and 90-day mortality rates were 2·3 and 4·4 per cent respectively, and 6·2 per cent of patients developed an anastomotic leak. The internally validated models, based on predictors selected from the literature, showed moderate discrimination (area under the receiver operating characteristic (ROC) curve 0·646 for 30-day mortality, 0·664 for 90-day mortality and 0·587 for anastomotic leakage) and good calibration. Based on available data, three case-mix adjustment models for postoperative outcomes in patients undergoing curative surgery for oesophagogastric cancer were developed. These models should be used for risk adjustment when assessing hospital performance in the National Health Service, and tested in other large health systems. © 2015 BJS Society Ltd Published by John Wiley & Sons Ltd.

Anesthesiologist- and System-Related Risk Factors for Risk-Adjusted Pediatric Anesthesia-Related Cardiac Arrest.

Science.gov (United States)

Zgleszewski, Steven E; Graham, Dionne A; Hickey, Paul R; Brustowicz, Robert M; Odegard, Kirsten C; Koka, Rahul; Seefelder, Christian; Navedo, Andres T; Randolph, Adrienne G

2016-02-01

Pediatric anesthesia-related cardiac arrest (ARCA) is an uncommon but potentially preventable adverse event. Infants and children with more severe underlying disease are at highest risk. We aimed to identify system- and anesthesiologist-related risk factors for ARCA. We analyzed a prospectively collected patient cohort data set of anesthetics administered from 2000 to 2011 to children at a large tertiary pediatric hospital. Pre-procedure systemic disease level was characterized by ASA physical status (ASA-PS). Two reviewers independently reviewed cardiac arrests and categorized their anesthesia relatedness. Factors associated with ARCA in the univariate analyses were identified for reevaluation after adjustment for patient age and ASA-PS. Cardiac arrest occurred in 142 of 276,209 anesthetics (incidence 5.1/10,000 anesthetics); 72 (2.6/10,000 anesthetics) were classified as anesthesia-related. In the univariate analyses, risk of ARCA was much higher in cardiac patients and for anesthesiologists with lower annual caseload and/or fewer annual days delivering anesthetics (all P risk adjustment for ASA-PS ≥ III and age ≤ 6 months, however, the association with lower annual days delivering anesthetics remained (P = 0.03), but the other factors were no longer significant. Case-mix explained most associations between higher risk of pediatric ARCA and anesthesiologist-related variables at our institution, but the association with fewer annual days delivering anesthetics remained. Our findings highlight the need for rigorous adjustment for patient risk factors in anesthesia patient safety studies.

Risk-adjusted performance evaluation in three academic thoracic surgery units using the Eurolung risk models.

Science.gov (United States)

Pompili, Cecilia; Shargall, Yaron; Decaluwe, Herbert; Moons, Johnny; Chari, Madhu; Brunelli, Alessandro

2018-01-03

The objective of this study was to evaluate the performance of 3 thoracic surgery centres using the Eurolung risk models for morbidity and mortality. This was a retrospective analysis performed on data collected from 3 academic centres (2014-2016). Seven hundred and twenty-one patients in Centre 1, 857 patients in Centre 2 and 433 patients in Centre 3 who underwent anatomical lung resections were analysed. The Eurolung1 and Eurolung2 models were used to predict risk-adjusted cardiopulmonary morbidity and 30-day mortality rates. Observed and risk-adjusted outcomes were compared within each centre. The observed morbidity of Centre 1 was in line with the predicted morbidity (observed 21.1% vs predicted 22.7%, P = 0.31). Centre 2 performed better than expected (observed morbidity 20.2% vs predicted 26.7%, P models were successfully used as risk-adjusting instruments to internally audit the outcomes of 3 different centres, showing their applicability for future quality improvement initiatives. © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Funding issues for Victorian hospitals: the risk-adjusted vision beyond casemix funding.

Science.gov (United States)

Antioch, K; Walsh, M

2000-01-01

This paper discusses casemix funding issues in Victoria impacting on teaching hospitals. For casemix payments to be acceptable, the average price and cost weights must be set at an appropriate standard. The average price is based on a normative, policy basis rather than benchmarking. The 'averaging principle' inherent in cost weights has resulted in some AN-DRG weights being too low for teaching hospitals that are key State-wide providers of high complexity services such as neurosurgery and trauma. Casemix data have been analysed using international risk adjustment methodologies to successfully negotiate with the Victorian State Government for specified grants for several high complexity AN-DRGs. A risk-adjusted capitation funding model has also been developed for cystic fibrosis patients treated by The Alfred, called an Australian Health Maintenance Organisation (AHMO). This will facilitate the development of similar models by both the Victorian and Federal governments.

Rational Multi-curve Models with Counterparty-risk Valuation Adjustments

DEFF Research Database (Denmark)

Crépey, Stéphane; Macrina, Andrea; Nguyen, Tuyet Mai

2016-01-01

We develop a multi-curve term structure set-up in which the modelling ingredients are expressed by rational functionals of Markov processes. We calibrate to London Interbank Offer Rate swaptions data and show that a rational two-factor log-normal multi-curve model is sufficient to match market da...... with regulatory obligations. In order to compute counterparty-risk valuation adjustments, such as credit valuation adjustment, we show how default intensity processes with rational form can be derived. We flesh out our study by applying the results to a basis swap contract....... with accuracy. We elucidate the relationship between the models developed and calibrated under a risk-neutral measure Q and their consistent equivalence class under the real-world probability measure P. The consistent P-pricing models are applied to compute the risk exposures which may be required to comply...

A risk adjustment approach to estimating the burden of skin disease in the United States.

Science.gov (United States)

Lim, Henry W; Collins, Scott A B; Resneck, Jack S; Bolognia, Jean; Hodge, Julie A; Rohrer, Thomas A; Van Beek, Marta J; Margolis, David J; Sober, Arthur J; Weinstock, Martin A; Nerenz, David R; Begolka, Wendy Smith; Moyano, Jose V

2018-01-01

Direct insurance claims tabulation and risk adjustment statistical methods can be used to estimate health care costs associated with various diseases. In this third manuscript derived from the new national Burden of Skin Disease Report from the American Academy of Dermatology, a risk adjustment method that was based on modeling the average annual costs of individuals with or without specific diseases, and specifically tailored for 24 skin disease categories, was used to estimate the economic burden of skin disease. The results were compared with the claims tabulation method used in the first 2 parts of this project. The risk adjustment method estimated the direct health care costs of skin diseases to be $46 billion in 2013, approximately $15 billion less than estimates using claims tabulation. For individual skin diseases, the risk adjustment cost estimates ranged from 11% to 297% of those obtained using claims tabulation for the 10 most costly skin disease categories. Although either method may be used for purposes of estimating the costs of skin disease, the choice of method will affect the end result. These findings serve as an important reference for future discussions about the method chosen in health care payment models to estimate both the cost of skin disease and the potential cost impact of care changes. Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

Does risk-adjusted payment influence primary care providers’ decision on where to set up practices?

DEFF Research Database (Denmark)

Anell, Anders; Dackehag, Margareta; Dietrichson, Jens

2018-01-01

Background: Providing equal access to healthcare is an important objective in most health care systems. It is especially pertinent in systems like the Swedish primary care market, where private providers are free to establish themselves in any part of the country. To improve equity in access...... to care, 15 out 21 county councils in Sweden have implemented risk-adjusted capitation based on the Care Need Index, which increases capitation to primary care centers with a large share of patients with unfavorable socioeconomic and demographic characteristics. Our aim is to estimate the effects of using...... Index values. Results: Risk-adjusted capitation significantly increases the number of private primary care centers in areas with relatively high Care Need Index values. The adjustment results in a changed distribution of private centers within county councils; the total number of private centers does...

Development and Evaluation of an Automated Machine Learning Algorithm for In-Hospital Mortality Risk Adjustment Among Critical Care Patients.

Science.gov (United States)

Delahanty, Ryan J; Kaufman, David; Jones, Spencer S

2018-06-01

Risk adjustment algorithms for ICU mortality are necessary for measuring and improving ICU performance. Existing risk adjustment algorithms are not widely adopted. Key barriers to adoption include licensing and implementation costs as well as labor costs associated with human-intensive data collection. Widespread adoption of electronic health records makes automated risk adjustment feasible. Using modern machine learning methods and open source tools, we developed and evaluated a retrospective risk adjustment algorithm for in-hospital mortality among ICU patients. The Risk of Inpatient Death score can be fully automated and is reliant upon data elements that are generated in the course of usual hospital processes. One hundred thirty-one ICUs in 53 hospitals operated by Tenet Healthcare. A cohort of 237,173 ICU patients discharged between January 2014 and December 2016. The data were randomly split into training (36 hospitals), and validation (17 hospitals) data sets. Feature selection and model training were carried out using the training set while the discrimination, calibration, and accuracy of the model were assessed in the validation data set. Model discrimination was evaluated based on the area under receiver operating characteristic curve; accuracy and calibration were assessed via adjusted Brier scores and visual analysis of calibration curves. Seventeen features, including a mix of clinical and administrative data elements, were retained in the final model. The Risk of Inpatient Death score demonstrated excellent discrimination (area under receiver operating characteristic curve = 0.94) and calibration (adjusted Brier score = 52.8%) in the validation dataset; these results compare favorably to the published performance statistics for the most commonly used mortality risk adjustment algorithms. Low adoption of ICU mortality risk adjustment algorithms impedes progress toward increasing the value of the healthcare delivered in ICUs. The Risk of Inpatient Death

Risk-adjusted capitation: recent experiences in The Netherlands

NARCIS (Netherlands)

W.P.M.M. van de Ven (Wynand); E.M. van Barneveld (Erik); L.M. Lamers (Leida); R.C.J.A. van Vliet (René)

1994-01-01

textabstractThe market-oriented health care reforms taking place in the Netherlands show a clear resemblance to the proposals for managed competition in U.S. health care. In both countries good risk adjustment mechanisms that prevent cream skimming--that is, that

Diagnostic Risk Adjustment for Medicaid: The Disability Payment System

Science.gov (United States)

Kronick, Richard; Dreyfus, Tony; Lee, Lora; Zhou, Zhiyuan

1996-01-01

This article describes a system of diagnostic categories that Medicaid programs can use for adjusting capitation payments to health plans that enroll people with disability. Medicaid claims from Colorado, Michigan, Missouri, New York, and Ohio are analyzed to demonstrate that the greater predictability of costs among people with disabilities makes risk adjustment more feasible than for a general population and more critical to creating health systems for people with disability. The application of our diagnostic categories to State claims data is described, including estimated effects on subsequent-year costs of various diagnoses. The challenges of implementing adjustment by diagnosis are explored. PMID:10172665

Ants avoid superinfections by performing risk-adjusted sanitary care.

Science.gov (United States)

Konrad, Matthias; Pull, Christopher D; Metzler, Sina; Seif, Katharina; Naderlinger, Elisabeth; Grasse, Anna V; Cremer, Sylvia

2018-03-13

Being cared for when sick is a benefit of sociality that can reduce disease and improve survival of group members. However, individuals providing care risk contracting infectious diseases themselves. If they contract a low pathogen dose, they may develop low-level infections that do not cause disease but still affect host immunity by either decreasing or increasing the host's vulnerability to subsequent infections. Caring for contagious individuals can thus significantly alter the future disease susceptibility of caregivers. Using ants and their fungal pathogens as a model system, we tested if the altered disease susceptibility of experienced caregivers, in turn, affects their expression of sanitary care behavior. We found that low-level infections contracted during sanitary care had protective or neutral effects on secondary exposure to the same (homologous) pathogen but consistently caused high mortality on superinfection with a different (heterologous) pathogen. In response to this risk, the ants selectively adjusted the expression of their sanitary care. Specifically, the ants performed less grooming and more antimicrobial disinfection when caring for nestmates contaminated with heterologous pathogens compared with homologous ones. By modulating the components of sanitary care in this way the ants acquired less infectious particles of the heterologous pathogens, resulting in reduced superinfection. The performance of risk-adjusted sanitary care reveals the remarkable capacity of ants to react to changes in their disease susceptibility, according to their own infection history and to flexibly adjust collective care to individual risk.

Evaluating intergenerational risks: Probabillity adjusted rank-discounted utilitarianism

OpenAIRE

Asheim, Geir B.; Zuber, Stéphane

2015-01-01

Climate policies have stochastic consequences that involve a great number of generations. This calls for evaluating social risk (what kind of societies will future people be born into) rather than individual risk (what will happen to people during their own lifetimes). As a response we propose and axiomatize probability adjusted rank-discounted critical-level generalized utilitarianism (PARDCLU), through a key axiom that requires that the social welfare order both be ethical and satisfy first...

Risk-adjusted payment and performance assessment for primary care.

Science.gov (United States)

Ash, Arlene S; Ellis, Randall P

2012-08-01

Many wish to change incentives for primary care practices through bundled population-based payments and substantial performance feedback and bonus payments. Recognizing patient differences in costs and outcomes is crucial, but customized risk adjustment for such purposes is underdeveloped. Using MarketScan's claims-based data on 17.4 million commercially insured lives, we modeled bundled payment to support expected primary care activity levels (PCAL) and 9 patient outcomes for performance assessment. We evaluated models using 457,000 people assigned to 436 primary care physician panels, and among 13,000 people in a distinct multipayer medical home implementation with commercially insured, Medicare, and Medicaid patients. Each outcome is separately predicted from age, sex, and diagnoses. We define the PCAL outcome as a subset of all costs that proxies the bundled payment needed for comprehensive primary care. Other expected outcomes are used to establish targets against which actual performance can be fairly judged. We evaluate model performance using R(2)'s at patient and practice levels, and within policy-relevant subgroups. The PCAL model explains 67% of variation in its outcome, performing well across diverse patient ages, payers, plan types, and provider specialties; it explains 72% of practice-level variation. In 9 performance measures, the outcome-specific models explain 17%-86% of variation at the practice level, often substantially outperforming a generic score like the one used for full capitation payments in Medicare: for example, with grouped R(2)'s of 47% versus 5% for predicting "prescriptions for antibiotics of concern." Existing data can support the risk-adjusted bundled payment calculations and performance assessments needed to encourage desired transformations in primary care.

Risk and Protective Factors at Age 16: Psychological Adjustment in Children With a Cleft Lip and/or Palate.

Science.gov (United States)

Feragen, Kristin Billaud; Stock, Nicola Marie; Kvalem, Ingela Lundin

2015-09-01

Explore psychological functioning in adolescents with a cleft at age 16 from a broad perspective, including cognitive, emotional, behavioral, appearance-related, and psychosocial adjustment. High-risk groups were identified within each area of adjustment to investigate whether vulnerable adolescents were found across domains or whether risk was limited to specific areas of adjustment. Cross-sectional data based on psychological assessments at age 16 (N = 857). The effect of gender, cleft visibility, and the presence of an additional condition were investigated on all outcome variables. Results were compared with large national samples. Hopkins Symptom Checklist, Harter Self-Perception Scale for Adolescents, Child Experience Questionnaire, and Satisfaction With Appearance scale. The main factor influencing psychological adjustment across domains was gender, with girls in general reporting more psychological problems, as seen in reference groups. The presence of an additional condition also negatively affected some of the measures. No support was found for cleft visibility as a risk factor except for dissatisfaction with appearance. Correlation analyses of risk groups seem to point to an association between social and emotional risk and between social risk and dissatisfaction with appearance. Associations between other domains were found to be weak. The results point to areas of both risk and strength in adolescents born with a cleft lip and/or palate. Future research should investigate how protective factors could counteract potential risk in adolescents with a cleft.

Risk-adjusted capitation: Recent experiences in the Netherlands

NARCIS (Netherlands)

W.P.M.M. van de Ven (Wynand); R.C.J.A. van Vliet (René); E.M. van Barneveld (Erik); L.M. Lamers (Leida)

1994-01-01

textabstractThe market-oriented health care reforms taking place in the Netherlands show a clear resemblance to the proposals for managed competition in U.S. health care. In both countries good risk adjustment mechanisms that prevent cream skimming--that is, that prevent plans from selecting the

Personality, emotional adjustment, and cardiovascular risk: marriage as a mechanism.

Science.gov (United States)

Smith, Timothy W; Baron, Carolynne E; Grove, Jeremy L

2014-12-01

A variety of aspects of personality and emotional adjustment predict the development and course of coronary heart disease (CHD), as do indications of marital quality (e.g., satisfaction, conflict, strain, disruption). Importantly, the personality traits and aspects of emotional adjustment that predict CHD are also related to marital quality. In such instances of correlated risk factors, traditional epidemiological and clinical research typically either ignores the potentially overlapping effects or examines independent associations through statistical controls, approaches that can misrepresent the key components and mechanisms of psychosocial effects on CHD. The interpersonal perspective in personality and clinical psychology provides an alternative and integrative approach, through its structural and process models of interpersonal behavior. We present this perspective on psychosocial risk and review research on its application to the integration of personality, emotional adjustment, and marital processes as closely interrelated influences on health and disease. © 2013 Wiley Periodicals, Inc.

[Risk adjusted assessment of quality of perinatal centers - results of perinatal/neonatal quality surveillance in Saxonia].

Science.gov (United States)

Koch, R; Gmyrek, D; Vogtmann, Ch

2005-12-01

The weak point of the country-wide perinatal/neonatal quality surveillance as a tool for evaluation of achievements of a distinct clinic, is the ignorance of interhospital differences in the case-mix of patients. Therefore, that approach can not result in a reliable bench marking. To adjust the results of quality assessment of different hospitals according to their risk profile of patients by multivariate analysis. The perinatal/neonatal data base of 12.783 newborns of the saxonian quality surveillance from 1998 to 2000 was analyzed. 4 relevant quality indicators of newborn outcome -- a) severe intraventricular hemorrhage in preterm infants 2500 g and d) hypoxic-ischemic encephalopathy -- were targeted to find out specific risk predictors by considering 26 risk factors. A logistic regression model was used to develop the risk predictors. Risk predictors for the 4 quality indicators could be described by 3 - 9 out of 26 analyzed risk factors. The AUC (ROC)-values for these quality indicators were 82, 89, 89 and 89 %, what signifies their reliability. Using the new specific predictors for calculation the risk adjusted incidence rates of quality indicator yielded in some remarkable changes. The apparent differences in the outcome criteria of analyzed hospitals were found to be much less pronounced. The application of the proposed method for risk adjustment of quality indicators makes it possible to perform a more objective comparison of neonatal outcome criteria between different hospitals or regions.

Alternative Payment Models Should Risk-Adjust for Conversion Total Hip Arthroplasty: A Propensity Score-Matched Study.

Science.gov (United States)

McLawhorn, Alexander S; Schairer, William W; Schwarzkopf, Ran; Halsey, David A; Iorio, Richard; Padgett, Douglas E

2017-12-06

For Medicare beneficiaries, hospital reimbursement for nonrevision hip arthroplasty is anchored to either diagnosis-related group code 469 or 470. Under alternative payment models, reimbursement for care episodes is not further risk-adjusted. This study's purpose was to compare outcomes of primary total hip arthroplasty (THA) vs conversion THA to explore the rationale for risk adjustment for conversion procedures. All primary and conversion THAs from 2007 to 2014, excluding acute hip fractures and cancer patients, were identified in the National Surgical Quality Improvement Program database. Conversion and primary THA patients were matched 1:1 using propensity scores, based on preoperative covariates. Multivariable logistic regressions evaluated associations between conversion THA and 30-day outcomes. A total of 2018 conversions were matched to 2018 primaries. There were no differences in preoperative covariates. Conversions had longer operative times (148 vs 95 minutes, P reimbursement models shift toward bundled payment paradigms, conversion THA appears to be a procedure for which risk adjustment is appropriate. Copyright © 2017 Elsevier Inc. All rights reserved.

Breeds of risk-adjusted fundamentalist strategies in an order-driven market

Science.gov (United States)

LiCalzi, Marco; Pellizzari, Paolo

2006-01-01

This paper studies an order-driven stock market where agents have heterogeneous estimates of the fundamental value of the risky asset. The agents are budget-constrained and follow a value-based trading strategy which buys or sells depending on whether the price of the asset is below or above its risk-adjusted fundamental value. This environment generates returns that are remarkably leptokurtic and fat-tailed. By extending the study over a grid of different parameters for the fundamentalist trading strategy, we exhibit the existence of monotone relationships between the bid-ask spread demanded by the agents and several statistics of the returns. We conjecture that this effect, coupled with positive dependence of the risk premium on the volatility, generates positive feedbacks that might explain volatility bursts.

[Family characteristics, organic risk factors, psychopathological picture and premorbid adjustment of hospitalized adolescent patients].

Science.gov (United States)

Małkiewicz-Borkowska, M; Namysłowska, I; Siewierska, A; Puzyńska, E; Sredniawa, H; Zechowski, C; Iwanek, A; Ruszkowska, E

1996-01-01

The relation of some family characteristics such as cohesion and adaptability with organic risk factors, developmental psychopathology, clinical picture and premorbid adjustment was assessed in the group of 100 hospitalized adolescent patients and families. We found correlation between: some of organic risk factors (pathology of neonatal period, pathology of early childhood), some of indicators of developmental psychopathology (eating disorders, conduct disorders), some of clinical signs (mannerism, grandiosity, hostility, suspciousness, disturbances of content of thinking), premorbid adjustment, and variables related to families, described before. We think that biological variables characterizing child (pathology of neonatal period, pathology of early childhood) have an influence on some family characteristics as independent variable. General system theory and circular thinking support these conclusions. In order to verify them, it is necessary to undertake further investigations, based on other methodology, using this results as preliminary findings.

Scalability of a Methodology for Generating Technical Trading Rules with GAPs Based on Risk-Return Adjustment and Incremental Training

Science.gov (United States)

de La Cal, E. A.; Fernández, E. M.; Quiroga, R.; Villar, J. R.; Sedano, J.

In previous works a methodology was defined, based on the design of a genetic algorithm GAP and an incremental training technique adapted to the learning of series of stock market values. The GAP technique consists in a fusion of GP and GA. The GAP algorithm implements the automatic search for crisp trading rules taking as objectives of the training both the optimization of the return obtained and the minimization of the assumed risk. Applying the proposed methodology, rules have been obtained for a period of eight years of the S&P500 index. The achieved adjustment of the relation return-risk has generated rules with returns very superior in the testing period to those obtained applying habitual methodologies and even clearly superior to Buy&Hold. This work probes that the proposed methodology is valid for different assets in a different market than previous work.

Risk adjustment for case mix and the effect of surgeon volume on morbidity.

Science.gov (United States)

Maas, Matthew B; Jaff, Michael R; Rordorf, Guy A

2013-06-01

complications. Variables selected for risk adjustment in studies using administrative databases appear to be inadequate to control for case mix bias between low-volume and high-volume surgeons. Risk adjustment should empirically analyze for case mix imbalances between surgeons to identify meaningful risk modifiers in clinical practice such as the American Society of Anesthesiologists Physical Status classification. A true relationship between surgeon volume and outcomes remains uncertain, and caution is advised in developing policies based on these findings.

Can rent adjustment clauses reduce the income risk of farms?

OpenAIRE

Hotopp, Henning; Mußhoff, Oliver

2012-01-01

Risk management is gaining importance in agriculture. In addition to traditional instruments, new risk management instruments are increasingly being proposed. These proposals include the rent adjustment clauses (RACs), which seem to be an unusual instrument at first sight. In contrast with conventional instruments, RACs intentionally allow fixed-cost ‘rent payments’ to fluctuate. We investigate the whole-farm risk reduction potential of different types of RACs via a historical simulation....

Risk selection and risk adjustment: improving insurance in the individual and small group markets.

Science.gov (United States)

Baicker, Katherine; Dow, William H

2009-01-01

Insurance market reforms face the key challenge of addressing the threat that risk selection poses to the availability, of stable, high-value insurance policies that provide long-term risk protection. Many of the strategies in use today fail to address this breakdown in risk pooling, and some even exacerbate it. Flexible risk adjustment schemes are a promising avenue for promoting market stability and limiting insurer cream-skimming, potentially providing greater benefits at lower cost. Reforms intended to increase insurance coverage and the value of care delivered will be much more effective if implemented in conjunction with policies that address these fundamental selection issues.

Inappropriate use of payment weights to risk adjust readmission rates.

Science.gov (United States)

Fuller, Richard L; Goldfield, Norbert I; Averill, Richard F; Hughes, John S

2012-01-01

In this article, the authors demonstrate that the use of relative weights, as incorporated within the National Quality Forum-endorsed PacifiCare readmission measure, is inappropriate for risk adjusting rates of hospital readmission.

Development and Validation of Perioperative Risk-Adjustment Models for Hip Fracture Repair, Total Hip Arthroplasty, and Total Knee Arthroplasty.

Science.gov (United States)

Schilling, Peter L; Bozic, Kevin J

2016-01-06

Comparing outcomes across providers requires risk-adjustment models that account for differences in case mix. The burden of data collection from the clinical record can make risk-adjusted outcomes difficult to measure. The purpose of this study was to develop risk-adjustment models for hip fracture repair (HFR), total hip arthroplasty (THA), and total knee arthroplasty (TKA) that weigh adequacy of risk adjustment against data-collection burden. We used data from the American College of Surgeons National Surgical Quality Improvement Program to create derivation cohorts for HFR (n = 7000), THA (n = 17,336), and TKA (n = 28,661). We developed logistic regression models for each procedure using age, sex, American Society of Anesthesiologists (ASA) physical status classification, comorbidities, laboratory values, and vital signs-based comorbidities as covariates, and validated the models with use of data from 2012. The derivation models' C-statistics for mortality were 80%, 81%, 75%, and 92% and for adverse events were 68%, 68%, 60%, and 70% for HFR, THA, TKA, and combined procedure cohorts. Age, sex, and ASA classification accounted for a large share of the explained variation in mortality (50%, 58%, 70%, and 67%) and adverse events (43%, 45%, 46%, and 68%). For THA and TKA, these three variables were nearly as predictive as models utilizing all covariates. HFR model discrimination improved with the addition of comorbidities and laboratory values; among the important covariates were functional status, low albumin, high creatinine, disseminated cancer, dyspnea, and body mass index. Model performance was similar in validation cohorts. Risk-adjustment models using data from health records demonstrated good discrimination and calibration for HFR, THA, and TKA. It is possible to provide adequate risk adjustment using only the most predictive variables commonly available within the clinical record. This finding helps to inform the trade-off between model performance and data

Relevance of the c-statistic when evaluating risk-adjustment models in surgery.

Science.gov (United States)

Merkow, Ryan P; Hall, Bruce L; Cohen, Mark E; Dimick, Justin B; Wang, Edward; Chow, Warren B; Ko, Clifford Y; Bilimoria, Karl Y

2012-05-01

The measurement of hospital quality based on outcomes requires risk adjustment. The c-statistic is a popular tool used to judge model performance, but can be limited, particularly when evaluating specific operations in focused populations. Our objectives were to examine the interpretation and relevance of the c-statistic when used in models with increasingly similar case mix and to consider an alternative perspective on model calibration based on a graphical depiction of model fit. From the American College of Surgeons National Surgical Quality Improvement Program (2008-2009), patients were identified who underwent a general surgery procedure, and procedure groups were increasingly restricted: colorectal-all, colorectal-elective cases only, and colorectal-elective cancer cases only. Mortality and serious morbidity outcomes were evaluated using logistic regression-based risk adjustment, and model c-statistics and calibration curves were used to compare model performance. During the study period, 323,427 general, 47,605 colorectal-all, 39,860 colorectal-elective, and 21,680 colorectal cancer patients were studied. Mortality ranged from 1.0% in general surgery to 4.1% in the colorectal-all group, and serious morbidity ranged from 3.9% in general surgery to 12.4% in the colorectal-all procedural group. As case mix was restricted, c-statistics progressively declined from the general to the colorectal cancer surgery cohorts for both mortality and serious morbidity (mortality: 0.949 to 0.866; serious morbidity: 0.861 to 0.668). Calibration was evaluated graphically by examining predicted vs observed number of events over risk deciles. For both mortality and serious morbidity, there was no qualitative difference in calibration identified between the procedure groups. In the present study, we demonstrate how the c-statistic can become less informative and, in certain circumstances, can lead to incorrect model-based conclusions, as case mix is restricted and patients become

The Experience of Risk-Adjusted Capitation Payment for Family Physicians in Iran: A Qualitative Study.

Science.gov (United States)

Esmaeili, Reza; Hadian, Mohammad; Rashidian, Arash; Shariati, Mohammad; Ghaderi, Hossien

2016-04-01

When a country's health system is faced with fundamental flaws that require the redesign of financing and service delivery, primary healthcare payment systems are often reformed. This study was conducted with the purpose of exploring the experiences of risk-adjusted capitation payment of urban family physicians in Iran when it comes to providing primary health care (PHC). This is a qualitative study using the framework method. Data were collected via digitally audio-recorded semi-structured interviews with 24 family physicians and 5 executive directors in two provinces of Iran running the urban family physician pilot program. The participants were selected using purposive and snowball sampling. The codes were extracted using inductive and deductive methods. Regarding the effects of risk-adjusted capitation on the primary healthcare setting, five themes with 11 subthemes emerged, including service delivery, institutional structure, financing, people's behavior, and the challenges ahead. Our findings indicated that the health system is enjoying some major changes in the primary healthcare setting through the implementation of risk-adjusted capitation payment. With regard to the current challenges in Iran's health system, using risk-adjusted capitation as a primary healthcare payment system can lead to useful changes in the health system's features. However, future research should focus on the development of the risk-adjusted capitation model.

Monitoring risk-adjusted medical outcomes allowing for changes over time.

Science.gov (United States)

Steiner, Stefan H; Mackay, R Jock

2014-10-01

We consider the problem of monitoring and comparing medical outcomes, such as surgical performance, over time. Performance is subject to change due to a variety of reasons including patient heterogeneity, learning, deteriorating skills due to aging, etc. For instance, we expect inexperienced surgeons to improve their skills with practice. We propose a graphical method to monitor surgical performance that incorporates risk adjustment to account for patient heterogeneity. The procedure gives more weight to recent outcomes and down-weights the influence of outcomes further in the past. The chart is clinically interpretable as it plots an estimate of the failure rate for a "standard" patient. The chart also includes a measure of uncertainty in this estimate. We can implement the method using historical data or start from scratch. As the monitoring proceeds, we can base the estimated failure rate on a known risk model or use the observed outcomes to update the risk model as time passes. We illustrate the proposed method with an example from cardiac surgery. © The Author 2013. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Designing and evaluating risk-based surveillance systems

DEFF Research Database (Denmark)

Willeberg, Preben; Nielsen, Liza Rosenbaum; Salman, Mo

2012-01-01

Risk-based surveillance systems reveal occurrence of disease or infection in a sample of population units, which are selected on the basis of risk factors for the condition under study. The purpose of such systems for supporting practical animal disease policy formulations and management decisions...... with prudent use of resources while maintaining acceptable system performance. High-risk category units are selected for testing by identification of the presence of specific high-risk factor(s), while disregarding other factors that might also influence the risk. On this basis we argue that the most...... applicable risk estimate for use in designing and evaluating a risk-based surveillance system would be a crude (unadjusted) relative risk, odds ratio or apparent prevalence. Risk estimates found in the published literature, however, are often the results of multivariable analyses implicitly adjusting...

12 CFR 615.5210 - Risk-adjusted assets.

Science.gov (United States)

2010-01-01

... appropriate credit conversion factor in § 615.5212, is assigned to one of the risk categories specified in... risk-based capital requirement for the credit-enhanced assets, the risk-based capital required under..., determine the appropriate risk weight for any asset or credit equivalent amount that does not fit wholly...

A method to adjust radiation dose-response relationships for clinical risk factors

DEFF Research Database (Denmark)

Appelt, Ane Lindegaard; Vogelius, Ivan R

2012-01-01

Several clinical risk factors for radiation induced toxicity have been identified in the literature. Here, we present a method to quantify the effect of clinical risk factors on radiation dose-response curves and apply the method to adjust the dose-response for radiation pneumonitis for patients...

Risk-adjusted hospital outcomes for children's surgery.

Science.gov (United States)

Saito, Jacqueline M; Chen, Li Ern; Hall, Bruce L; Kraemer, Kari; Barnhart, Douglas C; Byrd, Claudia; Cohen, Mark E; Fei, Chunyuan; Heiss, Kurt F; Huffman, Kristopher; Ko, Clifford Y; Latus, Melissa; Meara, John G; Oldham, Keith T; Raval, Mehul V; Richards, Karen E; Shah, Rahul K; Sutton, Laura C; Vinocur, Charles D; Moss, R Lawrence

2013-09-01

BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program-Pediatric was initiated in 2008 to drive quality improvement in children's surgery. Low mortality and morbidity in previous analyses limited differentiation of hospital performance. Participating institutions included children's units within general hospitals and free-standing children's hospitals. Cases selected by Current Procedural Terminology codes encompassed procedures within pediatric general, otolaryngologic, orthopedic, urologic, plastic, neurologic, thoracic, and gynecologic surgery. Trained personnel abstracted demographic, surgical profile, preoperative, intraoperative, and postoperative variables. Incorporating procedure-specific risk, hierarchical models for 30-day mortality and morbidities were developed with significant predictors identified by stepwise logistic regression. Reliability was estimated to assess the balance of information versus error within models. In 2011, 46 281 patients from 43 hospitals were accrued; 1467 codes were aggregated into 226 groupings. Overall mortality was 0.3%, composite morbidity 5.8%, and surgical site infection (SSI) 1.8%. Hierarchical models revealed outlier hospitals with above or below expected performance for composite morbidity in the entire cohort, pediatric abdominal subgroup, and spine subgroup; SSI in the entire cohort and pediatric abdominal subgroup; and urinary tract infection in the entire cohort. Based on reliability estimates, mortality discriminates performance poorly due to very low event rate; however, reliable model construction for composite morbidity and SSI that differentiate institutions is feasible. The National Surgical Quality Improvement Program-Pediatric expansion has yielded risk-adjusted models to differentiate hospital performance in composite and specific morbidities. However, mortality has low utility as a children's surgery performance indicator. Programmatic improvements have resulted in

Impact of Race/Ethnicity and Socioeconomic Status on Risk-Adjusted Hospital Readmission Rates Following Hip and Knee Arthroplasty.

Science.gov (United States)

Martsolf, Grant R; Barrett, Marguerite L; Weiss, Audrey J; Kandrack, Ryan; Washington, Raynard; Steiner, Claudia A; Mehrotra, Ateev; SooHoo, Nelson F; Coffey, Rosanna

2016-08-17

Readmission rates following total hip arthroplasty (THA) and total knee arthroplasty (TKA) are increasingly used to measure hospital performance. Readmission rates that are not adjusted for race/ethnicity and socioeconomic status, patient risk factors beyond a hospital's control, may not accurately reflect a hospital's performance. In this study, we examined the extent to which risk-adjusting for race/ethnicity and socioeconomic status affected hospital performance in terms of readmission rates following THA and TKA. We calculated 2 sets of risk-adjusted readmission rates by (1) using the Centers for Medicare & Medicaid Services standard risk-adjustment algorithm that incorporates patient age, sex, comorbidities, and hospital effects and (2) adding race/ethnicity and socioeconomic status to the model. Using data from the Healthcare Cost and Utilization Project, 2011 State Inpatient Databases, we compared the relative performances of 1,194 hospitals across the 2 methods. Addition of race/ethnicity and socioeconomic status to the risk-adjustment algorithm resulted in (1) little or no change in the risk-adjusted readmission rates at nearly all hospitals; (2) no change in the designation of the readmission rate as better, worse, or not different from the population mean at >99% of the hospitals; and (3) no change in the excess readmission ratio at >97% of the hospitals. Inclusion of race/ethnicity and socioeconomic status in the risk-adjustment algorithm led to a relative-performance change in readmission rates following THA and TKA at socioeconomic status in risk-adjusted THA and TKA readmission rates used for hospital accountability, payment, and public reporting. Prognostic Level III. See instructions for Authors for a complete description of levels of evidence. Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.

Conference Innovations in Derivatives Market : Fixed Income Modeling, Valuation Adjustments, Risk Management, and Regulation

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Grbac, Zorana; Scherer, Matthias; Zagst, Rudi

2016-01-01

This book presents 20 peer-reviewed chapters on current aspects of derivatives markets and derivative pricing. The contributions, written by leading researchers in the field as well as experienced authors from the financial industry, present the state of the art in: • Modeling counterparty credit risk: credit valuation adjustment, debit valuation adjustment, funding valuation adjustment, and wrong way risk. • Pricing and hedging in fixed-income markets and multi-curve interest-rate modeling. • Recent developments concerning contingent convertible bonds, the measuring of basis spreads, and the modeling of implied correlations. The recent financial crisis has cast tremendous doubts on the classical view on derivative pricing. Now, counterparty credit risk and liquidity issues are integral aspects of a prudent valuation procedure and the reference interest rates are represented by a multitude of curves according to their different periods and maturities. A panel discussion included in the book (featuring D...

Measuring Risk-adjusted Customer Lifetime Value and its Impact on Relationship Marketing Strategies and Shareholder Value

OpenAIRE

Ryals, Lynette; Knox, Simon

2005-01-01

The calculations which underlie efforts to balance marketing spending on customer acquisition and customer retention are usually based on either single- period customer profitability or forecasts of customer lifetime value (CLTV). This paper argues instead for risk-adjusted CLTV, which is termed the economic value (EV) of a customer, as the means for marketing to assess both customer profitability and shareholder value gains.

[Do laymen understand information about hospital quality? An empirical verification using risk-adjusted mortality rates as an example].

Science.gov (United States)

Sander, Uwe; Kolb, Benjamin; Taheri, Fatemeh; Patzelt, Christiane; Emmert, Martin

2017-11-01

The effect of public reporting to improve quality in healthcare is reduced by the limited intelligibility of information about the quality of healthcare providers. This may result in worse health-related choices especially for older people and those with lower levels of education. There is, as yet, little information as to whether laymen understand the concepts behind quality comparisons and if this comprehension is correlated with hospital choices. An instrument with 20 items was developed to analyze the intelligibility of five technical terms which were used in German hospital report cards to explain risk-adjusted death rates. Two online presentations of risk-adjusted death rates for five hospitals in the style of hospital report cards were developed. An online survey of 353 volunteers tested the comprehension of the risk-adjusted mortality rates and included an experimental hospital choice. The intelligibility of five technical terms was tested: risk-adjusted, actual and expected death rate, reference range and national average. The percentages of correct answers for the five technical terms were in the range of 75.0-60.2%. Between 23.8% and 5.1% of the respondents were not able to answer the question about the technical term itself. The least comprehensible technical terms were "risk-adjusted death rate" and "reference range". The intelligibility of the 20 items that were used to test the comprehension of the risk-adjusted mortality was between 89.5% and 14.2%. The two items that proved to be least comprehensible were related to the technical terms "risk-adjusted death rate" and "reference range". For all five technical terms it was found that a better comprehension correlated significantly with better hospital choices. We found a better than average intelligibility for the technical terms "actual and expected death rate" and for "national average". The least understandable were "risk-adjusted death rate" and "reference range". Since the self

Risk-adjusted survival after tissue versus mechanical aortic valve replacement: a 23-year assessment.

Science.gov (United States)

Gaca, Jeffrey G; Clare, Robert M; Rankin, J Scott; Daneshmand, Mani A; Milano, Carmelo A; Hughes, G Chad; Wolfe, Walter G; Glower, Donald D; Smith, Peter K

2013-11-01

Detailed analyses of risk-adjusted outcomes after mitral valve surgery have documented significant survival decrements with tissue valves at any age. Several recent studies of prosthetic aortic valve replacement (AVR) also have suggested a poorer performance of tissue valves, although analyses have been limited to small matched series. The study aim was to test the hypothesis that AVR with tissue valves is associated with a lower risk-adjusted survival, as compared to mechanical valves. Between 1986 and 2009, primary isolated AVR, with or without coronary artery bypass grafting (CABG), was performed with currently available valve types in 2148 patients (1108 tissue valves, 1040 mechanical). Patients were selected for tissue valves to be used primarily in the elderly. Baseline and operative characteristics were documented prospectively with a consistent variable set over the entire 23-year period. Follow up was obtained with mailed questionnaires, supplemented by National Death Index searches. The average time to death or follow up was seven years, and follow up for survival was 96.2% complete. Risk-adjusted survival characteristics for the two groups were evaluated using a Cox proportional hazards model with stepwise selection of candidate variables. Differences in baseline characteristics between groups were (tissue versus mechanical): median age 73 versus 61 years; non-elective surgery 32% versus 28%; CABG 45% versus 35%; median ejection fraction 55% versus 55%; renal failure 6% versus 1%; diabetes 18% versus 7% (pvalves; however, after risk adjustment for the adverse profiles of tissue valve patients, no significant difference was observed in survival after tissue or mechanical AVR. Thus, the hypothesis did not hold, and risk-adjusted survival was equivalent, of course qualified by the fact that selection bias was evident. With selection criteria that employed tissue AVR more frequently in elderly patients, tissue and mechanical valves achieved similar survival

The Effect of Adding Comorbidities to Current Centers for Disease Control and Prevention Central-Line-Associated Bloodstream Infection Risk-Adjustment Methodology.

Science.gov (United States)

Jackson, Sarah S; Leekha, Surbhi; Magder, Laurence S; Pineles, Lisa; Anderson, Deverick J; Trick, William E; Woeltje, Keith F; Kaye, Keith S; Stafford, Kristen; Thom, Kerri; Lowe, Timothy J; Harris, Anthony D

2017-09-01

BACKGROUND Risk adjustment is needed to fairly compare central-line-associated bloodstream infection (CLABSI) rates between hospitals. Until 2017, the Centers for Disease Control and Prevention (CDC) methodology adjusted CLABSI rates only by type of intensive care unit (ICU). The 2017 CDC models also adjust for hospital size and medical school affiliation. We hypothesized that risk adjustment would be improved by including patient demographics and comorbidities from electronically available hospital discharge codes. METHODS Using a cohort design across 22 hospitals, we analyzed data from ICU patients admitted between January 2012 and December 2013. Demographics and International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) discharge codes were obtained for each patient, and CLABSIs were identified by trained infection preventionists. Models adjusting only for ICU type and for ICU type plus patient case mix were built and compared using discrimination and standardized infection ratio (SIR). Hospitals were ranked by SIR for each model to examine and compare the changes in rank. RESULTS Overall, 85,849 ICU patients were analyzed and 162 (0.2%) developed CLABSI. The significant variables added to the ICU model were coagulopathy, paralysis, renal failure, malnutrition, and age. The C statistics were 0.55 (95% CI, 0.51-0.59) for the ICU-type model and 0.64 (95% CI, 0.60-0.69) for the ICU-type plus patient case-mix model. When the hospitals were ranked by adjusted SIRs, 10 hospitals (45%) changed rank when comorbidity was added to the ICU-type model. CONCLUSIONS Our risk-adjustment model for CLABSI using electronically available comorbidities demonstrated better discrimination than did the CDC model. The CDC should strongly consider comorbidity-based risk adjustment to more accurately compare CLABSI rates across hospitals. Infect Control Hosp Epidemiol 2017;38:1019-1024.

Improved implementation of the risk-adjusted Bernoulli CUSUM chart to monitor surgical outcome quality.

Science.gov (United States)

Keefe, Matthew J; Loda, Justin B; Elhabashy, Ahmad E; Woodall, William H

2017-06-01

The traditional implementation of the risk-adjusted Bernoulli cumulative sum (CUSUM) chart for monitoring surgical outcome quality requires waiting a pre-specified period of time after surgery before incorporating patient outcome information. We propose a simple but powerful implementation of the risk-adjusted Bernoulli CUSUM chart that incorporates outcome information as soon as it is available, rather than waiting a pre-specified period of time after surgery. A simulation study is presented that compares the performance of the traditional implementation of the risk-adjusted Bernoulli CUSUM chart to our improved implementation. We show that incorporating patient outcome information as soon as it is available leads to quicker detection of process deterioration. Deterioration of surgical performance could be detected much sooner using our proposed implementation, which could lead to the earlier identification of problems. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Beyond preadoptive risk: The impact of adoptive family environment on adopted youth's psychosocial adjustment.

Science.gov (United States)

Ji, Juye; Brooks, Devon; Barth, Richard P; Kim, Hansung

2010-07-01

Adopted children often are exposed to preadoptive stressors--such as prenatal substance exposure, child maltreatment, and out-of-home placements--that increase their risks for psychosocial maladjustment. Psychosocial adjustment of adopted children emerges as the product of pre- and postadoptive factors. This study builds on previous research, which fails to simultaneously assess the influences of pre- and postadoptive factors, by examining the impact of adoptive family sense of coherence on adoptee's psychosocial adjustment beyond the effects of preadoptive risks. Using a sample of adoptive families (n = 385) taking part in the California Long Range Adoption Study, structural equation modeling analyses were performed. Results indicate a significant impact of family sense of coherence on adoptees' psychosocial adjustment and a considerably less significant role of preadoptive risks. The findings suggest the importance of assessing adoptive family's ability to respond to stress and of helping families to build and maintain their capacity to cope with stress despite the sometimes fractious pressures of adoption.

Regression Trees Identify Relevant Interactions: Can This Improve the Predictive Performance of Risk Adjustment?

Science.gov (United States)

Buchner, Florian; Wasem, Jürgen; Schillo, Sonja

2017-01-01

Risk equalization formulas have been refined since their introduction about two decades ago. Because of the complexity and the abundance of possible interactions between the variables used, hardly any interactions are considered. A regression tree is used to systematically search for interactions, a methodologically new approach in risk equalization. Analyses are based on a data set of nearly 2.9 million individuals from a major German social health insurer. A two-step approach is applied: In the first step a regression tree is built on the basis of the learning data set. Terminal nodes characterized by more than one morbidity-group-split represent interaction effects of different morbidity groups. In the second step the 'traditional' weighted least squares regression equation is expanded by adding interaction terms for all interactions detected by the tree, and regression coefficients are recalculated. The resulting risk adjustment formula shows an improvement in the adjusted R 2 from 25.43% to 25.81% on the evaluation data set. Predictive ratios are calculated for subgroups affected by the interactions. The R 2 improvement detected is only marginal. According to the sample level performance measures used, not involving a considerable number of morbidity interactions forms no relevant loss in accuracy. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Reliability of risk-adjusted outcomes for profiling hospital surgical quality.

Science.gov (United States)

Krell, Robert W; Hozain, Ahmed; Kao, Lillian S; Dimick, Justin B

2014-05-01

Quality improvement platforms commonly use risk-adjusted morbidity and mortality to profile hospital performance. However, given small hospital caseloads and low event rates for some procedures, it is unclear whether these outcomes reliably reflect hospital performance. To determine the reliability of risk-adjusted morbidity and mortality for hospital performance profiling using clinical registry data. A retrospective cohort study was conducted using data from the American College of Surgeons National Surgical Quality Improvement Program, 2009. Participants included all patients (N = 55,466) who underwent colon resection, pancreatic resection, laparoscopic gastric bypass, ventral hernia repair, abdominal aortic aneurysm repair, and lower extremity bypass. Outcomes included risk-adjusted overall morbidity, severe morbidity, and mortality. We assessed reliability (0-1 scale: 0, completely unreliable; and 1, perfectly reliable) for all 3 outcomes. We also quantified the number of hospitals meeting minimum acceptable reliability thresholds (>0.70, good reliability; and >0.50, fair reliability) for each outcome. For overall morbidity, the most common outcome studied, the mean reliability depended on sample size (ie, how high the hospital caseload was) and the event rate (ie, how frequently the outcome occurred). For example, mean reliability for overall morbidity was low for abdominal aortic aneurysm repair (reliability, 0.29; sample size, 25 cases per year; and event rate, 18.3%). In contrast, mean reliability for overall morbidity was higher for colon resection (reliability, 0.61; sample size, 114 cases per year; and event rate, 26.8%). Colon resection (37.7% of hospitals), pancreatic resection (7.1% of hospitals), and laparoscopic gastric bypass (11.5% of hospitals) were the only procedures for which any hospitals met a reliability threshold of 0.70 for overall morbidity. Because severe morbidity and mortality are less frequent outcomes, their mean

Behavioral Risk Factors: Selected Metropolitan Area Risk Trends (SMART) MMSA Age-adjusted Prevalence Data (2011 to Present)

Data.gov (United States)

U.S. Department of Health & Human Services — 2011 to present. BRFSS SMART MMSA age-adjusted prevalence combined land line and cell phone data. The Selected Metropolitan Area Risk Trends (SMART) project uses the...

A Proportional Hazards Regression Model for the Subdistribution with Covariates-adjusted Censoring Weight for Competing Risks Data

DEFF Research Database (Denmark)

He, Peng; Eriksson, Frank; Scheike, Thomas H.

2016-01-01

function by fitting the Cox model for the censoring distribution and using the predictive probability for each individual. Our simulation study shows that the covariate-adjusted weight estimator is basically unbiased when the censoring time depends on the covariates, and the covariate-adjusted weight......With competing risks data, one often needs to assess the treatment and covariate effects on the cumulative incidence function. Fine and Gray proposed a proportional hazards regression model for the subdistribution of a competing risk with the assumption that the censoring distribution...... and the covariates are independent. Covariate-dependent censoring sometimes occurs in medical studies. In this paper, we study the proportional hazards regression model for the subdistribution of a competing risk with proper adjustments for covariate-dependent censoring. We consider a covariate-adjusted weight...

Measuring Profitability Impacts of Information Technology: Use of Risk Adjusted Measures.

Science.gov (United States)

Singh, Anil; Harmon, Glynn

2003-01-01

Focuses on understanding how investments in information technology are reflected in the income statements and balance sheets of firms. Shows that the relationship between information technology investments and corporate profitability is much better explained by using risk-adjusted measures of corporate profitability than using the same measures…

FDG PET/CT diagnostic criteria may need adjustment based on MRI to estimate the presurgical risk of extrapelvic infiltration in patients with uterine endometrial cancer

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Sudo, Satoko; Sakuragi, Noriaki [Hokkaido University Graduate School of Medicine, Department of Gynecology, Sapporo (Japan); Hattori, Naoya; Manabe, Osamu; Hirata, Kenji; Tamaki, Nagara [Hokkaido University Graduate School of Medicine, Department of Nuclear Medicine, Kitaku, Sapporo (Japan); Kato, Fumi; Mimura, Rie; Magota, Keiichi; Sugimori, Hiroyuki [Hokkaido University Graduate School of Medicine, Department of Diagnostic and Interventional Radiology, Sapporo (Japan)

2015-04-01

The staging of endometrial cancer requires surgery which carries the risk of morbidity. FDG PET/CT combined with anatomical imaging may reduce the number of unnecessary lymphadenectomies by demonstrating the risk of extrapelvic infiltration. The purpose of this study was to optimize FDG PET/CT diagnostic criteria for risk assessment in endometrial cancer after first-line risk triage with MRI. The study population comprised 37 patients who underwent curative surgery for the treatment of endometrial cancer. First, the risk of extrapelvic infiltration was triaged using MRI. Second, multiple glucose metabolic profiles of the primary lesion were assessed with FDG PET/CT, and these were correlated with the histopathological risk of extrapelvic infiltration including lymphovascular space invasion (LVSI) and high-grade malignancy (grades 2 and 3). The results of histological correlation were used to adjust FDG PET/CT diagnostic criteria. Presurgical assessment using MRI was positive for deep (>50 %) myometrial invasion in 17 patients. The optimal FDG PET/CT diagnostic criteria vary depending on the results of MRI. Specifically, SUVmax (≥16.0) was used to indicate LVSI risk with an overall diagnostic accuracy of 88.2 % in patients with MRI findings showing myometrial invasion. High-grade malignancy did not correlate with any of metabolic profiles in this patient group. In the remaining patients without myometrial invasion, lesion glycolysis (LG) or metabolic volume were better indicators of LVSI than SUVmax with the same diagnostic accuracy of 80.0 %. In addition, LG (≥26.9) predicted high-grade malignancy with an accuracy of 72.2 %. Using the optimized cut-off criteria for LVSI, glucose metabolic profiling of primary lesions correctly predicted lymph node metastasis with an accuracy of 73.0 %, which was comparable with the accuracy of visual assessment for lymph node metastasis using MRI and FDG PET/CT. FDG PET/CT diagnostic criteria may need adjustment based on the

Measurement Of Shariah Stock Performance Using Risk Adjusted Performance

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Zuhairan Y Yunan

2015-03-01

Full Text Available The aim of this research is to analyze the shariah stock performance using risk adjusted performance method. There are three parameters to measure the stock performance i.e. Sharpe, Treynor, and Jensen. This performance’s measurements calculate the return and risk factor from shariah stocks. The data that used on this research is using the data of stocks at Jakarta Islamic Index. Sampling method that used on this paper is purposive sampling. This research is using ten companies as a sample. The result shows that from three parameters, the stock that have a best performance are AALI, ANTM, ASII, CPIN, INDF, KLBF, LSIP, and UNTR.DOI: 10.15408/aiq.v7i1.1364

Performance of Comorbidity, Risk Adjustment, and Functional Status Measures in Expenditure Prediction for Patients With Diabetes

OpenAIRE

Maciejewski, Matthew L.; Liu, Chuan-Fen; Fihn, Stephan D.

2009-01-01

OBJECTIVE?To compare the ability of generic comorbidity and risk adjustment measures, a diabetes-specific measure, and a self-reported functional status measure to explain variation in health care expenditures for individuals with diabetes. RESEARCH DESIGN AND METHODS?This study included a retrospective cohort of 3,092 diabetic veterans participating in a multisite trial. Two comorbidity measures, four risk adjusters, a functional status measure, a diabetes complication count, and baseline ex...

[Susceptibility to strategy of the drug component of the IPHCC+RxGroups classification system in a risk-adjusted morbidity compensation scheme--a conceptional and data-supported analysis].

Science.gov (United States)

Behrend, C; Felder, S; Busse, R

2007-01-01

A report commissioned by the German Ministry of Health recommends to the existing scheme for calculating risk-adjusted transfers to sickness funds supplement with the IPHCC+RxGroups method. The method is based on inpatient diagnoses and prescribed drugs as health status measures deduced from prior use. The present study investigates the sickness fund's expected net return from gaming based on the drug component of the risk adjuster. The study explores three possible strategies using the RxGroups method. For the stimulations, insurees are assigned to additional indications or to higher valued RxGroups within the same indication. Then, costs and financial benefits attributable to the altered drug use are estimated and compared with the status quo. The study uses 2000 and 2001 sample data of more than 370,000 insurees of Germany's company-based sickness funds system (BKK). While upgrading increases overall costs, it can be beneficial for the individual sickness funds. Their net return crucially depends on the number of sickness funds gaming the system: the more participating in the game, the smaller is the average net return. Moreover, not participating often is even worse, which in turn points to a prisoner's dilemma. When extending the risk adjustment scheme in social health insurance, the German legislator should take into account the perverse incentives of risk adjusters such as the described prescription drug model.

Process monitoring in intensive care with the use of cumulative expected minus observed mortality and risk-adjusted P charts.

Science.gov (United States)

Cockings, Jerome G L; Cook, David A; Iqbal, Rehana K

2006-02-01

A health care system is a complex adaptive system. The effect of a single intervention, incorporated into a complex clinical environment, may be different from that expected. A national database such as the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme in the UK represents a centralised monitoring, surveillance and reporting system for retrospective quality and comparative audit. This can be supplemented with real-time process monitoring at a local level for continuous process improvement, allowing early detection of the impact of both unplanned and deliberately imposed changes in the clinical environment. Demographic and UK Acute Physiology and Chronic Health Evaluation II (APACHE II) data were prospectively collected on all patients admitted to a UK regional hospital between 1 January 2003 and 30 June 2004 in accordance with the ICNARC Case Mix Programme. We present a cumulative expected minus observed (E-O) plot and the risk-adjusted p chart as methods of continuous process monitoring. We describe the construction and interpretation of these charts and show how they can be used to detect planned or unplanned organisational process changes affecting mortality outcomes. Five hundred and eighty-nine adult patients were included. The overall death rate was 0.78 of predicted. Calibration showed excess survival in ranges above 30% risk of death. The E-O plot confirmed a survival above that predicted. Small transient variations were seen in the slope that could represent random effects, or real but transient changes in the quality of care. The risk-adjusted p chart showed several observations below the 2 SD control limits of the expected mortality rate. These plots provide rapid analysis of risk-adjusted performance suitable for local application and interpretation. The E-O chart provided rapid easily visible feedback of changes in risk-adjusted mortality, while the risk-adjusted p chart allowed statistical evaluation. Local analysis of

State infant mortality: an ecologic study to determine modifiable risks and adjusted infant mortality rates.

Science.gov (United States)

Paul, David A; Mackley, Amy; Locke, Robert G; Stefano, John L; Kroelinger, Charlan

2009-05-01

To determine factors contributing to state infant mortality rates (IMR) and develop an adjusted IMR in the United States for 2001 and 2002. Ecologic study of factors contributing to state IMR. State IMR for 2001 and 2002 were obtained from the United States linked death and birth certificate data from the National Center for Health Statistics. Factors investigated using multivariable linear regression included state racial demographics, ethnicity, state population, median income, education, teen birth rate, proportion of obesity, smoking during pregnancy, diabetes, hypertension, cesarean delivery, prenatal care, health insurance, self-report of mental illness, and number of in-vitro fertilization procedures. Final risk adjusted IMR's were standardized and states were compared with the United States adjusted rates. Models for IMR in individual states in 2001 (r2 = 0.66, P < 0.01) and 2002 (r2 = 0.81, P < 0.01) were tested. African-American race, teen birth rate, and smoking during pregnancy remained independently associated with state infant mortality rates for 2001 and 2002. Ninety five percent confidence intervals (CI) were calculated around the regression lines to model the expected IMR. After adjustment, some states maintained a consistent IMR; for instance, Vermont and New Hampshire remained low, while Delaware and Louisiana remained high. However, other states such as Mississippi, which have traditionally high infant mortality rates, remained within the expected 95% CI for IMR after adjustment indicating confounding affected the initial unadjusted rates. Non-modifiable demographic variables, including the percentage of non-Hispanic African-American and Hispanic populations of the state are major factors contributing to individual variation in state IMR. Race and ethnicity may confound or modify the IMR in states that shifted inside or outside the 95% CI following adjustment. Other factors including smoking during pregnancy and teen birth rate, which are

A comparison of internal versus external risk-adjustment for monitoring clinical outcomes

NARCIS (Netherlands)

Koetsier, Antonie; de Keizer, Nicolette; Peek, Niels

2011-01-01

Internal and external prognostic models can be used to calculate severity of illness adjusted mortality risks. However, it is unclear what the consequences are of using an external model instead of an internal model when monitoring an institution's clinical performance. Theoretically, using an

Age-adjusted high-sensitivity troponin T cut-off value for risk stratification of pulmonary embolism.

Science.gov (United States)

Kaeberich, Anja; Seeber, Valerie; Jiménez, David; Kostrubiec, Maciej; Dellas, Claudia; Hasenfuß, Gerd; Giannitsis, Evangelos; Pruszczyk, Piotr; Konstantinides, Stavros; Lankeit, Mareike

2015-05-01

High-sensitivity troponin T (hsTnT) helps in identifying pulmonary embolism patients at low risk of an adverse outcome. In 682 normotensive pulmonary embolism patients we investigate whether an optimised hsTnT cut-off value and adjustment for age improve the identification of patients at elevated risk. Overall, 25 (3.7%) patients had an adverse 30-day outcome. The established hsTnT cut-off value of 14 pg·mL(-1) retained its high prognostic value (OR (95% CI) 16.64 (2.24-123.74); p=0.006) compared with the cut-off value of 33 pg·mL(-1) calculated by receiver operating characteristic analysis (7.14 (2.64-19.26); pvalue of 45 pg·mL(-1) but not the established cut-off value of 14 pg·mL(-1) predicted an adverse outcome. An age-adjusted hsTnT cut-off value (≥14 pg·mL(-1) for patients aged risk (12.4% adverse outcome). Risk assessment of normotensive pulmonary embolism patients was improved by the introduction of an age-adjusted hsTnT cut-off value. A three-step approach helped identify patients at higher risk of an adverse outcome who might benefit from advanced therapy. Copyright ©ERS 2015.

Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions.

Science.gov (United States)

Davenport, Daniel L; Henderson, William G; Mosca, Cecilia L; Khuri, Shukri F; Mentzer, Robert M

2007-12-01

Since the Institute of Medicine patient safety reports, a number of survey-based measures of organizational climate safety factors (OCSFs) have been developed. The goal of this study was to measure the impact of OCSFs on risk-adjusted surgical morbidity and mortality. Surveys were administered to staff on general/vascular surgery services during a year. Surveys included multiitem scales measuring OCSFs. Additionally, perceived levels of communication and collaboration with coworkers were assessed. The National Surgical Quality Improvement Program was used to assess risk-adjusted morbidity and mortality. Correlations between outcomes and OCSFs were calculated and between outcomes and communication/collaboration with attending and resident doctors, nurses, and other providers. Fifty-two sites participated in the survey: 44 Veterans Affairs and 8 academic medical centers. A total of 6,083 surveys were returned, for a response rate of 52%. The OCSF measures of teamwork climate, safety climate, working conditions, recognition of stress effects, job satisfaction, and burnout demonstrated internal validity but did not correlate with risk-adjusted outcomes. Reported levels of communication/collaboration with attending and resident doctors correlated with risk-adjusted morbidity. Survey-based teamwork, safety climate, and working conditions scales are not confirmed to measure organizational factors that influence risk-adjusted surgical outcomes. Reported communication/collaboration with attending and resident doctors on surgical services influenced patient morbidity. This suggests the importance of doctors' coordination and decision-making roles on surgical teams in providing high-quality and safe care. We propose risk-adjusted morbidity as an effective measure of surgical patient safety.

Evaluating the Investment Benefit of Multinational Enterprises' International Projects Based on Risk Adjustment: Evidence from China

Science.gov (United States)

Chen, Chong

2016-01-01

This study examines the international risks faced by multinational enterprises to understand their impact on the evaluation of investment projects. Moreover, it establishes a 'three-dimensional' theoretical framework of risk identification to analyse the composition of international risk indicators of multinational enterprises based on the theory…

The case for risk-based premiums in public health insurance.

Science.gov (United States)

Zweifel, Peter; Breuer, Michael

2006-04-01

Uniform, risk-independent insurance premiums are accepted as part of 'managed competition' in health care. However, they are not compatible with optimality of health insurance contracts in the presence of both ex ante and ex post moral hazard. They have adverse effects on insurer behaviour even if risk adjustment is taken into account. Risk-based premiums combined with means-tested, tax-financed transfers are advocated as an alternative.

School Adjustment of Pupils with ADHD: Cognitive, Emotional and Temperament Risk Factors

Science.gov (United States)

Sanchez-Perez, Noelia; Gonzalez-Salinas, Carmen

2013-01-01

From different research perspectives, the cognitive and emotional characteristics associated with ADHD in children have been identified as risk factors for the development of diverse adjustment problems in the school context. Research in nonclinical population can additionally help in understanding ADHD deficits, since children with specific…

Adjustment for smoking reduces radiation risk: fifth analysis of mortality of nuclear industry workers in Japan, 1999-2010

Energy Technology Data Exchange (ETDEWEB)

Kudo, S.; Ishida, J.; Yoshimoto, K.; Mizuno, S.; Ohshima, S.; Kasagi, F., E-mail: s_kudo@rea.or.jp [Instituto of Radiation Epidemiology, Radiation Effects Association, 1-9-16 Kajicho, Chiyoda-ku, 101-0044 Tokyo (Japan)

2015-10-15

Full text: Many cohort studies among nuclear industry workers have been carried out to determine the possible health effects of low-level radiation. In those studies, confounding factors, for example, age was adjusted to exclude the effect of difference of mortality by age to estimate radiation risk. But there are few studies adjusting for smoking that is known as a strong factor which affects mortality. Radiation Effects Association (Rea) initiated a cohort study of nuclear industry workers mortality in 1990. To examine non-radiation factors confounding on the mortality risk among the radiation workers, Rea have performed life-style questionnaire surveys among the part of workers at 1997 and 2003 and found the correlation between radiation dose and smoking rate. Mortality follow-up were made on 75,442 male respondents for an average of 8.3 years during the observation period 1999-2010. Estimates of Excess Relative Risk percent (Err %) per 10 mSv were obtained by using the Poisson regression. The Err for all causes was statistically significant (1.05 (90 % CI 0.31 : 1.80)), but no longer significant after adjusting for smoking (0.45 (-0.24 : 1.13)). The Err for all cancers excluding leukemia was not significant (0.92 (-0.30 : 2.16)), but after adjusting for smoking, it decreased (0.36 (-0.79 : 1.50)). Thus smoking has a large effect to obscure a radiation risk, so adjustment for smoking is important to estimate radiation risk. (Author)

Adjustment for smoking reduces radiation risk: fifth analysis of mortality of nuclear industry workers in Japan, 1999-2010

International Nuclear Information System (INIS)

Kudo, S.; Ishida, J.; Yoshimoto, K.; Mizuno, S.; Ohshima, S.; Kasagi, F.

2015-10-01

Full text: Many cohort studies among nuclear industry workers have been carried out to determine the possible health effects of low-level radiation. In those studies, confounding factors, for example, age was adjusted to exclude the effect of difference of mortality by age to estimate radiation risk. But there are few studies adjusting for smoking that is known as a strong factor which affects mortality. Radiation Effects Association (Rea) initiated a cohort study of nuclear industry workers mortality in 1990. To examine non-radiation factors confounding on the mortality risk among the radiation workers, Rea have performed life-style questionnaire surveys among the part of workers at 1997 and 2003 and found the correlation between radiation dose and smoking rate. Mortality follow-up were made on 75,442 male respondents for an average of 8.3 years during the observation period 1999-2010. Estimates of Excess Relative Risk percent (Err %) per 10 mSv were obtained by using the Poisson regression. The Err for all causes was statistically significant (1.05 (90 % CI 0.31 : 1.80)), but no longer significant after adjusting for smoking (0.45 (-0.24 : 1.13)). The Err for all cancers excluding leukemia was not significant (0.92 (-0.30 : 2.16)), but after adjusting for smoking, it decreased (0.36 (-0.79 : 1.50)). Thus smoking has a large effect to obscure a radiation risk, so adjustment for smoking is important to estimate radiation risk. (Author)

Risk adjusted financial costs of photovoltaics

Energy Technology Data Exchange (ETDEWEB)

Szabo, Sandor; Jaeger-Waldau, Arnulf [Joint Research Centre, Institute for Energy, Via E. Fermi 2749, I-21020 Ispra (Italy); Szabo, Laszlo [Joint Research Centre, Institute for Prospective Technological Studies C. Inca Garcilaso, 3. E-41092 Sevilla (Spain)

2010-07-15

Recent research shows significant differences in the levelised photovoltaics (PV) electricity cost calculations. The present paper points out that no unique or absolute cost figure can be justified, the correct solution is to use a range of cost figures that is determined in a dynamic power portfolio interaction within the financial scheme, support mechanism and industry cost reduction. The paper draws attention to the increasing role of financial investors in the PV segment of the renewable energy market and the importance they attribute to the risks of all options in the power generation portfolio. Based on these trends, a former version of a financing model is adapted to project the energy mix changes in the EU electricity market due to investors behaviour with different risk tolerance/aversion. The dynamic process of translating these risks into the return expectation in the financial appraisal and investment decision making is also introduced. By doing so, the paper sets up a potential electricity market trend with the associated risk perception and classification. The necessary risk mitigation tasks for all stakeholders in the PV market are summarised which aims to avoid the burden of excessive risk premiums in this market segment. (author)

Risk adjusted financial costs of photovoltaics

International Nuclear Information System (INIS)

Szabo, Sandor; Jaeger-Waldau, Arnulf; Szabo, Laszlo

2010-01-01

Recent research shows significant differences in the levelised photovoltaics (PV) electricity cost calculations. The present paper points out that no unique or absolute cost figure can be justified, the correct solution is to use a range of cost figures that is determined in a dynamic power portfolio interaction within the financial scheme, support mechanism and industry cost reduction. The paper draws attention to the increasing role of financial investors in the PV segment of the renewable energy market and the importance they attribute to the risks of all options in the power generation portfolio. Based on these trends, a former version of a financing model is adapted to project the energy mix changes in the EU electricity market due to investors behaviour with different risk tolerance/aversion. The dynamic process of translating these risks into the return expectation in the financial appraisal and investment decision making is also introduced. By doing so, the paper sets up a potential electricity market trend with the associated risk perception and classification. The necessary risk mitigation tasks for all stakeholders in the PV market are summarised which aims to avoid the burden of excessive risk premiums in this market segment.

Refining Risk Adjustment for the Proposed CMS Surgical Hip and Femur Fracture Treatment Bundled Payment Program.

Science.gov (United States)

Cairns, Mark A; Ostrum, Robert F; Clement, R Carter

2018-02-21

The U.S. Centers for Medicare & Medicaid Services (CMS) has been considering the implementation of a mandatory bundled payment program, the Surgical Hip and Femur Fracture Treatment (SHFFT) model. However, bundled payments without appropriate risk adjustment may be inequitable to providers and may restrict access to care for certain patients. The SHFFT proposal includes adjustment using the Diagnosis-Related Group (DRG) and geographic location. The goal of the current study was to identify and quantify patient factors that could improve risk adjustment for SHFFT bundled payments. We retrospectively reviewed a 5% random sample of Medicare data from 2008 to 2012. A total of 27,898 patients were identified who met SHFFT inclusion criteria (DRG 480, 481, and 482). Reimbursement was determined for each patient over the bundle period (the surgical hospitalization and 90 days of post-discharge care). Multivariable regression was performed to test demographic factors, comorbidities, geographic location, and specific surgical procedures for associations with reimbursement. The average reimbursement was $23,632 ± $17,587. On average, reimbursements for male patients were $1,213 higher than for female patients (p payments; e.g., reimbursement for those ≥85 years of age averaged $2,282 ± $389 less than for those aged 65 to 69 (p reimbursement, but dementia was associated with lower payments, by an average of $2,354 ± $243 (p reimbursement ranging from $22,527 to $24,033. Less common procedures varied by >$20,000 in average reimbursement (p reimbursement (p reimbursed by an average of $10,421 ± $543 more than DRG 482. Payments varied significantly by state (p ≤ 0.01). Risk adjustment incorporating specific comorbidities demonstrated better performance than with use of DRG alone (r = 0.22 versus 0.15). Our results suggest that the proposed SHFFT bundled payment model should use more robust risk-adjustment methods to ensure that providers are reimbursed fairly and that

Fatherhood status and risk of prostate cancer: nationwide, population-based case-control study.

Science.gov (United States)

Wirén, Sara M; Drevin, Linda I; Carlsson, Sigrid V; Akre, Olof; Holmberg, Erik C; Robinson, David E; Garmo, Hans G; Stattin, Pär E

2013-08-15

Previous studies have shown a decreased risk of prostate cancer for childless men; however, the cause of the association remains to be elucidated. The aim of our study was to assess the risk of prostate cancer by fatherhood status, also considering potential confounding factors. In a case-control study in Prostate Cancer data Base Sweden 2.0, a nationwide, population-based cohort, data on number of children, marital status, education, comorbidity and tumor characteristics obtained through nationwide healthcare registers and demographic databases for 117,328 prostate cancer cases and 562,644 controls, matched on birth year and county of residence, were analyzed. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for prostate cancer overall and by risk category, adjusting for marital status and education. Childless men had a decreased risk of prostate cancer compared to fathers, OR = 0.83 (95% CI = 0.82-0.84), and risk was lower for low-risk prostate cancer, OR = 0.74 (95% CI = 0.72-0.77), than for metastatic prostate cancer, OR = 0.93 (95% CI = 0.90-0.97). Adjustment for marital status and education attenuated the association in the low-risk category, adjusted OR = 0.87 (95% CI = 0.84-0.91), whereas OR for metastatic cancer remained virtually unchanged, adjusted OR = 0.92 (95% CI = 0.88-0.96). Our data indicate that the association between fatherhood status and prostate cancer to a large part is due to socioeconomic factors influencing healthcare-seeking behavior including testing of prostate-specific antigen levels. Copyright © 2013 UICC.

Fatherhood status and risk of prostate cancer: Nationwide, population-based case–control study

Science.gov (United States)

Wirén, Sara M; Drevin, Linda I; Carlsson, Sigrid V; Akre, Olof; Holmberg, Erik C; Robinson, David E; Garmo, Hans G; Stattin, Pär E

2013-01-01

Previous studies have shown a decreased risk of prostate cancer for childless men; however, the cause of the association remains to be elucidated. The aim of our study was to assess the risk of prostate cancer by fatherhood status, also considering potential confounding factors. In a case–control study in Prostate Cancer data Base Sweden 2.0, a nationwide, population-based cohort, data on number of children, marital status, education, comorbidity and tumor characteristics obtained through nationwide healthcare registers and demographic databases for 117,328 prostate cancer cases and 562,644 controls, matched on birth year and county of residence, were analyzed. Conditional logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) for prostate cancer overall and by risk category, adjusting for marital status and education. Childless men had a decreased risk of prostate cancer compared to fathers, OR = 0.83 (95% CI = 0.82–0.84), and risk was lower for low-risk prostate cancer, OR = 0.74 (95% CI = 0.72–0.77), than for metastatic prostate cancer, OR = 0.93 (95% CI = 0.90–0.97). Adjustment for marital status and education attenuated the association in the low-risk category, adjusted OR = 0.87 (95% CI = 0.84–0.91), whereas OR for metastatic cancer remained virtually unchanged, adjusted OR = 0.92 (95% CI = 0.88–0.96). Our data indicate that the association between fatherhood status and prostate cancer to a large part is due to socioeconomic factors influencing healthcare-seeking behavior including testing of prostate-specific antigen levels. PMID:23354735

Usefulness of administrative databases for risk adjustment of adverse events in surgical patients.

Science.gov (United States)

Rodrigo-Rincón, Isabel; Martin-Vizcaíno, Marta P; Tirapu-León, Belén; Zabalza-López, Pedro; Abad-Vicente, Francisco J; Merino-Peralta, Asunción; Oteiza-Martínez, Fabiola

2016-03-01

The aim of this study was to assess the usefulness of clinical-administrative databases for the development of risk adjustment in the assessment of adverse events in surgical patients. The study was conducted at the Hospital of Navarra, a tertiary teaching hospital in northern Spain. We studied 1602 hospitalizations of surgical patients from 2008 to 2010. We analysed 40 comorbidity variables included in the National Surgical Quality Improvement (NSQIP) Program of the American College of Surgeons using 2 sources of information: The clinical and administrative database (CADB) and the data extracted from the complete clinical records (CR), which was considered the gold standard. Variables were catalogued according to compliance with the established criteria: sensitivity, positive predictive value and kappa coefficient >0.6. The average number of comorbidities per study participant was 1.6 using the CR and 0.95 based on CADB (p<.0001). Thirteen types of comorbidities (accounting for 8% of the comorbidities detected in the CR) were not identified when the CADB was the source of information. Five of the 27 remaining comorbidities complied with the 3 established criteria; 2 pathologies fulfilled 2 criteria, whereas 11 fulfilled 1, and 9 did not fulfil any criterion. CADB detected prevalent comorbidities such as comorbid hypertension and diabetes. However, the CABD did not provide enough information to assess the variables needed to perform the risk adjustment proposed by the NSQIP for the assessment of adverse events in surgical patients. Copyright © 2015. Publicado por Elsevier España, S.L.U.

Household adjustment to flood risk: a survey of coastal residents in Texas and Florida, United States.

Science.gov (United States)

Brody, Samuel D; Lee, Yoonjeong; Highfield, Wesley E

2017-07-01

Individual households have increasingly borne responsibility for reducing the adverse impacts of flooding on their property. Little observational research has been conducted, however, at the household level to examine the major factors contributing to the selection of a particular household adjustment. This study addresses the issue by evaluating statistically the factors influencing the adoption of various household flood hazard adjustments. The results indicate that respondents with higher-value homes or longer housing tenure are more likely to adopt structural and expensive techniques. In addition, the information source and the Community Rating System (CRS) score for the jurisdiction where the household is located have a significant bearing on household adjustment. In contrast, proximity to risk zones and risk perception yield somewhat mixed results or behave counter to assumptions in the literature. The study findings provide insights that will be of value to governments and decision-makers interested in encouraging homeowners to take protective action given increasing flood risk. © 2017 The Author(s). Disasters © Overseas Development Institute, 2017.

Appendectomy and Risk of Subsequent Diverticular Disease Requiring Hospitalization: A Population-Based Case-Control Study.

Science.gov (United States)

Sköldberg, Filip; Olén, Ola; Ekbom, Anders; Schmidt, Peter T

2018-07-01

Appendicitis and acute diverticulitis share clinical features and are both influenced by genetic and environmental factors. Appendectomy has been positively associated with diverticular disease in hospital-based case-control studies. The aim of the present study was to investigate, in a population-based setting, whether appendectomy, with or without appendicitis, is associated with an altered risk of hospitalization with diverticular disease. This was a population-based case-control study. The study was based on national healthcare and population registers. We studied 41,988 individuals hospitalized between 2000 and 2010 with a first-time diagnosis of colonic diverticular disease and 413,115 matched control subjects. The association between appendectomy with or without appendicitis and diverticular disease was investigated by conditional logistic regression, including a model adjusting for hospital use. A total of 2813 cases (6.7%) and 19,037 controls (4.6%) had a previous record of appendectomy (appendectomy with acute appendicitis: adjusted OR = 1.31 (95% CI, 1.24-1.39); without appendicitis: adjusted OR = 1.30 (95% CI, 1.23-1.38)). Appendectomy was most strongly associated with an increased risk of diverticular disease within 1 year (with appendicitis: adjusted OR = 2.26 (95% CI, 1.61-3.16); without appendicitis: adjusted OR = 3.98 (95% CI, 2.71-5.83)), but the association was still present ≥20 years after appendectomy (with appendicitis: adjusted OR = 1.22 (95% CI, 1.12-1.32); without appendicitis: adjusted OR = 1.19 (95% CI, 1.10-1.28)). Detailed clinical information on the cases was not available. There were unmeasured potential confounders, such as smoking and dietary factors. The findings are consistent with a hypothesis of appendectomy causing an increased risk of diverticular disease, for example, by affecting the mucosal immune system or the gut microbiome. However, several other mechanisms may contribute to, or account for, the positive association

Suicide risk in relation to level of urbanicity - a population-based linkage study

DEFF Research Database (Denmark)

Qin, Ping

2005-01-01

from various Danish longitudinal registers. Data were analysed with conditional logistic regression. RESULTS: This study confirms that people living in more urbanized areas are at a higher risk of suicide than their counterparts in less urbanized areas. However, this excess risk is largely eliminated...... when adjusted for personal marital, income, and ethnic differences; it is even reversed when further adjusted for psychiatric status. Moreover, the impact of urbanicity on suicide risk differs significantly by sex and across age. Urban living reduces suicide risk significantly among men, especially......BACKGROUND: The extent to which the high suicide rate in urban areas is influenced by exposures to risk factors for suicide other than urbanicity remains unknown. This population-based study aims to investigate suicide risk in relation to the level of urbanicity in the context of other factors...

[Remuneration distribution - should morbidity-dependent overall remuneration also be distributed after adjustments for morbidity?].

Science.gov (United States)

Walendzik, A; Trottmann, M; Leonhardt, R; Wasem, J

2013-04-01

In the 2009 reform of the German collective remuneration system for outpatient medical care, on the level of overall remuneration, the morbidity risk was transferred to the health funds fulfilling a long-term demand of physicians. Nevertheless not transferring morbidity adjustment to the levels of physician groups and singular practices can lead to budgets not related to patient needs and to incentives for risk selection for individual doctors. The systematics of the distribution of overall remuneration in the German remuneration system for outpatient care are analysed focusing on the aspect of morbidity adjustment. Using diagnostic and pharmaceutical information of about half a million insured subjects, a risk adjustment model able to predict individual expenditures for outpatient care for different provider groups is presented. This model enables to additively split the individual care burden into several parts attributed to different physician groups. Conditions for the use of the model in the distribution of overall remuneration between physician groups are developed. A simulation of the use of diagnoses-based risk adjustment in standard service volumes then highlights the conditions for a successfull installation of standard service volumes representing a higher degree of risk adjustment. The presented estimation model is generally applicable for the distribution of overall remuneration to different physician groups. The simulation of standard service volumes using diagnosis-based risk adjustment does not provide a more accurate prediction of the expenditures on the level of physician practices than the age-related calculation currently used in the German remuneration system for outpatient medical care. Using elements of morbidity-based risk adjustment the current German collective system for outpatient medical care could be transformed towards a higher degree of distributional justice concerning medical care for patients and more appropriate incentives

Internet-Based Self-Help Intervention for ICD-11 Adjustment Disorder: Preliminary Findings.

Science.gov (United States)

Eimontas, Jonas; Rimsaite, Zivile; Gegieckaite, Goda; Zelviene, Paulina; Kazlauskas, Evaldas

2018-06-01

Adjustment disorder is one of the most diagnosed mental disorders. However, there is a lack of studies of specialized internet-based psychosocial interventions for adjustment disorder. We aimed to analyze the outcomes of an internet-based unguided self-help psychosocial intervention BADI for adjustment disorder in a two armed randomized controlled trial with a waiting list control group. In total 284 adult participants were randomized in this study. We measured adjustment disorder as a primary outcome, and psychological well-being as a secondary outcome at pre-intervention (T1) and one month after the intervention (T2). We found medium effect size of the intervention for the completer sample on adjustment disorder symptoms. Intervention was effective for those participants who used it at least one time in 30-day period. Our results revealed the potential of unguided internet-based self-help intervention for adjustment disorder. However, high dropout rates in the study limits the generalization of the outcomes of the intervention only to completers.

Price adjustment for traditional Chinese medicine procedures: Based on a standardized value parity model.

Science.gov (United States)

Wang, Haiyin; Jin, Chunlin; Jiang, Qingwu

2017-11-20

Traditional Chinese medicine (TCM) is an important part of China's medical system. Due to the prolonged low price of TCM procedures and the lack of an effective mechanism for dynamic price adjustment, the development of TCM has markedly lagged behind Western medicine. The World Health Organization (WHO) has emphasized the need to enhance the development of alternative and traditional medicine when creating national health care systems. The establishment of scientific and appropriate mechanisms to adjust the price of medical procedures in TCM is crucial to promoting the development of TCM. This study has examined incorporating value indicators and data on basic manpower expended, time spent, technical difficulty, and the degree of risk in the latest standards for the price of medical procedures in China, and this study also offers a price adjustment model with the relative price ratio as a key index. This study examined 144 TCM procedures and found that prices of TCM procedures were mainly based on the value of medical care provided; on average, medical care provided accounted for 89% of the price. Current price levels were generally low and the current price accounted for 56% of the standardized value of a procedure, on average. Current price levels accounted for a markedly lower standardized value of acupuncture, moxibustion, special treatment with TCM, and comprehensive TCM procedures. This study selected a total of 79 procedures and adjusted them by priority. The relationship between the price of TCM procedures and the suggested price was significantly optimized (p based on a standardized value parity model is a scientific and suitable method of price adjustment that can serve as a reference for other provinces and municipalities in China and other countries and regions that mainly have fee-for-service (FFS) medical care.

The Effect of Family Communication Patterns on Adopted Adolescent Adjustment

Science.gov (United States)

Rueter, Martha A.; Koerner, Ascan F.

2008-01-01

Adoption and family communication both affect adolescent adjustment. We proposed that adoption status and family communication interact such that adopted adolescents in families with certain communication patterns are at greater risk for adjustment problems. We tested this hypothesis using a community-based sample of 384 adoptive and 208…

Psychosocial Adjustment and Sibling Relationships in Siblings of Children with Autism Spectrum Disorder: Risk and Protective Factors

Science.gov (United States)

Walton, Katherine M.; Ingersoll, Brooke R.

2015-01-01

This study compared sibling adjustment and relationships in siblings of children with Autism Spectrum Disorder (ASD-Sibs; n = 69) and siblings of children with typical development (TD-Sibs; n = 93). ASD-Sibs and TD-Sibs demonstrated similar emotional/behavioral adjustment. Older male ASD-Sibs were at increased risk for difficulties. Sibling…

Odds per adjusted standard deviation: comparing strengths of associations for risk factors measured on different scales and across diseases and populations.

Science.gov (United States)

Hopper, John L

2015-11-15

How can the "strengths" of risk factors, in the sense of how well they discriminate cases from controls, be compared when they are measured on different scales such as continuous, binary, and integer? Given that risk estimates take into account other fitted and design-related factors-and that is how risk gradients are interpreted-so should the presentation of risk gradients. Therefore, for each risk factor X0, I propose using appropriate regression techniques to derive from appropriate population data the best fitting relationship between the mean of X0 and all the other covariates fitted in the model or adjusted for by design (X1, X2, … , Xn). The odds per adjusted standard deviation (OPERA) presents the risk association for X0 in terms of the change in risk per s = standard deviation of X0 adjusted for X1, X2, … , Xn, rather than the unadjusted standard deviation of X0 itself. If the increased risk is relative risk (RR)-fold over A adjusted standard deviations, then OPERA = exp[ln(RR)/A] = RR(s). This unifying approach is illustrated by considering breast cancer and published risk estimates. OPERA estimates are by definition independent and can be used to compare the predictive strengths of risk factors across diseases and populations. © The Author 2015. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Variation In Accountable Care Organization Spending And Sensitivity To Risk Adjustment: Implications For Benchmarking.

Science.gov (United States)

Rose, Sherri; Zaslavsky, Alan M; McWilliams, J Michael

2016-03-01

Spending targets (or benchmarks) for accountable care organizations (ACOs) participating in the Medicare Shared Savings Program must be set carefully to encourage program participation while achieving fiscal goals and minimizing unintended consequences, such as penalizing ACOs for serving sicker patients. Recently proposed regulatory changes include measures to make benchmarks more similar for ACOs in the same area with different historical spending levels. We found that ACOs vary widely in how their spending levels compare with those of other local providers after standard case-mix adjustments. Additionally adjusting for survey measures of patient health meaningfully reduced the variation in differences between ACO spending and local average fee-for-service spending, but substantial variation remained, which suggests that differences in care efficiency between ACOs and local non-ACO providers vary widely. Accordingly, measures to equilibrate benchmarks between high- and low-spending ACOs--such as setting benchmarks to risk-adjusted average fee-for-service spending in an area--should be implemented gradually to maintain participation by ACOs with high spending. Use of survey information also could help mitigate perverse incentives for risk selection and upcoding and limit unintended consequences of new benchmarking methodologies for ACOs serving sicker patients. Project HOPE—The People-to-People Health Foundation, Inc.

What is the empirical evidence that hospitals with higher-risk adjusted mortality rates provide poorer quality care? A systematic review of the literature

Directory of Open Access Journals (Sweden)

Mohammed Mohammed A

2007-06-01

Full Text Available Abstract Background Despite increasing interest and publication of risk-adjusted hospital mortality rates, the relationship with underlying quality of care remains unclear. We undertook a systematic review to ascertain the extent to which variations in risk-adjusted mortality rates were associated with differences in quality of care. Methods We identified studies in which risk-adjusted mortality and quality of care had been reported in more than one hospital. We adopted an iterative search strategy using three databases – Medline, HealthSTAR and CINAHL from 1966, 1975 and 1982 respectively. We identified potentially relevant studies on the basis of the title or abstract. We obtained these papers and included those which met our inclusion criteria. Results From an initial yield of 6,456 papers, 36 studies met the inclusion criteria. Several of these studies considered more than one process-versus-risk-adjusted mortality relationship. In total we found 51 such relationships in a widen range of clinical conditions using a variety of methods. A positive correlation between better quality of care and risk-adjusted mortality was found in under half the relationships (26/51 51% but the remainder showed no correlation (16/51 31% or a paradoxical correlation (9/51 18%. Conclusion The general notion that hospitals with higher risk-adjusted mortality have poorer quality of care is neither consistent nor reliable.

Use of surveillance data for prevention of healthcare-associated infection: risk adjustment and reporting dilemmas.

LENUS (Irish Health Repository)

O'Neill, Eoghan

2009-08-01

Healthcare-associated or nosocomial infection (HCAI) is of increasing importance to healthcare providers and the public. Surveillance is crucial but must be adjusted for risk, especially when used for interhospital comparisons or for public reporting.

Case mix adjustment of health outcomes, resource use and process indicators in childbirth care: a register-based study.

Science.gov (United States)

Mesterton, Johan; Lindgren, Peter; Ekenberg Abreu, Anna; Ladfors, Lars; Lilja, Monica; Saltvedt, Sissel; Amer-Wåhlin, Isis

2016-05-31

Unwarranted variation in care practice and outcomes has gained attention and inter-hospital comparisons are increasingly being used to highlight and understand differences between hospitals. Adjustment for case mix is a prerequisite for meaningful comparisons between hospitals with different patient populations. The objective of this study was to identify and quantify maternal characteristics that impact a set of important indicators of health outcomes, resource use and care process and which could be used for case mix adjustment of comparisons between hospitals. In this register-based study, 139 756 deliveries in 2011 and 2012 were identified in regional administrative systems from seven Swedish regions, which together cover 67 % of all deliveries in Sweden. Data were linked to the Medical birth register and Statistics Sweden's population data. A number of important indicators in childbirth care were studied: Caesarean section (CS), induction of labour, length of stay, perineal tears, haemorrhage > 1000 ml and post-partum infections. Sociodemographic and clinical characteristics deemed relevant for case mix adjustment of outcomes and resource use were identified based on previous literature and based on clinical expertise. Adjustment using logistic and ordinary least squares regression analysis was performed to quantify the impact of these characteristics on the studied indicators. Almost all case mix factors analysed had an impact on CS rate, induction rate and length of stay and the effect was highly statistically significant for most factors. Maternal age, parity, fetal presentation and multiple birth were strong predictors of all these indicators but a number of additional factors such as born outside the EU, body mass index (BMI) and several complications during pregnancy were also important risk factors. A number of maternal characteristics had a noticeable impact on risk of perineal tears, while the impact of case mix factors was less pronounced for

48 CFR 215.404-71-3 - Contract type risk and working capital adjustment.

Science.gov (United States)

2010-10-01

.... Cost-plus-incentive-free (4) 1.0 0 to 2. Cost-plus-fixed-fee (4) 0.5 0 to 1. Time-and-materials... considered cost-plus-fixed-fee contracts for the purposes of assigning profit values. They shall not receive... CONTRACTING BY NEGOTIATION Contract Pricing 215.404-71-3 Contract type risk and working capital adjustment. (a...

Desirability of Outcome Ranking (DOOR) and Response Adjusted for Duration of Antibiotic Risk (RADAR).

Science.gov (United States)

Evans, Scott R; Rubin, Daniel; Follmann, Dean; Pennello, Gene; Huskins, W Charles; Powers, John H; Schoenfeld, David; Chuang-Stein, Christy; Cosgrove, Sara E; Fowler, Vance G; Lautenbach, Ebbing; Chambers, Henry F

2015-09-01

Clinical trials that compare strategies to optimize antibiotic use are of critical importance but are limited by competing risks that distort outcome interpretation, complexities of noninferiority trials, large sample sizes, and inadequate evaluation of benefits and harms at the patient level. The Antibacterial Resistance Leadership Group strives to overcome these challenges through innovative trial design. Response adjusted for duration of antibiotic risk (RADAR) is a novel methodology utilizing a superiority design and a 2-step process: (1) categorizing patients into an overall clinical outcome (based on benefits and harms), and (2) ranking patients with respect to a desirability of outcome ranking (DOOR). DOORs are constructed by assigning higher ranks to patients with (1) better overall clinical outcomes and (2) shorter durations of antibiotic use for similar overall clinical outcomes. DOOR distributions are compared between antibiotic use strategies. The probability that a randomly selected patient will have a better DOOR if assigned to the new strategy is estimated. DOOR/RADAR represents a new paradigm in assessing the risks and benefits of new strategies to optimize antibiotic use. © The Author 2015. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

The relationship between the C-statistic of a risk-adjustment model and the accuracy of hospital report cards: a Monte Carlo Study.

Science.gov (United States)

Austin, Peter C; Reeves, Mathew J

2013-03-01

Hospital report cards, in which outcomes following the provision of medical or surgical care are compared across health care providers, are being published with increasing frequency. Essential to the production of these reports is risk-adjustment, which allows investigators to account for differences in the distribution of patient illness severity across different hospitals. Logistic regression models are frequently used for risk adjustment in hospital report cards. Many applied researchers use the c-statistic (equivalent to the area under the receiver operating characteristic curve) of the logistic regression model as a measure of the credibility and accuracy of hospital report cards. To determine the relationship between the c-statistic of a risk-adjustment model and the accuracy of hospital report cards. Monte Carlo simulations were used to examine this issue. We examined the influence of 3 factors on the accuracy of hospital report cards: the c-statistic of the logistic regression model used for risk adjustment, the number of hospitals, and the number of patients treated at each hospital. The parameters used to generate the simulated datasets came from analyses of patients hospitalized with a diagnosis of acute myocardial infarction in Ontario, Canada. The c-statistic of the risk-adjustment model had, at most, a very modest impact on the accuracy of hospital report cards, whereas the number of patients treated at each hospital had a much greater impact. The c-statistic of a risk-adjustment model should not be used to assess the accuracy of a hospital report card.

Mate guarding in the Seychelles warbler is energetically costly and adjusted to paternity risk.

Science.gov (United States)

Komdeur, J

2001-10-22

Males may increase their fitness through extra-pair copulations (copulations outside the pair bond) that result in extra-pair fertilizations, but also risk lost paternity when they leave their own mate unguarded. The fitness costs of cuckoldry for Seychelles warblers (Acrocephalus sechellensis) are considerable because warblers have a single-egg clutch and, given the short breeding season, no time for a successful replacement clutch. Neighbouring males are the primary threat to a male's genetic paternity. Males minimize their loss of paternity by guarding their mates to prevent them from having extra-pair copulations during their fertile period. Here, I provide experimental evidence that mate-guarding behaviour is energetically costly and that the expression of this trade-off is adjusted to paternity risk (local male density). Free-living males that were induced to reduce mate guarding spent significantly more time foraging and gained significantly better body condition than control males. The larger the reduction in mate guarding, the more pronounced was the increase in foraging and body condition (accounting for food availability). An experimental increase in paternity risk resulted in an increase in mate-guarding intensity and a decrease in foraging and body condition, and vice versa. This is examined using both cross-sectional and longitudinal data. This study on the Seychelles warbler offers experimental evidence that mate guarding is energetically costly and adjusted to paternity risk.

Energy-Saving Performance of Flap-Adjustment-Based Centrifugal Fan

Directory of Open Access Journals (Sweden)

Genglin Chen

2018-01-01

Full Text Available The current paper mainly focuses on finding a more appropriate way to enhance the fan performance at off-design conditions. The centrifugal fan (CF based on flap-adjustment (FA has been investigated through theoretical, experimental, and finite element methods. To obtain a more predominant performance of CF from the different adjustments, we carried out a comparative analysis on FA and leading-adjustment (LA in aerodynamic performances, which included the adjusted angle of blades, total pressure, efficiency, system-efficiency, adjustment-efficiency, and energy-saving rate. The contribution of this paper is the integrated performance curve of the CF. Finally, the results showed that the effects of FA and LA on economic performance and energy savings of the fan varied with the blade angles. Furthermore, FA was feasible, which is more sensitive than LA. Moreover, the CF with FA offered a more extended flow-range of high economic characteristic in comparison with LA. Finally, when the operation flow-range extends, energy-saving rate of the fan with FA would have improvement.

Critical review of methods for risk ranking of food related hazards, based on risks for human health

DEFF Research Database (Denmark)

van der Fels-Klerx, H. J.; van Asselt, E. D.; Raley, M.

2018-01-01

This study aimed to critically review methods for ranking risks related to food safety and dietary hazards on the basis of their anticipated human health impacts. A literature review was performed to identify and characterize methods for risk ranking from the fields of food, environmental science......, and the risk ranking method characterized. The methods were then clustered - based on their characteristics - into eleven method categories. These categories included: risk assessment, comparative risk assessment, risk ratio method, scoring method, cost of illness, health adjusted life years, multi......-criteria decision analysis, risk matrix, flow charts/decision trees, stated preference techniques and expert synthesis. Method categories were described by their characteristics, weaknesses and strengths, data resources, and fields of applications. It was concluded there is no single best method for risk ranking...

5 CFR 9901.312 - Maximum rates of base salary and adjusted salary.

Science.gov (United States)

2010-01-01

... 5 Administrative Personnel 3 2010-01-01 2010-01-01 false Maximum rates of base salary and adjusted salary. 9901.312 Section 9901.312 Administrative Personnel DEPARTMENT OF DEFENSE HUMAN RESOURCES....312 Maximum rates of base salary and adjusted salary. (a) Subject to § 9901.105, the Secretary may...

Cumulative socioeconomic status risk, allostatic load, and adjustment: a prospective latent profile analysis with contextual and genetic protective factors.

Science.gov (United States)

Brody, Gene H; Yu, Tianyi; Chen, Yi-fu; Kogan, Steven M; Evans, Gary W; Beach, Steven R H; Windle, Michael; Simons, Ronald L; Gerrard, Meg; Gibbons, Frederick X; Philibert, Robert A

2013-05-01

The health disparities literature has identified a common pattern among middle-aged African Americans that includes high rates of chronic disease along with low rates of psychiatric disorders despite exposure to high levels of cumulative socioeconomic status (SES) risk. The current study was designed to test hypotheses about the developmental precursors to this pattern. Hypotheses were tested with a representative sample of 443 African American youths living in the rural South. Cumulative SES risk and protective processes were assessed at ages 11-13 years; psychological adjustment was assessed at ages 14-18 years; genotyping at the 5-HTTLPR was conducted at age 16 years; and allostatic load (AL) was assessed at age 19 years. A latent profile analysis identified 5 profiles that evinced distinct patterns of SES risk, AL, and psychological adjustment, with 2 relatively large profiles designated as focal profiles: a physical health vulnerability profile characterized by high SES risk/high AL/low adjustment problems, and a resilient profile characterized by high SES risk/low AL/low adjustment problems. The physical health vulnerability profile mirrored the pattern found in the adult health disparities literature. Multinomial logistic regression analyses indicated that carrying an s allele at the 5-HTTLPR and receiving less peer support distinguished the physical health vulnerability profile from the resilient profile. Protective parenting and planful self-regulation distinguished both focal profiles from the other 3 profiles. The results suggest the public health importance of preventive interventions that enhance coping and reduce the effects of stress across childhood and adolescence.

A typology of interpartner conflict and maternal parenting practices in high-risk families: examining spillover and compensatory models and implications for child adjustment.

Science.gov (United States)

Sturge-Apple, Melissa L; Davies, Patrick T; Cicchetti, Dante; Fittoria, Michael G

2014-11-01

The present study incorporates a person-based approach to identify spillover and compartmentalization patterns of interpartner conflict and maternal parenting practices in an ethnically diverse sample of 192 2-year-old children and their mothers who had experienced higher levels of socioeconomic risk. In addition, we tested whether sociocontextual variables were differentially predictive of theses profiles and examined how interpartner-parenting profiles were associated with children's physiological and psychological adjustment over time. As expected, latent class analyses extracted three primary profiles of functioning: adequate functioning, spillover, and compartmentalizing families. Furthermore, interpartner-parenting profiles were differentially associated with both sociocontextual predictors and children's adjustment trajectories. The findings highlight the developmental utility of incorporating person-based approaches to models of interpartner conflict and maternal parenting practices.

A comparative evaluation of risk-adjustment models for benchmarking amputation-free survival after lower extremity bypass.

Science.gov (United States)

Simons, Jessica P; Goodney, Philip P; Flahive, Julie; Hoel, Andrew W; Hallett, John W; Kraiss, Larry W; Schanzer, Andres

2016-04-01

Providing patients and payers with publicly reported risk-adjusted quality metrics for the purpose of benchmarking physicians and institutions has become a national priority. Several prediction models have been developed to estimate outcomes after lower extremity revascularization for critical limb ischemia, but the optimal model to use in contemporary practice has not been defined. We sought to identify the highest-performing risk-adjustment model for amputation-free survival (AFS) at 1 year after lower extremity bypass (LEB). We used the national Society for Vascular Surgery Vascular Quality Initiative (VQI) database (2003-2012) to assess the performance of three previously validated risk-adjustment models for AFS. The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL), Finland National Vascular (FINNVASC) registry, and the modified Project of Ex-vivo vein graft Engineering via Transfection III (PREVENT III [mPIII]) risk scores were applied to the VQI cohort. A novel model for 1-year AFS was also derived using the VQI data set and externally validated using the PIII data set. The relative discrimination (Harrell c-index) and calibration (Hosmer-May goodness-of-fit test) of each model were compared. Among 7754 patients in the VQI who underwent LEB for critical limb ischemia, the AFS was 74% at 1 year. Each of the previously published models for AFS demonstrated similar discriminative performance: c-indices for BASIL, FINNVASC, mPIII were 0.66, 0.60, and 0.64, respectively. The novel VQI-derived model had improved discriminative ability with a c-index of 0.71 and appropriate generalizability on external validation with a c-index of 0.68. The model was well calibrated in both the VQI and PIII data sets (goodness of fit P = not significant). Currently available prediction models for AFS after LEB perform modestly when applied to national contemporary VQI data. Moreover, the performance of each model was inferior to that of the novel VQI-derived model

Group-based parent training programmes for improving emotional and behavioural adjustment in young children.

Science.gov (United States)

Barlow, Jane; Bergman, Hanna; Kornør, Hege; Wei, Yinghui; Bennett, Cathy

2016-08-01

reduced negative behaviour (SMD -0.22, 95% CI -0.39 to -0.06; 7 studies, 941 participants, moderate quality evidence), and improved positive behaviour (SMD 0.48, 95% CI 0.17 to 0.79; 4 studies, 173 participants, moderate quality evidence) as rated by independent observers postintervention. No further meta-analyses were possible. Results of subgroup analyses show no evidence for treatment duration (seven weeks or less versus more than eight weeks) and inconclusive evidence for prevention versus treatment interventions. The findings of this review, which relate to the broad group of universal and at-risk (targeted) children and parents, provide tentative support for the use of group-based parenting programmes to improve the overall emotional and behavioural adjustment of children with a maximum mean age of three years and 11 months, in the short-term. There is, however, a need for more research regarding the role that these programmes might play in the primary prevention of both emotional and behavioural problems, and their long-term effectiveness.

Adjustment of lifetime risks of space radiation-induced cancer by the healthy worker effect and cancer misclassification

Directory of Open Access Journals (Sweden)

Leif E. Peterson

2015-12-01

Conclusions. The typical life table approach for projecting lifetime risk of radiation-induced cancer mortality and incidence for astronauts and radiation workers can be improved by adjusting for HWE while simulating the uncertainty of input rates, input excess risk coefficients, and bias correction factors during multiple Monte Carlo realizations of the life table.

One idea of portfolio risk control for absolute return strategy risk adjustments by signals from correlation behavior

Science.gov (United States)

Nishiyama, N.

2001-12-01

Absolute return strategy provided from fund of funds (FOFs) investment schemes is the focus in Japanese Financial Community. FOFs investment mainly consists of hedge fund investment and it has two major characteristics which are low correlation against benchmark index and little impact from various external changes in the environment given maximizing return. According to the historical track record of survival hedge funds in this business world, they maintain a stable high return and low risk. However, one must keep in mind that low risk would not be equal to risk free. The failure of Long-term capital management (LTCM) that took place in the summer of 1998 was a symbolized phenomenon. The summer of 1998 exhibited a certain limitation of traditional value at risk (VaR) and some possibility that traditional VaR could be ineffectual to the nonlinear type of fluctuation in the market. In this paper, I try to bring self-organized criticality (SOC) into portfolio risk control. SOC would be well known as a model of decay in the natural world. I analyzed nonlinear type of fluctuation in the market as SOC and applied SOC to capture complicated market movement using threshold point of SOC and risk adjustments by scenario correlation as implicit signals. Threshold becomes the control parameter of risk exposure to set downside floor and forecast extreme nonlinear type of fluctuation under a certain probability. Simulation results would show synergy effect of portfolio risk control between SOC and absolute return strategy.

Population-Adjusted Street Connectivity, Urbanicity and Risk of Obesity in the U.S

Science.gov (United States)

Wang, Fahui; Wen, Ming; Xu, Yanqing

2013-01-01

Street connectivity, defined as the number of (3-way or more) intersections per area unit, is an important index of built environments as a proxy for walkability in a neighborhood. This paper examines its geographic variations across the rural-urban continuum (urbanicity), major racial-ethnic groups and various poverty levels. The population-adjusted street connectivity index is proposed as a better measure than the regular index for a large area such as county due to likely concentration of population in limited space within the large area. Based on the data from the Behavioral Risk Factor Surveillance System (BRFSS), this paper uses multilevel modeling to analyze its association with physical activity and obesity while controlling for various individual and county-level variables. Analysis of data subsets indicates that the influences of individual and county-level variables on obesity risk vary across areas of different urbanization levels. The positive influence of street connectivity on obesity control is limited to the more but not the mostly urbanized areas. This demonstrates the value of obesogenic environment research in different geographic settings, helps us reconcile and synthesize some seemingly contradictory results reported in different studies, and also promotes that effective policies need to be highly sensitive to the diversity of demographic groups and geographically adaptable. PMID:23667278

Impact of selected risk factors on quality-adjusted life expectancy in Denmark

DEFF Research Database (Denmark)

Brønnum-Hansen, Henrik; Juel, Knud; Davidsen, Michael

2007-01-01

AIMS: The construct quality-adjusted life years (QALYs) combines mortality and overall health status and can be used to quantify the impact of risk factors on population health. The purpose of the study was to estimate the impact of tobacco smoking, high alcohol consumption, physical inactivity...... Health Survey 2000, and Danish EQ-5D values. RESULTS: The quality-adjusted life expectancy of 25-year-olds was 10-11 QALYs shorter for heavy smokers than for those who never smoke. The difference in life expectancy was 9-10 years. Men and women with high alcohol consumption could expect to lose about 5...... and 3 QALYs, respectively. Sedentary persons could expect to have about 7 fewer QALYs than physically active persons. Obesity shortened QALYs by almost 3 for men and 6 for women. CONCLUSIONS: Smoking, high alcohol consumption, physical inactivity, and obesity strongly reduce life expectancy and health...

Performance of risk-adjusted control charts to monitor in-hospital mortality of intensive care unit patients: A simulation study

NARCIS (Netherlands)

Koetsier, Antonie; de Keizer, Nicolette F.; de Jonge, Evert; Cook, David A.; Peek, Niels

2012-01-01

Objectives: Increases in case-mix adjusted mortality may be indications of decreasing quality of care. Risk-adjusted control charts can be used for in-hospital mortality monitoring in intensive care units by issuing a warning signal when there are more deaths than expected. The aim of this study was

Risk Based Milk Pricing Model at Dairy Farmers Level

Directory of Open Access Journals (Sweden)

W. Septiani

2017-12-01

Full Text Available The milk price from a cooperative institution to farmer does not fully cover the production cost. Though, dairy farmers encounter various risks and uncertainties in conducting their business. The highest risk in milk supply lies in the activities at the farm. This study was designed to formulate a model for calculating milk price at farmer’s level based on risk. Risks that occur on farms include the risk of cow breeding, sanitation, health care, cattle feed management, milking and milk sales. This research used the location of the farm in West Java region. There were five main stages in the preparation of this model, (1 identification and analysis of influential factors, (2 development of a conceptual model, (3 structural analysis and the amount of production costs, (4 model calculation of production cost with risk factors, and (5 risk based milk pricing model. This research built a relationship between risks on smallholder dairy farms with the production costs to be incurred by the farmers. It was also obtained the formulation of risk adjustment factor calculation for the variable costs of production in dairy cattle farm. The difference in production costs with risk and the total production cost without risk was about 8% to 10%. It could be concluded that the basic price of milk proposed based on the research was around IDR 4,250-IDR 4,350/L for 3 to 4 cows ownership. Increasing farmer income was expected to be obtained by entering the value of this risk in the calculation of production costs. 

Risk-adjusted capitation funding models for chronic disease in Australia: alternatives to casemix funding.

Science.gov (United States)

Antioch, K M; Walsh, M K

2002-01-01

Under Australian casemix funding arrangements that use Diagnosis-Related Groups (DRGs) the average price is policy based, not benchmarked. Cost weights are too low for State-wide chronic disease services. Risk-adjusted Capitation Funding Models (RACFM) are feasible alternatives. A RACFM was developed for public patients with cystic fibrosis treated by an Australian Health Maintenance Organization (AHMO). Adverse selection is of limited concern since patients pay solidarity contributions via Medicare levy with no premium contributions to the AHMO. Sponsors paying premium subsidies are the State of Victoria and the Federal Government. Cost per patient is the dependent variable in the multiple regression. Data on DRG 173 (cystic fibrosis) patients were assessed for heteroskedasticity, multicollinearity, structural stability and functional form. Stepwise linear regression excluded non-significant variables. Significant variables were 'emergency' (1276.9), 'outlier' (6377.1), 'complexity' (3043.5), 'procedures' (317.4) and the constant (4492.7) (R(2)=0.21, SE=3598.3, F=14.39, Probpayment (constant). The model explained 21% of the variance in cost per patient. The payment rate is adjusted by a best practice annual admission rate per patient. The model is a blended RACFM for in-patient, out-patient, Hospital In The Home, Fee-For-Service Federal payments for drugs and medical services; lump sum lung transplant payments and risk sharing through cost (loss) outlier payments. State and Federally funded home and palliative services are 'carved out'. The model, which has national application via Coordinated Care Trials and by Australian States for RACFMs may be instructive for Germany, which plans to use Australian DRGs for casemix funding. The capitation alternative for chronic disease can improve equity, allocative efficiency and distributional justice. The use of Diagnostic Cost Groups (DCGs) is a promising alternative classification system for capitation arrangements.

The Impact of Capital Structure on Economic Capital and Risk Adjusted Performance

OpenAIRE

Porteous, Bruce; Tapadar, Pradip

2008-01-01

The impact that capital structure and capital asset allocation have on financial services firm economic capital and risk adjusted performance is considered. A stochastic modelling approach is used in conjunction with banking and insurance examples. It is demonstrated that gearing up Tier 1 capital with Tier 2 capital can be in the interests of bank Tier 1 capital providers, but may not always be so for insurance Tier 1 capital providers. It is also shown that, by allocating a bank or insuranc...

Inclusion of Highest Glasgow Coma Scale Motor Component Score in Mortality Risk Adjustment for Benchmarking of Trauma Center Performance.

Science.gov (United States)

Gomez, David; Byrne, James P; Alali, Aziz S; Xiong, Wei; Hoeft, Chris; Neal, Melanie; Subacius, Harris; Nathens, Avery B

2017-12-01

The Glasgow Coma Scale (GCS) is the most widely used measure of traumatic brain injury (TBI) severity. Currently, the arrival GCS motor component (mGCS) score is used in risk-adjustment models for external benchmarking of mortality. However, there is evidence that the highest mGCS score in the first 24 hours after injury might be a better predictor of death. Our objective was to evaluate the impact of including the highest mGCS score on the performance of risk-adjustment models and subsequent external benchmarking results. Data were derived from the Trauma Quality Improvement Program analytic dataset (January 2014 through March 2015) and were limited to the severe TBI cohort (16 years or older, isolated head injury, GCS ≤8). Risk-adjustment models were created that varied in the mGCS covariates only (initial score, highest score, or both initial and highest mGCS scores). Model performance and fit, as well as external benchmarking results, were compared. There were 6,553 patients with severe TBI across 231 trauma centers included. Initial and highest mGCS scores were different in 47% of patients (n = 3,097). Model performance and fit improved when both initial and highest mGCS scores were included, as evidenced by improved C-statistic, Akaike Information Criterion, and adjusted R-squared values. Three-quarters of centers changed their adjusted odds ratio decile, 2.6% of centers changed outlier status, and 45% of centers exhibited a ≥0.5-SD change in the odds ratio of death after including highest mGCS score in the model. This study supports the concept that additional clinical information has the potential to not only improve the performance of current risk-adjustment models, but can also have a meaningful impact on external benchmarking strategies. Highest mGCS score is a good potential candidate for inclusion in additional models. Copyright © 2017 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Assessing At-Risk Youth Using the Reynolds Adolescent Adjustment Screening Inventory with a Latino Population

Science.gov (United States)

Balkin, Richard S.; Cavazos, Javier, Jr.; Hernandez, Arthur E.; Garcia, Roberto; Dominguez, Denise L.; Valarezo, Alexandra

2013-01-01

Factor analyses were conducted on scores from the Reynolds Adolescent Adjustment Screening Inventory (RAASI; Reynolds, 2001) representing at-risk Latino youth. The 4-factor model of the RAASI did not exhibit a good fit. However, evidence of generalizability for Latino youth was noted. (Contains 3 tables.)

Contrast Enhancement Algorithm Based on Gap Adjustment for Histogram Equalization

Science.gov (United States)

Chiu, Chung-Cheng; Ting, Chih-Chung

2016-01-01

Image enhancement methods have been widely used to improve the visual effects of images. Owing to its simplicity and effectiveness histogram equalization (HE) is one of the methods used for enhancing image contrast. However, HE may result in over-enhancement and feature loss problems that lead to unnatural look and loss of details in the processed images. Researchers have proposed various HE-based methods to solve the over-enhancement problem; however, they have largely ignored the feature loss problem. Therefore, a contrast enhancement algorithm based on gap adjustment for histogram equalization (CegaHE) is proposed. It refers to a visual contrast enhancement algorithm based on histogram equalization (VCEA), which generates visually pleasing enhanced images, and improves the enhancement effects of VCEA. CegaHE adjusts the gaps between two gray values based on the adjustment equation, which takes the properties of human visual perception into consideration, to solve the over-enhancement problem. Besides, it also alleviates the feature loss problem and further enhances the textures in the dark regions of the images to improve the quality of the processed images for human visual perception. Experimental results demonstrate that CegaHE is a reliable method for contrast enhancement and that it significantly outperforms VCEA and other methods. PMID:27338412

Contrast Enhancement Algorithm Based on Gap Adjustment for Histogram Equalization

Directory of Open Access Journals (Sweden)

Chung-Cheng Chiu

2016-06-01

Full Text Available Image enhancement methods have been widely used to improve the visual effects of images. Owing to its simplicity and effectiveness histogram equalization (HE is one of the methods used for enhancing image contrast. However, HE may result in over-enhancement and feature loss problems that lead to unnatural look and loss of details in the processed images. Researchers have proposed various HE-based methods to solve the over-enhancement problem; however, they have largely ignored the feature loss problem. Therefore, a contrast enhancement algorithm based on gap adjustment for histogram equalization (CegaHE is proposed. It refers to a visual contrast enhancement algorithm based on histogram equalization (VCEA, which generates visually pleasing enhanced images, and improves the enhancement effects of VCEA. CegaHE adjusts the gaps between two gray values based on the adjustment equation, which takes the properties of human visual perception into consideration, to solve the over-enhancement problem. Besides, it also alleviates the feature loss problem and further enhances the textures in the dark regions of the images to improve the quality of the processed images for human visual perception. Experimental results demonstrate that CegaHE is a reliable method for contrast enhancement and that it significantly outperforms VCEA and other methods.

The need for unique risk adjustment for surgical site infections at a high-volume, tertiary care center with inherent high-risk colorectal procedures.

Science.gov (United States)

Gorgun, E; Benlice, C; Hammel, J; Hull, T; Stocchi, L

2017-08-01

The aim of the present study was to create a unique risk adjustment model for surgical site infection (SSI) in patients who underwent colorectal surgery (CRS) at the Cleveland Clinic (CC) with inherent high risk factors by using a nationwide database. The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify patients who underwent CRS between 2005 and 2010. Initially, CC cases were identified from all NSQIP data according to case identifier and separated from the other NSQIP centers. Demographics, comorbidities, and outcomes were compared. Logistic regression analyses were used to assess the association between SSI and center-related factors. A total of 70,536 patients met the inclusion criteria and underwent CRS, 1090 patients (1.5%) at the CC and 69,446 patients (98.5%) at other centers. Male gender, work-relative value unit, diagnosis of inflammatory bowel disease, pouch formation, open surgery, steroid use, and preoperative radiotherapy rates were significantly higher in the CC cases. Overall morbidity and individual postoperative complication rates were found to be similar in the CC and other centers except for the following: organ-space SSI and sepsis rates (higher in the CC cases); and pneumonia and ventilator dependency rates (higher in the other centers). After covariate adjustment, the estimated degree of difference between the CC and other institutions with respect to organ-space SSI was reduced (OR 1.38, 95% CI 1.08-1.77). The unique risk adjustment strategy may provide center-specific comprehensive analysis, especially for hospitals that perform inherently high-risk procedures. Higher surgical complexity may be the reason for increased SSI rates in the NSQIP at tertiary care centers.

Competing Risk Approach (CRA) for Estimation of Disability Adjusted Life Years (DALY's) for Female Breast Cancer in India.

Science.gov (United States)

Kunnavil, Radhika; Thirthahalli, Chethana; Nooyi, Shalini Chandrashekar; Shivaraj, N S; Murthy, Nandagudi Srinivasa

2015-10-01

Competing Risk Approach (CRA) has been used to compute burden of disease in terms of Disability Adjusted Life Years (DALYs) based on a life table for an initially disease-free cohort over time. To compute Years of Life Lost (YLL) due to premature mortality, Years of life lost due to Disability (YLD), DALYs and loss in expectation of life (LEL) using competing risk approach for female breast cancer patients for the year 2008 in India. The published data on breast cancer by age & sex, incidence & mortality for the year 2006-2008 relating to six population based cancer registries (PBCR) under Indian Council of Medical Research (ICMR), general mortality rates of 2007 in India, published in national health profile 2010; based on Sample Registration System (SRS) were utilized for computations. Three life tables were constructed by applying attrition of factors: (i) risk of death from all causes ('a'; where a is the general death rate); (ii) risk of incidence and that of death from causes other than breast cancer ('b-a+c'; where 'b' is the incidence of breast cancer and 'c' is the mortality of breast cancer); and (iii) risk of death from all other causes after excluding cancer mortality ('a-c'). Taking the differences in Total Person Years Lived (TPYL), YLD and YLL were derived along with LEL. CRA revealed that the DALYs were 40209 per 100,000 females in the life time of 0-70+ years with a LEL of 0.11 years per person. Percentage of YLL to DALYs was 28.20% in the cohort. The method of calculation of DALYs based on the CRA is simple and this will help to identify the burden of diseases using minimal information in terms of YLL, YLD, DALYs and LEL.

Engine control system having fuel-based adjustment

Science.gov (United States)

Willi, Martin L [Dunlap, IL; Fiveland, Scott B [Metamora, IL; Montgomery, David T [Edelstein, IL; Gong, Weidong [Dunlap, IL

2011-03-15

A control system for an engine having a cylinder is disclosed having an engine valve configured to affect a fluid flow of the cylinder, an actuator configured to move the engine valve, and an in-cylinder sensor configured to generate a signal indicative of a characteristic of fuel entering the cylinder. The control system also has a controller in communication with the actuator and the sensor. The controller is configured to determine the characteristic of the fuel based on the signal and selectively regulate the actuator to adjust a timing of the engine valve based on the characteristic of the fuel.

Coronary risk assessment by point-based vs. equation-based Framingham models: significant implications for clinical care.

Science.gov (United States)

Gordon, William J; Polansky, Jesse M; Boscardin, W John; Fung, Kathy Z; Steinman, Michael A

2010-11-01

US cholesterol guidelines use original and simplified versions of the Framingham model to estimate future coronary risk and thereby classify patients into risk groups with different treatment strategies. We sought to compare risk estimates and risk group classification generated by the original, complex Framingham model and the simplified, point-based version. We assessed 2,543 subjects age 20-79 from the 2001-2006 National Health and Nutrition Examination Surveys (NHANES) for whom Adult Treatment Panel III (ATP-III) guidelines recommend formal risk stratification. For each subject, we calculated the 10-year risk of major coronary events using the original and point-based Framingham models, and then compared differences in these risk estimates and whether these differences would place subjects into different ATP-III risk groups (20% risk). Using standard procedures, all analyses were adjusted for survey weights, clustering, and stratification to make our results nationally representative. Among 39 million eligible adults, the original Framingham model categorized 71% of subjects as having "moderate" risk (20%) risk. Estimates of coronary risk by the original and point-based models often differed substantially. The point-based system classified 15% of adults (5.7 million) into different risk groups than the original model, with 10% (3.9 million) misclassified into higher risk groups and 5% (1.8 million) into lower risk groups, for a net impact of classifying 2.1 million adults into higher risk groups. These risk group misclassifications would impact guideline-recommended drug treatment strategies for 25-46% of affected subjects. Patterns of misclassifications varied significantly by gender, age, and underlying CHD risk. Compared to the original Framingham model, the point-based version misclassifies millions of Americans into risk groups for which guidelines recommend different treatment strategies.

Direct risk standardisation: a new method for comparing casemix adjusted event rates using complex models.

Science.gov (United States)

Nicholl, Jon; Jacques, Richard M; Campbell, Michael J

2013-10-29

Comparison of outcomes between populations or centres may be confounded by any casemix differences and standardisation is carried out to avoid this. However, when the casemix adjustment models are large and complex, direct standardisation has been described as "practically impossible", and indirect standardisation may lead to unfair comparisons. We propose a new method of directly standardising for risk rather than standardising for casemix which overcomes these problems. Using a casemix model which is the same model as would be used in indirect standardisation, the risk in individuals is estimated. Risk categories are defined, and event rates in each category for each centre to be compared are calculated. A weighted sum of the risk category specific event rates is then calculated. We have illustrated this method using data on 6 million admissions to 146 hospitals in England in 2007/8 and an existing model with over 5000 casemix combinations, and a second dataset of 18,668 adult emergency admissions to 9 centres in the UK and overseas and a published model with over 20,000 casemix combinations and a continuous covariate. Substantial differences between conventional directly casemix standardised rates and rates from direct risk standardisation (DRS) were found. Results based on DRS were very similar to Standardised Mortality Ratios (SMRs) obtained from indirect standardisation, with similar standard errors. Direct risk standardisation using our proposed method is as straightforward as using conventional direct or indirect standardisation, always enables fair comparisons of performance to be made, can use continuous casemix covariates, and was found in our examples to have similar standard errors to the SMR. It should be preferred when there is a risk that conventional direct or indirect standardisation will lead to unfair comparisons.

39 CFR 3010.25 - Limitation on unused rate adjustment authority rate adjustments.

Science.gov (United States)

2010-07-01

... only be applied together with inflation-based limitation rate adjustments or when inflation-based... used in lieu of an inflation-based limitation rate adjustment. ... 39 Postal Service 1 2010-07-01 2010-07-01 false Limitation on unused rate adjustment authority...

Flexible Multi-Objective Transmission Expansion Planning with Adjustable Risk Aversion

Directory of Open Access Journals (Sweden)

Jing Qiu

2017-07-01

Full Text Available This paper presents a multi-objective transmission expansion planning (TEP framework. Rather than using the conventional deterministic reliability criterion, a risk component based on the probabilistic reliability criterion is incorporated into the TEP objectives. This risk component can capture the stochastic nature of power systems, such as load and wind power output variations, component availability, and incentive-based demand response (IBDR costs. Specifically, the formulation of risk value after risk aversion is explicitly given, and it aims to provide network planners with the flexibility to conduct risk analysis. Thus, a final expansion plan can be selected according to individual risk preferences. Moreover, the economic value of IBDR is modeled and integrated into the cost objective. In addition, a relatively new multi-objective evolutionary algorithm called the MOEA/D is introduced and employed to find Pareto optimal solutions, and tradeoffs between overall cost and risk are provided. The proposed approach is numerically verified on the Garver’s six-bus, IEEE 24-bus RTS and Polish 2383-bus systems. Case study results demonstrate that the proposed approach can effectively reduce cost and hedge risk in relation to increasing wind power integration.

FIRE SAFETY IN NUCLEAR POWER PLANTS: A RISK-INFORMED AND PERFORMANCE-BASED APPROACH

International Nuclear Information System (INIS)

AZARM, M.A.; TRAVIS, R.J.

1999-01-01

The consideration of risk in regulatory decision-making has long been a part of NRC's policy and practice. Initially, these considerations were qualitative and were based on risk insights. The early regulations relied on good practices, past insights, and accepted standards. As a result, most NRC regulations were prescriptive and were applied uniformly to all areas within the regulatory scope. Risk technology is changing regulations by prioritizing the areas within regulatory scope based on risk, thereby focusing on the risk-important areas. Performance technology, on the other hand, is changing the regulations by allowing requirements to be adjusted based on the specific performance expected and manifested, rather than a prior prescriptive requirement. Consistent with the objectives of risk-informed and performance-based regulatory requirements, BNL evaluated the feasibility of applying risk- and performance-technologies to modifying NRC's current regulations on fire protection for nuclear power plants. This feasibility study entailed several case studies (trial applications). This paper describes the results of two of them. Besides the case studies, the paper discusses an overall evaluation of methodologies for fire-risk analysis to support the risk-informed regulation. It identifies some current shortcomings and proposes some near-term solutions

Size-Adjustable Microdroplets Generation Based on Microinjection

Directory of Open Access Journals (Sweden)

Shibao Li

2017-03-01

Full Text Available Microinjection is a promising tool for microdroplet generation, while the microinjection for microdroplets generation still remains a challenging issue due to the Laplace pressure at the micropipette opening. Here, we apply a simple and robust substrate-contacting microinjection method to microdroplet generation, presenting a size-adjustable microdroplets generation method based on a critical injection (CI model. Firstly, the micropipette is adjusted to a preset injection pressure. Secondly, the micropipette is moved down to contact the substrate, then, the Laplace pressure in the droplet is no longer relevant and the liquid flows out in time. The liquid constantly flows out until the micropipette is lifted, ending the substrate-contacting situation, which results in the recovery of the Laplace pressure at the micropipette opening, and the liquid injection is terminated. We carry out five groups of experiments whereupon 1600 images are captured within each group and the microdroplet radius of each image is detected. Then we determine the relationship among microdroplet radius, radius at the micropipette opening, time, and pressure, and, two more experiments are conducted to verify the relationship. To verify the effectiveness of the substrate-contacting method and the relationship, we conducted two experiments with six desired microdroplet radii are set in each experiment, by adjusting the injection time with a given pressure, and adjusting the injection pressure with a given time. Then, six arrays of microdroplets are obtained in each experiment. The results of the experiments show that the standard errors of the microdroplet radii are less than 2% and the experimental errors fall in the range of ±5%. The average operating speed is 20 microdroplets/min and the minimum radius of the microdroplets is 25 μm. This method has a simple experimental setup that enables easy manipulation and lower cost.

Community-based stillbirth rates and risk factors in rural Sarlahi, Nepal.

Science.gov (United States)

Lee, Anne C; Mullany, Luke C; Tielsch, James M; Katz, Joanne; Khatry, Subarna K; Leclerq, Steven C; Adhikari, Ramesh K; Darmstadt, Gary L

2011-06-01

To assess stillbirth rates and antepartum risk factors in rural Nepal. Data were collected prospectively during a cluster-randomized, community-based trial in Sarlahi, Nepal, from 2002 to 2006. Multivariate regression modeling was performed to calculate adjusted relative risk estimates. Among 24531 births, the stillbirth rate was 35.4 per 1000 births (term stillbirth rate 21.2 per 1000 births). Most births occurred at home without a skilled birth attendant. The majority (69%) of intrapartum maternal deaths resulted in stillbirth. The adjusted RR (aRR) of stillbirth was 2.74 among nulliparas and 1.47 among mothers with history of a child death. Mothers above the age of 30 years carried a 1.59-fold higher risk for stillbirth than mothers who were 20-24 years old. The stillbirth risk was lower among households where the father had any formal education (aRR 0.70). Land ownership (aRR 0.85) and Pahadi ethnicity (aRR 0.67; reference: Madhesi ethnicity) were associated with significantly lower risks of stillbirth. Stillbirth rates were high in rural Nepal, with the majority of stillbirths occurring at full-term gestation. Nulliparity, history of prior child loss, maternal age above 30 years, Madhesi ethnicity, and socioeconomic disadvantage were significant risk factors for stillbirth. Clinicaltrials.govNCT00 109616. Copyright © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Balancing the risks and benefits of drinking water disinfection: disability adjusted life-years on the scale.

OpenAIRE

Havelaar, A H; De Hollander, A E; Teunis, P F; Evers, E G; Van Kranen, H J; Versteegh, J F; Van Koten, J E; Slob, W

2000-01-01

To evaluate the applicability of disability adjusted life-years (DALYs) as a measure to compare positive and negative health effects of drinking water disinfection, we conducted a case study involving a hypothetical drinking water supply from surface water. This drinking water supply is typical in The Netherlands. We compared the reduction of the risk of infection with Cryptosporidium parvum by ozonation of water to the concomitant increase in risk of renal cell cancer arising from the produc...

Lifestyle factors, medication use and risk for ischaemic heart disease hospitalisation: a longitudinal population-based study.

Directory of Open Access Journals (Sweden)

Anthony S Gunnell

Full Text Available BACKGROUND: Lifestyle factors have been implicated in ischaemic heart disease (IHD development however a limited number of longitudinal studies report results stratified by cardio-protective medication use. PURPOSE: This study investigated the influence of self-reported lifestyle factors on hospitalisation for IHD, stratified by blood pressure and/or lipid-lowering therapy. METHODS: A population-based cohort of 14,890 participants aged 45+ years and IHD-free was identified from the Western Australian Health and wellbeing Surveillance System (2004 to 2010 inclusive, and linked with hospital administrative data. Adjusted hazard ratios for future IHD-hospitalisation were estimated using Cox regression. RESULTS: Current smokers remained at higher risk for IHD-hospitalisation (adjusted HR=1.57; 95% CI: 1.22-2.03 after adjustment for medication use, as did those considered overweight (BMI=25-29 kg/m(2; adjusted HR=1.28; 95% CI: 1.04-1.57 or obese (BMI of ≥30 kg/m(2; adjusted HR=1.31; 95% CI: 1.03-1.66. Weekly leisure-time physical activity (LTPA of 150 minutes or more and daily intake of 3 or more fruit/vegetable servings reduced risk by 21% (95% CI: 0.64-0.97 and 26% (95% CI: 0.58-0.96 respectively. Benefits of LTPA appeared greatest in those on blood pressure lowering medication (adjusted HR=0.50; 95% CI: 0.31-0.82 [for LTPA=150 mins]. IHD risk in smokers was most pronounced in those taking neither medication (adjusted HR=2.00; 95% CI: 1.41-2.83. CONCLUSION: This study confirms the contribution of previously reported lifestyle factors towards IHD hospitalisation, even after adjustment for antihypertensive and lipid-lowering medication use. Medication stratified results suggest that IHD risks related to LTPA and smoking may differ according to medication use.

AUTOMATIC ADJUSTMENT OF WIDE-BASE GOOGLE STREET VIEW PANORAMAS

Directory of Open Access Journals (Sweden)

E. Boussias-Alexakis

2016-06-01

Full Text Available This paper focuses on the issue of sparse matching in cases of extremely wide-base panoramic images such as those acquired by Google Street View in narrow urban streets. In order to effectively use affine point operators for bundle adjustment, panoramas must be suitably rectified to simulate affinity. To this end, a custom piecewise planar projection (triangular prism projection is applied. On the assumption that the image baselines run parallel to the street façades, the estimated locations of the vanishing lines of the façade plane allow effectively removing projectivity and applying the ASIFT point operator on panorama pairs. Results from comparisons with multi-panorama adjustment, based on manually measured image points, and ground truth indicate that such an approach, if further elaborated, may well provide a realistic answer to the matching problem in the case of demanding panorama configurations.

Splenectomy and increased subsequent cancer risk: a nationwide population-based cohort study.

Science.gov (United States)

Sun, Li-Min; Chen, Hsuan-Ju; Jeng, Long-Bin; Li, Tsai-Chung; Wu, Shih-Chi; Kao, Chia-Hung

2015-08-01

Splenectomy has been suggested to have an impact on immunological function, and subsequent development of cancer has been recognized as a possible adverse effect of splenectomy. This study evaluated the possible association between splenectomy and malignancy in Taiwan. A cohort study consisted of including 2,603 patients with nontraumatic and 2,295 patients with traumatic splenectomy, and then randomly frequency matched with 4 participants without splenectomy. The Cox proportional hazard regression analysis was conducted to estimate the influence of splenectomy on cancer risk. Both nontraumatic and traumatic splenectomy had a significantly higher risk for overall cancer development (adjusted hazard ratios are 2.64 and 1.29 for nontraumatic and traumatic reasons, respectively). After adjusting for age, sex, and comorbidities, patients with splenectomy were associated with significantly higher risks for developing certain gastrointestinal tract cancers, other head and neck cancers, and hematological malignancies, and the phenomenon is more prominent in nontraumatic splenectomy group. This nationwide population-based study found that people with splenectomy have higher risks of developing overall cancer, as well as certain site-specific cancers, especially for patients with nontraumatic reasons. Copyright © 2015 Elsevier Inc. All rights reserved.

77 FR 52977 - Regulatory Capital Rules: Advanced Approaches Risk-Based Capital Rule; Market Risk Capital Rule

Science.gov (United States)

2012-08-30

...-weighted assets for residential mortgages, securitization exposures, and counterparty credit risk. The.... Risk-Weighted Assets--Proposed Modifications to the Advanced Approaches Rules A. Counterparty Credit... Margin Period of Risk 3. Changes to the Internal Models Methodology (IMM) 4. Credit Valuation Adjustments...

Lung cancer among coal miners, ore miners and quarrymen : smoking-adjusted risk estimates from the synergy pooled analysis of case-control studies

NARCIS (Netherlands)

Taeger, Dirk; Pesch, Beate; Kendzia, Benjamin; Behrens, Thomas; Jöckel, Karl-Heinz; Dahmann, Dirk; Siemiatycki, Jack; Kromhout, Hans; Vermeulen, Roel; Peters, Susan; Olsson, Ann; Brüske, Irene; Wichmann, Heinz-Erich; Stücker, Isabelle; Guida, Florence; Tardón, Adonina; Merletti, Franco; Mirabelli, Dario; Richiardi, Lorenzo; Pohlabeln, Hermann; Ahrens, Wolfgang; Landi, Maria Teresa; Caporaso, Neil; Pesatori, Angela Cecilia; Mukeriya, Anush; Szeszenia-Dabrowska, Neonila; Lissowska, Jolanta; Gustavsson, Per; Field, John; Marcus, Michael W; Fabianova, Eleonora; 't Mannetje, Andrea; Pearce, Neil; Rudnai, Peter; Bencko, Vladimir; Janout, Vladimir; Dumitru, Rodica Stanescu; Foretova, Lenka; Forastiere, Francesco; John McLaughlin, John McLaughlin; Paul Demers, Paul Demers; Bas Bueno-de-Mesquita, Bas Bueno-de-Mesquita; Joachim Schüz, Joachim Schüz; Kurt Straif, Kurt Straif; Brüning, Thomas

2015-01-01

OBJECTIVES: Working in mines and quarries has been associated with an elevated lung cancer risk but with inconsistent results for coal miners. This study aimed to estimate the smoking-adjusted lung cancer risk among coal miners and compare the risk pattern with lung cancer risks among ore miners and

FIRE SAFETY IN NUCLEAR POWER PLANTS: A RISK-INFORMED AND PERFORMANCE-BASED APPROACH

Energy Technology Data Exchange (ETDEWEB)

AZARM,M.A.; TRAVIS,R.J.

1999-11-14

The consideration of risk in regulatory decision-making has long been a part of NRC's policy and practice. Initially, these considerations were qualitative and were based on risk insights. The early regulations relied on good practices, past insights, and accepted standards. As a result, most NRC regulations were prescriptive and were applied uniformly to all areas within the regulatory scope. Risk technology is changing regulations by prioritizing the areas within regulatory scope based on risk, thereby focusing on the risk-important areas. Performance technology, on the other hand, is changing the regulations by allowing requirements to be adjusted based on the specific performance expected and manifested, rather than a prior prescriptive requirement. Consistent with the objectives of risk-informed and performance-based regulatory requirements, BNL evaluated the feasibility of applying risk- and performance-technologies to modifying NRC's current regulations on fire protection for nuclear power plants. This feasibility study entailed several case studies (trial applications). This paper describes the results of two of them. Besides the case studies, the paper discusses an overall evaluation of methodologies for fire-risk analysis to support the risk-informed regulation. It identifies some current shortcomings and proposes some near-term solutions.

Alcohol consumption, physical activity, and chronic disease risk factors: a population-based cross-sectional survey

Directory of Open Access Journals (Sweden)

Djoussé Luc

2006-05-01

Full Text Available Abstract Background Whether the association of alcohol consumption and cardiovascular disease is the product of confounding and the degree to which this concern applies to other behaviors are unclear. Methods Using the 2003 Behavioral Risk Factor Surveillance System, a population-based telephone survey of adults in the US, we compared chronic disease risk factors between 123,359 abstainers and 126,674 moderate drinkers, defined as intake of ≤ 2 drinks per day among men and ≤ 1 drink per day among women, using age- and sex- and multivariable-adjusted models. We also compared sedentary and active individuals, defined as moderate physical activity ≥ 30 minutes per day for ≥ 5 days per week, or vigorous activity for ≥ 20 minutes per day on ≥ 3 days. Results Chronic disease risk factors and features of unhealthy lifestyle were generally more prevalent among abstainers than drinkers in age- and sex-adjusted analyses, but these differences were generally attenuated or eliminated by additional adjustment for race and education. For low fruit and vegetable intake, divorced marital status, and absence of a personal physician, adjustment for race and education reversed initially positive age- and sex-adjusted associations with abstention. Comparison of sedentary and active individuals produced similar findings, with generally lower levels of risk factors among more physical active individuals. Conclusion The differences between abstainers and drinkers are attenuated after adjustment for limited sociodemographic features, and sedentary and active individuals share a similar pattern. Although observational studies of both factors may be susceptible to uncontrolled confounding, our results provide no evidence that moderate drinking is unique in this regard. Ultimately, randomized trials of all such lifestyle factors will be needed to answer these questions definitively.

Covariate-adjusted measures of discrimination for survival data

DEFF Research Database (Denmark)

White, Ian R; Rapsomaniki, Eleni; Frikke-Schmidt, Ruth

2015-01-01

by the study design (e.g. age and sex) influence discrimination and can make it difficult to compare model discrimination between studies. Although covariate adjustment is a standard procedure for quantifying disease-risk factor associations, there are no covariate adjustment methods for discrimination...... statistics in censored survival data. OBJECTIVE: To develop extensions of the C-index and D-index that describe the prognostic ability of a model adjusted for one or more covariate(s). METHOD: We define a covariate-adjusted C-index and D-index for censored survival data, propose several estimators......, and investigate their performance in simulation studies and in data from a large individual participant data meta-analysis, the Emerging Risk Factors Collaboration. RESULTS: The proposed methods perform well in simulations. In the Emerging Risk Factors Collaboration data, the age-adjusted C-index and D-index were...

A scenario-based procedure for seismic risk analysis

International Nuclear Information System (INIS)

Kluegel, J.-U.; Mualchin, L.; Panza, G.F.

2006-12-01

A new methodology for seismic risk analysis based on probabilistic interpretation of deterministic or scenario-based hazard analysis, in full compliance with the likelihood principle and therefore meeting the requirements of modern risk analysis, has been developed. The proposed methodology can easily be adjusted to deliver its output in a format required for safety analysts and civil engineers. The scenario-based approach allows the incorporation of all available information collected in a geological, seismotectonic and geotechnical database of the site of interest as well as advanced physical modelling techniques to provide a reliable and robust deterministic design basis for civil infrastructures. The robustness of this approach is of special importance for critical infrastructures. At the same time a scenario-based seismic hazard analysis allows the development of the required input for probabilistic risk assessment (PRA) as required by safety analysts and insurance companies. The scenario-based approach removes the ambiguity in the results of probabilistic seismic hazard analysis (PSHA) which relies on the projections of Gutenberg-Richter (G-R) equation. The problems in the validity of G-R projections, because of incomplete to total absence of data for making the projections, are still unresolved. Consequently, the information from G-R must not be used in decisions for design of critical structures or critical elements in a structure. The scenario-based methodology is strictly based on observable facts and data and complemented by physical modelling techniques, which can be submitted to a formalised validation process. By means of sensitivity analysis, knowledge gaps related to lack of data can be dealt with easily, due to the limited amount of scenarios to be investigated. The proposed seismic risk analysis can be used with confidence for planning, insurance and engineering applications. (author)

Adjustment Criterion and Algorithm in Adjustment Model with Uncertain

Directory of Open Access Journals (Sweden)

SONG Yingchun

2015-02-01

Full Text Available Uncertainty often exists in the process of obtaining measurement data, which affects the reliability of parameter estimation. This paper establishes a new adjustment model in which uncertainty is incorporated into the function model as a parameter. A new adjustment criterion and its iterative algorithm are given based on uncertainty propagation law in the residual error, in which the maximum possible uncertainty is minimized. This paper also analyzes, with examples, the different adjustment criteria and features of optimal solutions about the least-squares adjustment, the uncertainty adjustment and total least-squares adjustment. Existing error theory is extended with new observational data processing method about uncertainty.

A Risk-Based Interval Two-Stage Programming Model for Agricultural System Management under Uncertainty

Directory of Open Access Journals (Sweden)

Ye Xu

2016-01-01

Full Text Available Nonpoint source (NPS pollution caused by agricultural activities is main reason that water quality in watershed becomes worse, even leading to deterioration. Moreover, pollution control is accompanied with revenue’s fall for agricultural system. How to design and generate a cost-effective and environmentally friendly agricultural production pattern is a critical issue for local managers. In this study, a risk-based interval two-stage programming model (RBITSP was developed. Compared to general ITSP model, significant contribution made by RBITSP model was that it emphasized importance of financial risk under various probabilistic levels, rather than only being concentrated on expected economic benefit, where risk is expressed as the probability of not meeting target profit under each individual scenario realization. This way effectively avoided solutions’ inaccuracy caused by traditional expected objective function and generated a variety of solutions through adjusting weight coefficients, which reflected trade-off between system economy and reliability. A case study of agricultural production management with the Tai Lake watershed was used to demonstrate superiority of proposed model. Obtained results could be a base for designing land-structure adjustment patterns and farmland retirement schemes and realizing balance of system benefit, system-failure risk, and water-body protection.

Disease-Specific Trends of Comorbidity Coding and Implications for Risk Adjustment in Hospital Administrative Data.

Science.gov (United States)

Nimptsch, Ulrike

2016-06-01

To investigate changes in comorbidity coding after the introduction of diagnosis related groups (DRGs) based prospective payment and whether trends differ regarding specific comorbidities. Nationwide administrative data (DRG statistics) from German acute care hospitals from 2005 to 2012. Observational study to analyze trends in comorbidity coding in patients hospitalized for common primary diseases and the effects on comorbidity-related risk of in-hospital death. Comorbidity coding was operationalized by Elixhauser diagnosis groups. The analyses focused on adult patients hospitalized for the primary diseases of heart failure, stroke, and pneumonia, as well as hip fracture. When focusing the total frequency of diagnosis groups per record, an increase in depth of coding was observed. Between-hospital variations in depth of coding were present throughout the observation period. Specific comorbidity increases were observed in 15 of the 31 diagnosis groups, and decreases in comorbidity were observed for 11 groups. In patients hospitalized for heart failure, shifts of comorbidity-related risk of in-hospital death occurred in nine diagnosis groups, in which eight groups were directed toward the null. Comorbidity-adjusted outcomes in longitudinal administrative data analyses may be biased by nonconstant risk over time, changes in completeness of coding, and between-hospital variations in coding. Accounting for such issues is important when the respective observation period coincides with changes in the reimbursement system or other conditions that are likely to alter clinical coding practice. © Health Research and Educational Trust.

Behavioral Risk Factor Surveillance System (BRFSS) Age-Adjusted Prevalence Data (2011 to present)

Data.gov (United States)

U.S. Department of Health & Human Services — 2011 to present. BRFSS combined land line and cell phone age-adjusted prevalence data. The BRFSS is a continuous, state-based surveillance system that collects...

Mandatory pooling as a supplement to risk-adjusted capitation payments in a competitive health insurance market.

Science.gov (United States)

Van Barneveld, E M; Lamers, L M; van Vliet, R C; van de Ven, W P

1998-07-01

Risk-adjusted capitation payments (RACPs) to competing health insurers are an essential element of market-oriented health care reforms in many countries. RACPs based on demographic variables only are insufficient, because they leave ample room for cream skimming. However, the implementation of improved RACPs does not appear to be straightforward. A solution might be to supplement imperfect RACPs with a form of mandatory pooling that reduces the incentives for cream skimming. In a previous paper it was concluded that high-risk pooling (HRP), is a promising supplement to RACPs. The purpose of this paper is to compare HRP with two other main variants of mandatory pooling. These variants are called excess-of-loss (EOL) and proportional pooling (PP). Each variant includes ex post compensations to insurers for some members which depend to various degrees on actually incurred costs. Therefore, these pooling variants reduce the incentives for cream skimming which are inherent in imperfect RACPs, but they also reduce the incentives for efficiency and cost containment. As a rough measure of the latter incentives we use the percentage of total costs for which an insurer is at risk. This paper analyzes which of the three main pooling variants yields the greatest reduction of incentives for cream skimming given such a percentage. The results show that HRP is the most effective of the three pooling variants.

Does perceived stress increase the risk of atrial fibrillation? A population-based cohort study in Denmark

DEFF Research Database (Denmark)

Graff, Simon; Prior, Anders; Fenger-Grøn, Morten

2017-01-01

Background Psychological stress is associated with increased risk of acute cardiovascular diseases, as myocardial infarction. We recently found a higher risk of atrial fibrillation following an acute stressful life event, but it remains unknown whether this also applies to common and less acute....... Conclusions This large population-based cohort study did not reveal a higher risk of atrial fibrillation among persons with a high degree of perceived stress after adjustment for participants' baseline characteristics....

Psychosocial stress as a risk factor for sepsis: a population-based cohort study.

Science.gov (United States)

Ojard, Connor; Donnelly, John P; Safford, Monika M; Griffin, Russell; Wang, Henry E

2015-01-01

To characterize the relationship between stress and future risk of sepsis. We also evaluated the role of depression in this relationship. We used population-based data on 30,183 participants in the Reasons for Geographic and Racial Differences in Stroke cohort, characterizing stress using the Perceived Stress Scale (PSS) and depressive symptoms using the Center for Epidemiologic Studies Depression Scale (CES-D). We identified incident sepsis events as hospitalizations for a serious infection with the presence of at least two systemic inflammatory response syndrome criteria. We assessed associations between PSS and incidence of sepsis for 1 and 10 years of follow-up, adjusting for demographics and chronic medical conditions and assessing the role of health behaviors and CES-D in these relationships. In 2003 to 2012, 1500 participants experienced an episode of sepsis. Mean PSS and CES-D scores were 3.2 (2.9) and 1.2 (2.1). PSS was associated with increased 1-year adjusted incidence of sepsis (hazard ratio [HR] = 1.21 per PSS standard deviation, 95% confidence interval = 1.06-1.38); multivariable adjustment for health behaviors and CES-D did not change this association (1.20, 1.03-1.39). PSS was also associated with increased 10-year adjusted incidence of sepsis (HR = 1.07 per PSS standard deviation; 95% confidence interval = 1.02-1.13). Multivariable adjustment showed that health behaviors did not affect this long-term association, whereas the addition of CES-D reduced the association between PSS and sepsis during 10-year follow-up (HR = 1.04, 0.98-1.11). Increased stress was associated with higher 1-year adjusted incidence of sepsis, even after accounting for depressive symptoms. The association between stress and 10-year adjusted incidence of sepsis was also significant, but this association was reduced when adjusting for depressive symptoms. Reduction of stress may limit short-term sepsis risk.

Contact angle adjustment in equation-of-state-based pseudopotential model.

Science.gov (United States)

Hu, Anjie; Li, Longjian; Uddin, Rizwan; Liu, Dong

2016-05-01

The single component pseudopotential lattice Boltzmann model has been widely applied in multiphase simulation due to its simplicity and stability. In many studies, it has been claimed that this model can be stable for density ratios larger than 1000. However, the application of the model is still limited to small density ratios when the contact angle is considered. The reason is that the original contact angle adjustment method influences the stability of the model. Moreover, simulation results in the present work show that, by applying the original contact angle adjustment method, the density distribution near the wall is artificially changed, and the contact angle is dependent on the surface tension. Hence, it is very inconvenient to apply this method with a fixed contact angle, and the accuracy of the model cannot be guaranteed. To solve these problems, a contact angle adjustment method based on the geometry analysis is proposed and numerically compared with the original method. Simulation results show that, with our contact angle adjustment method, the stability of the model is highly improved when the density ratio is relatively large, and it is independent of the surface tension.

Capital adjustment cost and bias in income based dynamic panel models with fixed effects

OpenAIRE

Yoseph Yilma Getachew; Keshab Bhattarai; Parantap Basu

2012-01-01

The fixed effects (FE) estimator of "conditional convergence" in income based dynamic panel models could be biased downward when capital adjustment cost is present. Such a capital adjustment cost means a rising marginal cost of investment which could slow down the convergence. The standard FE regression fails to take into account of this capital adjustment cost and thus it could overestimate the rate of convergence. Using a Ramsey model with long-run adjustment cost of capital, we characteriz...

NWP-Based Adjustment of IMERG Precipitation for Flood-Inducing Complex Terrain Storms: Evaluation over CONUS

Directory of Open Access Journals (Sweden)

Xinxuan Zhang

2018-04-01

Full Text Available This paper evaluates the use of precipitation forecasts from a numerical weather prediction (NWP model for near-real-time satellite precipitation adjustment based on 81 flood-inducing heavy precipitation events in seven mountainous regions over the conterminous United States. The study is facilitated by the National Center for Atmospheric Research (NCAR real-time ensemble forecasts (called model, the Integrated Multi-satellitE Retrievals for GPM (IMERG near-real-time precipitation product (called raw IMERG and the Stage IV multi-radar/multi-sensor precipitation product (called Stage IV used as a reference. We evaluated four precipitation datasets (the model forecasts, raw IMERG, gauge-adjusted IMERG and model-adjusted IMERG through comparisons against Stage IV at six-hourly and event length scales. The raw IMERG product consistently underestimated heavy precipitation in all study regions, while the domain average rainfall magnitudes exhibited by the model were fairly accurate. The model exhibited error in the locations of intense precipitation over inland regions, however, while the IMERG product generally showed correct spatial precipitation patterns. Overall, the model-adjusted IMERG product performed best over inland regions by taking advantage of the more accurate rainfall magnitude from NWP and the spatial distribution from IMERG. In coastal regions, although model-based adjustment effectively improved the performance of the raw IMERG product, the model forecast performed even better. The IMERG product could benefit from gauge-based adjustment, as well, but the improvement from model-based adjustment was consistently more significant.

Auditing Neonatal Intensive Care: Is PREM a Good Alternative to CRIB for Mortality Risk Adjustment in Premature Infants?

Science.gov (United States)

Guenther, Kilian; Vach, Werner; Kachel, Walter; Bruder, Ingo; Hentschel, Roland

2015-01-01

Comparing outcomes at different neonatal intensive care units (NICUs) requires adjustment for intrinsic risk. The Clinical Risk Index for Babies (CRIB) is a widely used risk model, but it has been criticized for being affected by therapeutic decisions. The Prematurity Risk Evaluation Measure (PREM) is not supposed to be prone to treatment bias, but has not yet been validated. We aimed to validate the PREM, compare its accuracy to that of the original and modified versions of the CRIB and CRIB-II, and examine the congruence of risk categorization. Very-low-birth-weight (VLBW) infants with a gestational age (GA) auditing. It could be useful to combine scores. © 2015 S. Karger AG, Basel.

Physical and psychosocial risk factors for lateral epicondylitis: a population based case-referent study

DEFF Research Database (Denmark)

Haahr, J. P.; Andersen, JH

2003-01-01

AIMS: To assess the importance of physical and psychosocial risk factors for lateral epicondylitis (tennis elbow). METHODS: Case-referent study of 267 new cases of tennis elbow and 388 referents from the background population enrolled from general practices in Ringkjoebing County, Denmark. RESULTS......: Manual job tasks were associated with tennis elbow (odds ratio (OR) 3.1, 95% confidence interval (CI) 1.9 to 5.1). The self reported physical risk factors "posture" and "forceful work" were related to tennis elbow. Among women, work involving performing repeated movements of the arms was related...... index was established based on posture, repetition, and force. The adjusted ORs for tennis elbow at low, medium, and high strain were 1.4 (CI 0.8 to 2.7), 2.0 (CI 1.1 to 3.7), and 4.4 (CI 2.3 to 8.7). Low social support at work, adjusted for physical strain, was a risk factor among women (OR 2.4, CI 1...

Risk-based safety indicators

International Nuclear Information System (INIS)

Szikszai, T.

1997-01-01

The presentation discusses the following issues: The objectives of the risk-based indicator programme. The characteristics of the risk-based indicators. The objectives of risk-based safety indicators - in monitoring safety; in PSA applications. What indicators? How to produce the risk based indicators? PSA requirements

Tourette syndrome increases risk of bone fractures: a population-based cohort study.

Science.gov (United States)

Lu, Yuan-Yuan; Wang, Ming-Yu; Wei, I-Hua; Lin, Che-Chen; Huang, Chih-Chia

2017-05-01

This study assesses the risk of fractures among children with Tourette syndrome (TS), and identifies the effects of comorbidities and antipsychotics. We randomly sampled the claims data of 1 million enrollees in the National Health Insurance program of Taiwan, and identified 1258 children with TS diagnosed between 2000 and 2010. Additionally, 12,580 children without TS who were frequency matched for sex, age, residential area, parental occupation, and index year were identified for comparison. The children's cases were followed until December 31, 2010, or censored to ascertain incident fractures cases and associations with comorbidities of attention-deficit/hyperactivity disorder (ADHD) or obsessive-compulsive disorder (OCD) and treatments with antipsychotics, antidepressants, or clonidine. The TS cohort had a 1.27-fold higher incidence of fractures than did the comparison cohort (190.37 vs. 149.94 per 10,000 person-years), with an adjusted hazard ratio (HR) of 1.28 [95% confidence interval (CI) 1.06-1.55] based on multivariable Cox regression analysis. This increased risk of fractures was apparent for fractures of the skull, neck, and spine. Comorbid ADHD and OCD did not result in an additional risk of fractures. The children without both ADHD and OCD were also at a higher risk of fractures, indicating that TS alone increases the risk of fractures. The children taking antipsychotics had a reduced risk of fractures, and the adjusted HR decreased to 1.17 (95% CI 0.90-1.52). Children with TS have an increased risk of fractures. ADHD and OCD do not increase the risk further.

Cost Risk Analysis Based on Perception of the Engineering Process

Science.gov (United States)

Dean, Edwin B.; Wood, Darrell A.; Moore, Arlene A.; Bogart, Edward H.

1986-01-01

In most cost estimating applications at the NASA Langley Research Center (LaRC), it is desirable to present predicted cost as a range of possible costs rather than a single predicted cost. A cost risk analysis generates a range of cost for a project and assigns a probability level to each cost value in the range. Constructing a cost risk curve requires a good estimate of the expected cost of a project. It must also include a good estimate of expected variance of the cost. Many cost risk analyses are based upon an expert's knowledge of the cost of similar projects in the past. In a common scenario, a manager or engineer, asked to estimate the cost of a project in his area of expertise, will gather historical cost data from a similar completed project. The cost of the completed project is adjusted using the perceived technical and economic differences between the two projects. This allows errors from at least three sources. The historical cost data may be in error by some unknown amount. The managers' evaluation of the new project and its similarity to the old project may be in error. The factors used to adjust the cost of the old project may not correctly reflect the differences. Some risk analyses are based on untested hypotheses about the form of the statistical distribution that underlies the distribution of possible cost. The usual problem is not just to come up with an estimate of the cost of a project, but to predict the range of values into which the cost may fall and with what level of confidence the prediction is made. Risk analysis techniques that assume the shape of the underlying cost distribution and derive the risk curve from a single estimate plus and minus some amount usually fail to take into account the actual magnitude of the uncertainty in cost due to technical factors in the project itself. This paper addresses a cost risk method that is based on parametric estimates of the technical factors involved in the project being costed. The engineering

Willingness to pay for a quality-adjusted life year: an evaluation of attitudes towards risk and preferences.

Science.gov (United States)

Martín-Fernández, Jesus; Polentinos-Castro, Elena; del Cura-González, Ma Isabel; Ariza-Cardiel, Gloria; Abraira, Victor; Gil-LaCruz, Ana Isabel; García-Pérez, Sonia

2014-07-03

This paper examines the Willingness to Pay (WTP) for a quality-adjusted life year (QALY) expressed by people who attended the healthcare system as well as the association of attitude towards risk and other personal characteristics with their response. Health-state preferences, measured by EuroQol (EQ-5D-3L), were combined with WTP for recovering a perfect health state. WTP was assessed using close-ended, iterative bidding, contingent valuation method. Data on demographic and socioeconomic characteristics, as well as usage of health services by the subjects were collected. The attitude towards risk was evaluated by collecting risky behaviors data, by the subject's self-evaluation, and through lottery games. Six hundred and sixty two subjects participated and 449 stated a utility inferior to 1. WTP/QALY ratios varied significantly when payments with personal money (mean €10,119; median €673) or through taxes (mean €28,187; median €915) were suggested. Family income, area income, higher education level, greater use of healthcare services, and the number of co-inhabitants were associated with greater WTP/QALY ratios. Age and female gender were associated with lower WTP/QALY ratios. Risk inclination was independently associated with a greater WTP/QALY when "out of pocket" payments were suggested. Clear discrepancies were demonstrated between linearity and neutrality towards risk assumptions and experimental results. WTP/QALY ratios vary noticeably based on demographic and socioeconomic characteristics of the subject, but also on their attitude towards risk. Knowing the expression of preferences by patients from this outcome measurement can be of interest for health service planning.

Risk adjusted surgical audit in gynaecological oncology: P-POSSUM does not predict outcome.

Science.gov (United States)

Das, N; Talaat, A S; Naik, R; Lopes, A D; Godfrey, K A; Hatem, M H; Edmondson, R J

2006-12-01

To assess the Physiological and Operative Severity Score for the enumeration of mortality and morbidity (POSSUM) and its validity for use in gynaecological oncology surgery. All patients undergoing gynaecological oncology surgery at the Northern Gynaecological Oncology Centre (NGOC) Gateshead, UK over a period of 12months (2002-2003) were assessed prospectively. Mortality and morbidity predictions using the Portsmouth modification of the POSSUM algorithm (P-POSSUM) were compared to the actual outcomes. Performance of the model was also evaluated using the Hosmer and Lemeshow Chi square statistic (testing the goodness of fit). During this period 468 patients were assessed. The P-POSSUM appeared to over predict mortality rates for our patients. It predicted a 7% mortality rate for our patients compared to an observed rate of 2% (35 predicted deaths in comparison to 10 observed deaths), a difference that was statistically significant (H&L chi(2)=542.9, d.f. 8, prisk of mortality for gynaecological oncology patients undergoing surgery. The P-POSSUM algorithm will require further adjustments prior to adoption for gynaecological cancer surgery as a risk adjusted surgical audit tool.

Risk based modelling

International Nuclear Information System (INIS)

Chapman, O.J.V.; Baker, A.E.

1993-01-01

Risk based analysis is a tool becoming available to both engineers and managers to aid decision making concerning plant matters such as In-Service Inspection (ISI). In order to develop a risk based method, some form of Structural Reliability Risk Assessment (SRRA) needs to be performed to provide a probability of failure ranking for all sites around the plant. A Probabilistic Risk Assessment (PRA) can then be carried out to combine these possible events with the capability of plant safety systems and procedures, to establish the consequences of failure for the sites. In this way the probability of failures are converted into a risk based ranking which can be used to assist the process of deciding which sites should be included in an ISI programme. This paper reviews the technique and typical results of a risk based ranking assessment carried out for nuclear power plant pipework. (author)

Can parents adjust to the idea that their child is at risk for a sudden death?: Psychological impact of risk for Long QT Syndrome

NARCIS (Netherlands)

Hendriks, Karin S. W. H.; Grosfeld, F. J. M.; van Tintelen, J. P.; van Langen, I. M.; Wilde, A. A. M.; van den Bout, J.; ten Kroode, H. F. J.

2005-01-01

Can a parent adjust to the idea that its child is at risk for a sudden death? This question is raised by a diagnostic procedure in which children were tested for an inherited Long QT Syndrome (LQTS). This potentially life-threatening but treatable cardiac arrhythmia syndrome may cause sudden death,

Can parents adjust to the idea that their child is at risk for a sudden death? : Psychological impact of risk for Long QT Syndrome

NARCIS (Netherlands)

Hendriks, Karin S. W. H.; Grosfeld, FJM; van Tintelen, JP; van Langen, IM; Wilde, AAM; van den Bout, J; ten Kroode, HFJ

2005-01-01

Can a parent adjust to the idea that its child is at risk for a sudden death? This question is raised by a diagnostic procedure in which children were tested for an inherited Long QT Syndrome (LQTS). This potentially life-threatening but treatable cardiac arrhythmia syndrome may cause sudden death,

Spine-hip T-score difference predicts major osteoporotic fracture risk independent of FRAX(®): a population-based report from CAMOS.

Science.gov (United States)

Leslie, William D; Kovacs, Christopher S; Olszynski, Wojciech P; Towheed, Tanveer; Kaiser, Stephanie M; Prior, Jerilynn C; Josse, Robert G; Jamal, Sophie A; Kreiger, Nancy; Goltzman, David

2011-01-01

The WHO fracture risk assessment tool (FRAX(®)) estimates an individual's 10-yr major osteoporotic and hip fracture probabilities. When bone mineral density (BMD) is included in the FRAX calculation, only the femoral neck measurement can be used. Recently, a procedure was reported for adjusting major osteoporotic fracture probability from FRAX with femoral neck BMD based on the difference (offset) between the lumbar spine and the femoral neck T-score values. The objective of the current analysis was to independently evaluate this algorithm in a population-based cohort of 4575 women and 1813 men aged 50 yr and older from the Canadian Multicentre Osteoporosis Study. For women and men combined, there was a 15% (95% confidence interval 7-24%) increase in major osteoporotic fracture risk for each offset T-score after adjusting for FRAX probability calculated with femoral neck BMD. The effect was stronger in women than men, but a significant sex interaction was not detected. Among the full cohort, 5.5% had their risk category reclassified after using the offset adjustment. Sex- and age-dependent offsets (equivalent to an offset based on Z-scores) showed improved risk classification among individuals designated to be at moderate risk with the conventional FRAX probability measurement. In summary, the T-score difference between the lumbar spine and femoral neck is an independent risk factor for major osteoporotic fractures that is independent of the FRAX probability calculated with femoral neck BMD. Copyright © 2011 The International Society for Clinical Densitometry. Published by Elsevier Inc. All rights reserved.

Premorbid adjustment in individuals at ultra-high risk for developing psychosis

DEFF Research Database (Denmark)

Dannevang, Anders; Randers, Lasse; Gondan, Matthias

2017-01-01

between childhood and early adolescence. The UHR individuals had more premorbid adjustment difficulties on both the social and academic scale, and on the individual PAS scales. Conclusion: From childhood UHR individuals have lower levels of social and academic premorbid adjustment compared to healthy...... and academic scales were computed. Results: Compared to the healthy controls the UHR individuals’ social and academic premorbid adjustment declined across age periods. Social premorbid adjustment declined particularly between late adolescence and adulthood. Academic premorbid adjustment declined particularly...

Endogenous and Antipsychotic-Related Risks for Diabetes Mellitus in Young People With Schizophrenia: A Danish Population-Based Cohort Study.

Science.gov (United States)

Rajkumar, Anto P; Horsdal, Henriette Thisted; Wimberley, Theresa; Cohen, Dan; Mors, Ole; Børglum, Anders D; Gasse, Christiane

2017-07-01

Diabetes mellitus contributes to excessive cardiovascular deaths and reduced life expectancy in schizophrenia. This population-based cohort study investigated the endogenous risk for diabetes in antipsychotic-naive schizophrenia and evaluated the risks added by starting antipsychotic treatment in people with schizophrenia. The study followed all people born in Denmark on or after Jan. 1, 1977, until Jan. 1, 2013 (N=2,736,510). The Danish Psychiatric Central Research Register ascertained schizophrenia diagnoses. The Danish National Prescription Registry provided data on prescriptions of antipsychotics. Diabetes was ascertained from the Danish National Patient Register and Danish National Prescription Registry. The authors estimated the endogenous and antipsychotic-related risks for diabetes by using Cox proportional hazards regression models, while accounting for potential confounders. Of the cohort members, 14,118 (0.52%) developed diabetes, and 8,945 (0.33%) developed schizophrenia during follow-up (49,582,279 person-years). The adjusted hazard ratio for diabetes was 3.07 (95% confidence interval [CI], 1.71-5.41) in antipsychotic-naive schizophrenia compared with the general population. The risk for diabetes after starting antipsychotic treatment was significantly higher (adjusted hazard ratio, 3.64; 95% CI, 1.95-6.82) than the risk in antipsychotic-naive schizophrenia, after adjustment for family history of diabetes and other potential confounders. First-line treatment with either first-generation antipsychotics (adjusted hazard ratio, 3.06; 95% CI, 1.32-7.05) or second-generation antipsychotics (adjusted hazard ratio, 3.44; 95% CI, 1.73-6.83) increased the risk for diabetes without a statistically significant difference. Appropriate sensitivity analyses limited to type 2 diabetes corroborated these results. Schizophrenia confers a high endogenous risk for diabetes, and the risk is further increased by both first-generation and second-generation antipsychotics

Improving Risk Adjustment for Mortality After Pediatric Cardiac Surgery: The UK PRAiS2 Model.

Science.gov (United States)

Rogers, Libby; Brown, Katherine L; Franklin, Rodney C; Ambler, Gareth; Anderson, David; Barron, David J; Crowe, Sonya; English, Kate; Stickley, John; Tibby, Shane; Tsang, Victor; Utley, Martin; Witter, Thomas; Pagel, Christina

2017-07-01

Partial Risk Adjustment in Surgery (PRAiS), a risk model for 30-day mortality after children's heart surgery, has been used by the UK National Congenital Heart Disease Audit to report expected risk-adjusted survival since 2013. This study aimed to improve the model by incorporating additional comorbidity and diagnostic information. The model development dataset was all procedures performed between 2009 and 2014 in all UK and Ireland congenital cardiac centers. The outcome measure was death within each 30-day surgical episode. Model development followed an iterative process of clinical discussion and development and assessment of models using logistic regression under 25 × 5 cross-validation. Performance was measured using Akaike information criterion, the area under the receiver-operating characteristic curve (AUC), and calibration. The final model was assessed in an external 2014 to 2015 validation dataset. The development dataset comprised 21,838 30-day surgical episodes, with 539 deaths (mortality, 2.5%). The validation dataset comprised 4,207 episodes, with 97 deaths (mortality, 2.3%). The updated risk model included 15 procedural, 11 diagnostic, and 4 comorbidity groupings, and nonlinear functions of age and weight. Performance under cross-validation was: median AUC of 0.83 (range, 0.82 to 0.83), median calibration slope and intercept of 0.92 (range, 0.64 to 1.25) and -0.23 (range, -1.08 to 0.85) respectively. In the validation dataset, the AUC was 0.86 (95% confidence interval [CI], 0.82 to 0.89), and the calibration slope and intercept were 1.01 (95% CI, 0.83 to 1.18) and 0.11 (95% CI, -0.45 to 0.67), respectively, showing excellent performance. A more sophisticated PRAiS2 risk model for UK use was developed with additional comorbidity and diagnostic information, alongside age and weight as nonlinear variables. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Development of the adjusted nuclear cross-section library based on JENDL-3.2 for large FBR

International Nuclear Information System (INIS)

Yokoyama, Kenji; Ishikawa, Makoto; Numata, Kazuyuki

1999-04-01

JNC (and PNC) had developed the adjusted nuclear cross-section library in which the results of the JUPITER experiments were reflected. Using this adjusted library, the distinct improvement of the accuracy in nuclear design of FBR cores had been achieved. As a recent research, JNC develops a database of other integral data in addition to the JUPITER experiments, aiming at further improvement for accuracy and reliability. In 1991, the adjusted library based on JENDL-2, JFS-3-J2 (ADJ91R), was developed, and it has been used on the design research for FBR. As an evaluated nuclear library, however, JENDL-3.2 is recently used. Therefore, the authors developed an adjusted library based on JENDL-3.2 which is called JFS-3-J3.2(ADJ98). It is known that the adjusted library based on JENDL-2 overestimated the sodium void reactivity worth by 10-20%. It is expected that the adjusted library based on JENDL-3.2 solve the problem. The adjusted library JFS-3-J3.2(ADJ98) was produced with the same method as the adjusted library JFS-3-J2(ADJ91R) and used more integral parameters of JUPITER experiments than the adjusted library JFS-3-J2(ADJ91R). This report also describes the design accuracy estimation on a 600 MWe class FBR with the adjusted library JFS-3-J3.2(ADJ98). Its main nuclear design parameters (multiplication factor, burn-up reactivity loss, breeding ratio, etc.) except the sodium void reactivity worth which are calculated with the adjusted library JFS-3-J3.2(ADJ98) are almost the same as those predicted with JFS-3-J2(ADJ91R). As for the sodium void reactivity, the adjusted library JFS-3-J3.2(ADJ98) estimates about 4% smaller than the JFS-3-J2(ADJ91R) because of the change of the basic nuclear library from JENDL-2 to JENDL-3.2. (author)

Risks of road injuries in patients with bipolar disorder and associations with drug treatments: A population-based matched cohort study.

Science.gov (United States)

Chen, Vincent Chin-Hung; Yang, Yao-Hsu; Lee, Chuan-Pin; Wong, Jennifer; Ponton, Lynn; Lee, Yena; McIntyre, Roger S; Huang, Kuo-You; Wu, Shu-I

2018-01-15

Using a nation-wide, population-based dataset, we aimed to investigate the risk of road injury among individuals with bipolar disorder (BD) compared to individuals without BD. In addition, we investigated the putative moderating effects of prescription for lithium, anticonvulsants, antidepressants, and/or first- or second-generation antipsychotic agents on the association between BD and risk of road injury. As part of an16-year longitudinal cohort study, we compared the risk of road injuries among study subjects aged 16 and above with a diagnosis of BD, with ten age- and sex-matched sample of individuals without BD. Individuals were compared on measures of incidence on road injuries using medical claims data based on the ICD-9-CM codes: E800~807, E810~817, E819~830, E840~848. Time dependent Cox regression models were used to adjust for time-varying covariates such as age, and medication uses. Hazard ratios before and after adjusting for age, sex, other comorbidities, and drug use were calculated. 3953 people with BD were matched with 39,530 controls from general population. Adjusted hazard ratios revealed a 1.66-fold (95% CI 1.40-1.97) increase in risk of road injuries among bipolar subjects when compared to controls. Female gender, older age (i.e. over 80), residence in areas of highest levels of urbanization, and use of antidepressants were associated with a lower risk of road injuries. In this large, national, population-based cohort, BD was associated with an elevated risk of road injuries. However, prescriptions of antidepressants might help mitigate the foregoing risk. Copyright © 2017 Elsevier B.V. All rights reserved.

Risk of Suicide Attempt in Poststroke Patients: A Population-Based Cohort Study.

Science.gov (United States)

Harnod, Tomor; Lin, Cheng-Li; Kao, Chia-Hung

2018-01-10

This nationwide population-based cohort study evaluated the risk of and risk factors for suicide attempt in poststroke patients in Taiwan. The poststroke and nonstroke cohorts consisted of 713 690 patients and 1 426 009 controls, respectively. Adults (aged >18 years) who received new stroke diagnoses according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM ; codes 430-438) between 2000 and 2011 were included in the poststroke cohort. We calculated the adjusted hazard ratio for suicide attempt ( ICD-9-CM codes E950-E959) after adjustment for age, sex, monthly income, urbanization level, occupation category, and various comorbidities. Kaplan-Meier analysis was used to measure the cumulative incidence of suicide attempt, and the Fine and Gray method was used as a competing event when estimating death subhazard ratios and 95% confidence intervals between groups. The cumulative incidence of suicide attempt was higher in the poststroke cohort, and the adjusted hazard ratio of suicide attempt was 2.20 (95% confidence interval, 2.04-2.37) compared with that of the controls. The leading risk factors for poststroke suicide attempt were earning low monthly income (US dollars), living in less urbanized regions, doing manual labor, and having a stroke before age 50 years. The attempted suicide risk did not differ significantly between male and female patients in this study. These results convey crucial information to clinicians and governments for preventing suicide attempt in poststroke patients in Taiwan and other Asian countries. © 2018 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

The predictive value of an adjusted COPD assessment test score on the risk of respiratory-related hospitalizations in severe COPD patients.

Science.gov (United States)

Barton, Christopher A; Bassett, Katherine L; Buckman, Julie; Effing, Tanja W; Frith, Peter A; van der Palen, Job; Sloots, Joanne M

2017-02-01

We evaluated whether a chronic obstructive pulmonary disease (COPD) assessment test (CAT) with adjusted weights for the CAT items could better predict future respiratory-related hospitalizations than the original CAT. Two focus groups (respiratory nurses and physicians) generated two adjusted CAT algorithms. Two multivariate logistic regression models for infrequent (≤1/year) versus frequent (>1/year) future respiratory-related hospitalizations were defined: one with the adjusted CAT score that correlated best with future hospitalizations and one with the original CAT score. Patient characteristics related to future hospitalizations ( p ≤ 0.2) were also entered. Eighty-two COPD patients were included. The CAT algorithm derived from the nurse focus group was a borderline significant predictor of hospitalization risk (odds ratio (OR): 1.07; 95% confidence interval (CI): 1.00-1.14; p = 0.050) in a model that also included hospitalization frequency in the previous year (OR: 3.98; 95% CI: 1.30-12.16; p = 0.016) and anticholinergic risk score (OR: 3.08; 95% CI: 0.87-10.89; p = 0.081). Presence of ischemic heart disease and/or heart failure appeared 'protective' (OR: 0.17; 95% CI: 0.05-0.62; p = 0.007). The original CAT score was not significantly associated with hospitalization risk. In conclusion, as a predictor of respiratory-related hospitalizations, an adjusted CAT score was marginally significant (although the original CAT score was not). 'Previous respiratory-related hospitalizations' was the strongest factor in this equation.

Smoking and subsequent risk of leukemia in Japan: The Japan Public Health Center-based Prospective Study

Directory of Open Access Journals (Sweden)

Tomotaka Ugai

2017-07-01

Full Text Available Background: Cigarette smoking has been reported to be associated with an increased risk of leukemia. Most epidemiological evidence on the association between cigarette smoking and leukemia risk is from studies conducted in Western populations, however, and evidence from Asian populations is scarce. Methods: We conducted a large-scale population-based cohort study of 96,992 Japanese subjects (46,493 men and 50,499 women; age 40–69 years at baseline with an average 18.3 years of follow-up, during which we identified 90 cases of acute myeloid leukemia (AML, 19 of acute lymphoblastic leukemia (ALL, and 28 of chronic myeloid leukemia (CML. Hazard ratios (HRs and 95% confidence intervals (CIs were estimated using a Cox regression model adjusted for potential confounders. Results: When we adjusted for age, sex, and study area, our findings showed no significant association or increasing dose–response relationship between risk of AML and cigarette smoking overall. However, after further adjustment for body mass index and occupation, current smokers with more than 30 pack-years of cigarette smoking had a significantly increased risk of AML compared to never smokers among men (HR 2.21; 95% CI, 1.01–4.83. This increased risk was not clear among women. Conclusions: Our results suggest that cigarette smoking increases the risk of AML in Japanese men. The associations of smoking with AML among women, and with CML and ALL among men and women, should be assessed in future studies.

Migraine and risk of cardiovascular diseases: Danish population based matched cohort study.

Science.gov (United States)

Adelborg, Kasper; Szépligeti, Szimonetta Komjáthiné; Holland-Bill, Louise; Ehrenstein, Vera; Horváth-Puhó, Erzsébet; Henderson, Victor W; Sørensen, Henrik Toft

2018-01-31

To examine the risks of myocardial infarction, stroke (ischaemic and haemorrhagic), peripheral artery disease, venous thromboembolism, atrial fibrillation or atrial flutter, and heart failure in patients with migraine and in a general population comparison cohort. Nationwide, population based cohort study. All Danish hospitals and hospital outpatient clinics from 1995 to 2013. 51 032 patients with migraine and 510 320 people from the general population matched on age, sex, and calendar year. Comorbidity adjusted hazard ratios of cardiovascular outcomes based on Cox regression analysis. Higher absolute risks were observed among patients with incident migraine than in the general population across most outcomes and follow-up periods. After 19 years of follow-up, the cumulative incidences per 1000 people for the migraine cohort compared with the general population were 25 v 17 for myocardial infarction, 45 v 25 for ischaemic stroke, 11 v 6 for haemorrhagic stroke, 13 v 11 for peripheral artery disease, 27 v 18 for venous thromboembolism, 47 v 34 for atrial fibrillation or atrial flutter, and 19 v 18 for heart failure. Correspondingly, migraine was positively associated with myocardial infarction (adjusted hazard ratio 1.49, 95% confidence interval 1.36 to 1.64), ischaemic stroke (2.26, 2.11 to 2.41), and haemorrhagic stroke (1.94, 1.68 to 2.23), as well as venous thromboembolism (1.59, 1.45 to 1.74) and atrial fibrillation or atrial flutter (1.25, 1.16 to 1.36). No meaningful association was found with peripheral artery disease (adjusted hazard ratio 1.12, 0.96 to 1.30) or heart failure (1.04, 0.93 to 1.16). The associations, particularly for stroke outcomes, were stronger during the short term (0-1 years) after diagnosis than the long term (up to 19 years), in patients with aura than in those without aura, and in women than in men. In a subcohort of patients, the associations persisted after additional multivariable adjustment for body mass index and smoking

Low Risk Anomalies?

DEFF Research Database (Denmark)

Schneider, Paul; Wagner, Christian; Zechner, Josef

This paper shows theoretically and empirically that beta- and volatility-based low risk anomalies are driven by return skewness. The empirical patterns concisely match the predictions of our model that endogenizes the role of skewness for stock returns through default risk. With increasing downside...... risk, the standard capital asset pricing model (CAPM) increasingly overestimates expected equity returns relative to firms' true (skew-adjusted) market risk. Empirically, the profitability of betting against beta/volatility increases with firms' downside risk, and the risk-adjusted return differential...... of betting against beta/volatility among low skew firms compared to high skew firms is economically large. Our results suggest that the returns to betting against beta or volatility do not necessarily pose asset pricing puzzles but rather that such strategies collect premia that compensate for skew risk...

Perinatal risk factors in offenders with severe personality disorder: a population-based investigation.

Science.gov (United States)

Fazel, Seena; Bakiyeva, Liliya; Cnattingius, Sven; Grann, Martin; Hultman, Christina M; Lichtenstein, Paul; Geddes, John R

2012-10-01

Although perinatal factors are associated with the development of several psychiatric disorders, it is unknown whether these factors are linked with personality disorder. Cases of personality disorder were drawn from a national registry of all forensic psychiatric evaluations (n = 150). Two control groups were used: (1) A sample of forensic evaluations without any psychiatric disorder (n = 97) allowing for a nested case-control investigation; and (2) A population-based sample matched by age and gender with no history of psychiatric hospitalization (n = 1498). Prematurity (personality disorder, both in the nested and the population-based case-control comparisons with adjusted odds ratios (OR) for this risk factor ranging from 2 to 4. Asphyxia (adjusted OR = 2.4, 95% CI: 1.4-4.1) and complicated delivery (adjusted OR = 1.5, 1.0-2.1) were associated with personality disorder in the population-based study, and the former remained significant in multivariate models. Overall, perinatal complications were found to be associated with a later diagnosis of personality disorder in this selected sample. As with other psychiatric disorders where such associations have been demonstrated, changes during the perinatal period may lead to abnormal brain development and function.

Physical and psychosocial risk factors for lateral epicondylitis: a population based case-referent study

DEFF Research Database (Denmark)

Haahr, J. P.; Andersen, JH

2003-01-01

: Manual job tasks were associated with tennis elbow (odds ratio (OR) 3.1, 95% confidence interval (CI) 1.9 to 5.1). The self reported physical risk factors "posture" and "forceful work" were related to tennis elbow. Among women, work involving performing repeated movements of the arms was related...... index was established based on posture, repetition, and force. The adjusted ORs for tennis elbow at low, medium, and high strain were 1.4 (CI 0.8 to 2.7), 2.0 (CI 1.1 to 3.7), and 4.4 (CI 2.3 to 8.7). Low social support at work, adjusted for physical strain, was a risk factor among women (OR 2.4, CI 1......, tennis elbow among women was associated with low social support at work. The results for precision demanding movements and for vibration were less consistent...

Controlling chaos based on an adaptive adjustment mechanism

International Nuclear Information System (INIS)

Zheng Yongai

2006-01-01

In this paper, we extend the ideas and techniques developed by Huang [Huang W. Stabilizing nonlinear dynamical systems by an adaptive adjustment mechanism. Phys Rev E 2000;61:R1012-5] for controlling discrete-time chaotic system using adaptive adjustment mechanism to continuous-time chaotic system. Two control approaches, namely adaptive adjustment mechanism (AAM) and modified adaptive adjustment mechanism (MAAM), are investigated. In both case sufficient conditions for the stabilization of chaotic systems are given analytically. The simulation results on Chen chaotic system have verified the effectiveness of the proposed techniques

A risk-adjusted O-E CUSUM with monitoring bands for monitoring medical outcomes.

Science.gov (United States)

Sun, Rena Jie; Kalbfleisch, John D

2013-03-01

In order to monitor a medical center's survival outcomes using simple plots, we introduce a risk-adjusted Observed-Expected (O-E) Cumulative SUM (CUSUM) along with monitoring bands as decision criterion.The proposed monitoring bands can be used in place of a more traditional but complicated V-shaped mask or the simultaneous use of two one-sided CUSUMs. The resulting plot is designed to simultaneously monitor for failure time outcomes that are "worse than expected" or "better than expected." The slopes of the O-E CUSUM provide direct estimates of the relative risk (as compared to a standard or expected failure rate) for the data being monitored. Appropriate rejection regions are obtained by controlling the false alarm rate (type I error) over a period of given length. Simulation studies are conducted to illustrate the performance of the proposed method. A case study is carried out for 58 liver transplant centers. The use of CUSUM methods for quality improvement is stressed. Copyright © 2013, The International Biometric Society.

Calculation of Credit Valuation Adjustment Based on Least Square Monte Carlo Methods

Directory of Open Access Journals (Sweden)

Qian Liu

2015-01-01

Full Text Available Counterparty credit risk has become one of the highest-profile risks facing participants in the financial markets. Despite this, relatively little is known about how counterparty credit risk is actually priced mathematically. We examine this issue using interest rate swaps. This largely traded financial product allows us to well identify the risk profiles of both institutions and their counterparties. Concretely, Hull-White model for rate and mean-reverting model for default intensity have proven to be in correspondence with the reality and to be well suited for financial institutions. Besides, we find that least square Monte Carlo method is quite efficient in the calculation of credit valuation adjustment (CVA, for short as it avoids the redundant step to generate inner scenarios. As a result, it accelerates the convergence speed of the CVA estimators. In the second part, we propose a new method to calculate bilateral CVA to avoid double counting in the existing bibliographies, where several copula functions are adopted to describe the dependence of two first to default times.

Polycystic ovarian syndrome and the risk of subsequent primary ovarian insufficiency: a nationwide population-based study.

Science.gov (United States)

Pan, Mei-Lien; Chen, Li-Ru; Tsao, Hsiao-Mei; Chen, Kuo-Hu

2017-07-01

To evaluate the risk of subsequent primary ovarian insufficiency (POI) amongst patients with a history of polycystic ovarian syndrome (PCOS). This nationwide, population-based study is an inspection and review of data from the 1998 to 2012 Taiwan National Health Insurance Research Database. In a sample of 1,000,000 randomly sampled individuals, women with PCOS (exposure group; n = 7,049) and women without PCOS (contrast group; n = 70,490) were compared. Women initially diagnosed with PCOS at less than 15 or more than 35 years of age were excluded. Each woman with PCOS was age-matched to 10 women without PCOS. The diagnoses of PCOS and POI (coded using International Classification of Diseases, 9th Revision, Clinical Modification) were further confirmed with blood test results and ultrasonographic findings to ensure the accuracy of the diagnoses. POI occurred more among women with PCOS compared with women without PCOS (3.73% vs 0.44%; P analysis, the POI-free survival rates were significantly different between the exposure and contrast groups (P analysis revealed that the risk for POI was significantly higher in the exposure than in the contrast group (hazard ratio [HR] 8.64, 95% confidence interval [CI] 7.33-10.18) and remained similar after adjustment for covariates (adjusted HR 8.31, 95% CI 7.05-9.81). Compared with that of women without PCOS, the risk of POI was even higher for women with PCOS who did not receive metformin treatment (adjusted HR 9.93, 95% CI 8.28-11.90). However, the risk for POI was significantly reduced for women with PCOS who received metformin treatment (adjusted HR 5.66, 95% CI 4.36-7.35). As a possible precursor stage, prior PCOS is a significant and independent risk factor for development of POI. The use of metformin reduces the risk of POI.

Risk adjustment models for interhospital comparison of CS rates using Robson's ten group classification system and other socio-demographic and clinical variables.

Science.gov (United States)

Colais, Paola; Fantini, Maria P; Fusco, Danilo; Carretta, Elisa; Stivanello, Elisa; Lenzi, Jacopo; Pieri, Giulia; Perucci, Carlo A

2012-06-21

Caesarean section (CS) rate is a quality of health care indicator frequently used at national and international level. The aim of this study was to assess whether adjustment for Robson's Ten Group Classification System (TGCS), and clinical and socio-demographic variables of the mother and the fetus is necessary for inter-hospital comparisons of CS rates. The study population includes 64,423 deliveries in Emilia-Romagna between January 1, 2003 and December 31, 2004, classified according to theTGCS. Poisson regression was used to estimate crude and adjusted hospital relative risks of CS compared to a reference category. Analyses were carried out in the overall population and separately according to the Robson groups (groups I, II, III, IV and V-X combined). Adjusted relative risks (RR) of CS were estimated using two risk-adjustment models; the first (M1) including the TGCS group as the only adjustment factor; the second (M2) including in addition demographic and clinical confounders identified using a stepwise selection procedure. Percentage variations between crude and adjusted RRs by hospital were calculated to evaluate the confounding effect of covariates. The percentage variations from crude to adjusted RR proved to be similar in M1 and M2 model. However, stratified analyses by Robson's classification groups showed that residual confounding for clinical and demographic variables was present in groups I (nulliparous, single, cephalic, ≥37 weeks, spontaneous labour) and III (multiparous, excluding previous CS, single, cephalic, ≥37 weeks, spontaneous labour) and IV (multiparous, excluding previous CS, single, cephalic, ≥37 weeks, induced or CS before labour) and to a minor extent in groups II (nulliparous, single, cephalic, ≥37 weeks, induced or CS before labour) and IV (multiparous, excluding previous CS, single, cephalic, ≥37 weeks, induced or CS before labour). The TGCS classification is useful for inter-hospital comparison of CS section rates, but

Parallax adjustment algorithm based on Susan-Zernike moments

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Deng, Yan; Zhang, Kun; Shen, Xiaoqin; Zhang, Huiyun

2018-02-01

Precise parallax detection through definition evaluation and the adjustment of the assembly position of the objective lens or the reticle are important means of eliminating the parallax of the telescope system, so that the imaging screen and the reticle are clearly focused at the same time. An adaptive definition evaluation function based on Susan-Zernike moments is proposed. First, the image is preprocessed by the Susan operator to find the potential boundary edge. Then, the Zernike moments operator is used to determine the exact region of the reticle line with sub-pixel accuracy. The image definition is evaluated only in this related area. The evaluation function consists of the gradient difference calculated by the Zernike moments operator. By adjusting the assembly position of the objective lens, the imaging screen and the reticle will be simultaneously in the state of maximum definition, so the parallax can be eliminated. The experimental results show that the definition evaluation function proposed in this paper has the advantages of good focusing performance, strong anti-interference ability compared with the other commonly used definition evaluation functions.

Singularity-sensitive gauge-based radar rainfall adjustment methods for urban hydrological applications

Directory of Open Access Journals (Sweden)

L.-P. Wang

2015-09-01

Full Text Available Gauge-based radar rainfall adjustment techniques have been widely used to improve the applicability of radar rainfall estimates to large-scale hydrological modelling. However, their use for urban hydrological applications is limited as they were mostly developed based upon Gaussian approximations and therefore tend to smooth off so-called "singularities" (features of a non-Gaussian field that can be observed in the fine-scale rainfall structure. Overlooking the singularities could be critical, given that their distribution is highly consistent with that of local extreme magnitudes. This deficiency may cause large errors in the subsequent urban hydrological modelling. To address this limitation and improve the applicability of adjustment techniques at urban scales, a method is proposed herein which incorporates a local singularity analysis into existing adjustment techniques and allows the preservation of the singularity structures throughout the adjustment process. In this paper the proposed singularity analysis is incorporated into the Bayesian merging technique and the performance of the resulting singularity-sensitive method is compared with that of the original Bayesian (non singularity-sensitive technique and the commonly used mean field bias adjustment. This test is conducted using as case study four storm events observed in the Portobello catchment (53 km2 (Edinburgh, UK during 2011 and for which radar estimates, dense rain gauge and sewer flow records, as well as a recently calibrated urban drainage model were available. The results suggest that, in general, the proposed singularity-sensitive method can effectively preserve the non-normality in local rainfall structure, while retaining the ability of the original adjustment techniques to generate nearly unbiased estimates. Moreover, the ability of the singularity-sensitive technique to preserve the non-normality in rainfall estimates often leads to better reproduction of the urban

Singularity-sensitive gauge-based radar rainfall adjustment methods for urban hydrological applications

Science.gov (United States)

Wang, L.-P.; Ochoa-Rodríguez, S.; Onof, C.; Willems, P.

2015-09-01

Gauge-based radar rainfall adjustment techniques have been widely used to improve the applicability of radar rainfall estimates to large-scale hydrological modelling. However, their use for urban hydrological applications is limited as they were mostly developed based upon Gaussian approximations and therefore tend to smooth off so-called "singularities" (features of a non-Gaussian field) that can be observed in the fine-scale rainfall structure. Overlooking the singularities could be critical, given that their distribution is highly consistent with that of local extreme magnitudes. This deficiency may cause large errors in the subsequent urban hydrological modelling. To address this limitation and improve the applicability of adjustment techniques at urban scales, a method is proposed herein which incorporates a local singularity analysis into existing adjustment techniques and allows the preservation of the singularity structures throughout the adjustment process. In this paper the proposed singularity analysis is incorporated into the Bayesian merging technique and the performance of the resulting singularity-sensitive method is compared with that of the original Bayesian (non singularity-sensitive) technique and the commonly used mean field bias adjustment. This test is conducted using as case study four storm events observed in the Portobello catchment (53 km2) (Edinburgh, UK) during 2011 and for which radar estimates, dense rain gauge and sewer flow records, as well as a recently calibrated urban drainage model were available. The results suggest that, in general, the proposed singularity-sensitive method can effectively preserve the non-normality in local rainfall structure, while retaining the ability of the original adjustment techniques to generate nearly unbiased estimates. Moreover, the ability of the singularity-sensitive technique to preserve the non-normality in rainfall estimates often leads to better reproduction of the urban drainage system

Association of zolpidem use and subsequent increased risk of epilepsy: a population-based, case-control study.

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Harnod, Tomor; Wang, Yu-Chiao; Sung, Fung-Chang; Kao, Chia-Hung

2014-10-01

To evaluate the impact of long-term zolpidem use on the subsequent risk of epilepsy. We used data from the National Health Insurance system of Taiwan to conduct a population-based case-control study. We identified 4,972 newly diagnosed epilepsy patients (ICD-9-CM code 345) for the period of 2005-2010 as cases. For each epilepsy case, 4 controls without a history of epilepsy were randomly selected from the rest of the population. Zolpidem was used as a predictor of epilepsy. Patients with epilepsy exhibited an adjusted odds ratio (OR) of 1.86 (95% CI, 1.70-2.03) and were, therefore, more strongly associated with zolpidem exposure than control patients were. The adjusted OR of epilepsy increased with the increase of mean zolpidem exposure (g/y). Compared with the OR of nonusers, the adjusted OR was 1.64 (95% CI, 1.44-1.86) for those who had taken zolpidem and 2.38 (95% CI, 2.06-2.74) for those who had taken ≥ 20.0 g/y of zolpidem. An adjusted OR of 3.55 (95% CI, 2.94-4.28) was noted to be associated with epilepsy when users had stopped taking the drug less than 7 days earlier. The estimated risk declined to an OR of 1.62 (95% CI, 1.47-1.78) when users had stopped taking the drug more than 90 days earlier. This population-based, retrospective case-control study revealed a possible increase in epilepsy risk with zolpidem use, at either typical or supratherapeutic doses. These findings might stimulate public interest in safety issues regarding zolpidem use. © Copyright 2014 Physicians Postgraduate Press, Inc.

Risk of Psoriasis Following Terbinafine or Itraconazole Treatment for Onychomycosis: A Population-Based Case-Control Comparative Study.

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Chiu, Hsien-Yi; Chang, Wei-Lun; Tsai, Tsen-Fang; Tsai, Yi-Wen; Shiu, Ming-Neng

2018-03-01

Several case studies have reported an association between antifungal drug use and psoriasis risk. The objective of this study was to investigate the association between terbinafine/itraconazole exposure and psoriasis incidence. Among patients with onychomycosis in the Taiwan National Health Insurance Research Database, 3831 incident psoriasis cases were identified during 2004-2010 and compared with 3831 age- and sex-matched controls with the same look-back period. Multivariate conditional logistic regression was used for the analysis. The psoriasis cases were significantly more likely than matched controls to have used terbinafine or itraconazole (59.85 vs. 42.70%, respectively; p terbinafine/itraconazole use was associated with an increased psoriasis risk (adjusted odds ratio 1.33, 95% confidence interval 1.15-1.54). The association was stronger for more recent drug exposure (adjusted odds ratio 2.96, 95% confidence interval 2.25-3.90 for ≤ 90 days before the sampling date; adjusted odds ratio 1.04, 95% confidence interval 0.89-1.22 for > 360 days). In a comparison of patients receiving terbinafine or itraconazole only, psoriasis risk was higher for itraconazole (adjusted odds ratio 1.21, 95% confidence interval 1.05-1.40). This large population-based case-control analysis showed that exposure to terbinafine or itraconazole is associated with an increased risk of incident psoriasis. The finding of an increased psoriasis risk for antifungal drug users, particularly for itraconazole, deserves attention in clinical practice although further prospective studies are necessary to confirm our findings and clarify the biological mechanisms that underlie these associations.

A risk-adjusted financial model to estimate the cost of a video-assisted thoracoscopic surgery lobectomy programme.

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Brunelli, Alessandro; Tentzeris, Vasileios; Sandri, Alberto; McKenna, Alexandra; Liew, Shan Liung; Milton, Richard; Chaudhuri, Nilanjan; Kefaloyannis, Emmanuel; Papagiannopoulos, Kostas

2016-05-01

To develop a clinically risk-adjusted financial model to estimate the cost associated with a video-assisted thoracoscopic surgery (VATS) lobectomy programme. Prospectively collected data of 236 VATS lobectomy patients (August 2012-December 2013) were analysed retrospectively. Fixed and variable intraoperative and postoperative costs were retrieved from the Hospital Accounting Department. Baseline and surgical variables were tested for a possible association with total cost using a multivariable linear regression and bootstrap analyses. Costs were calculated in GBP and expressed in Euros (EUR:GBP exchange rate 1.4). The average total cost of a VATS lobectomy was €11 368 (range €6992-€62 535). Average intraoperative (including surgical and anaesthetic time, overhead, disposable materials) and postoperative costs [including ward stay, high dependency unit (HDU) or intensive care unit (ICU) and variable costs associated with management of complications] were €8226 (range €5656-€13 296) and €3029 (range €529-€51 970), respectively. The following variables remained reliably associated with total costs after linear regression analysis and bootstrap: carbon monoxide lung diffusion capacity (DLCO) 0.05) in 86% of the samples. A hypothetical patient with COPD and DLCO less than 60% would cost €4270 more than a patient without COPD and with higher DLCO values (€14 793 vs €10 523). Risk-adjusting financial data can help estimate the total cost associated with VATS lobectomy based on clinical factors. This model can be used to audit the internal financial performance of a VATS lobectomy programme for budgeting, planning and for appropriate bundled payment reimbursements. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Critical review of methods for risk ranking of food-related hazards, based on risks for human health.

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Van der Fels-Klerx, H J; Van Asselt, E D; Raley, M; Poulsen, M; Korsgaard, H; Bredsdorff, L; Nauta, M; D'agostino, M; Coles, D; Marvin, H J P; Frewer, L J

2018-01-22

This study aimed to critically review methods for ranking risks related to food safety and dietary hazards on the basis of their anticipated human health impacts. A literature review was performed to identify and characterize methods for risk ranking from the fields of food, environmental science and socio-economic sciences. The review used a predefined search protocol, and covered the bibliographic databases Scopus, CAB Abstracts, Web of Sciences, and PubMed over the period 1993-2013. All references deemed relevant, on the basis of predefined evaluation criteria, were included in the review, and the risk ranking method characterized. The methods were then clustered-based on their characteristics-into eleven method categories. These categories included: risk assessment, comparative risk assessment, risk ratio method, scoring method, cost of illness, health adjusted life years (HALY), multi-criteria decision analysis, risk matrix, flow charts/decision trees, stated preference techniques and expert synthesis. Method categories were described by their characteristics, weaknesses and strengths, data resources, and fields of applications. It was concluded there is no single best method for risk ranking. The method to be used should be selected on the basis of risk manager/assessor requirements, data availability, and the characteristics of the method. Recommendations for future use and application are provided.

The high-density lipoprotein-adjusted SCORE model worsens SCORE-based risk classification in a contemporary population of 30 824 Europeans

DEFF Research Database (Denmark)

Mortensen, Martin B; Afzal, Shoaib; Nordestgaard, Børge G

2015-01-01

.8 years of follow-up, 339 individuals died of CVD. In the SCORE target population (age 40-65; n = 30,824), fewer individuals were at baseline categorized as high risk (≥5% 10-year risk of fatal CVD) using SCORE-HDL compared with SCORE (10 vs. 17% in men, 1 vs. 3% in women). SCORE-HDL did not improve...... with SCORE, but deteriorated risk classification based on NRI. Future guidelines should consider lower decision thresholds and prioritize CVD morbidity and people above age 65....

Comparison of time adjustment clauses between DZ3910, AS4000 and STCC

Directory of Open Access Journals (Sweden)

David Finnie

2013-03-01

Full Text Available This article examines time adjustment clauses, as they relate to time adjustment between standard terms of construction contracts. DZ3910, AS4000 and STCC were compared on the basis of how risks are allocated, how this may impact on the contractor’s pricing, and ease of understanding for each clause. ASTCC was found to be the most easily interpreted contract, followed by AS4000 and then NZS3910. These assessments were based on the following: a whether each contract contains words with multiple meanings, b the number of words used per sentence, c the amount of internal cross-referencing, and d the clarity of the contract structure. The allowable pre-conditions for the contractor to claim a time adjustment are similar for all three contracts, and none of them expressly state which party is to bare the risk of buildability, or address the risk of a designer’s disclaimer clause. All of the contracts adopt the principle of contra preferentum which means that the employer bares the risk of variance if there are any ambiguities in the design documentation. Due to their similarities of risk allocation, all of the contracts provide the employer with a similar amount of price surety. AS4000 is the only contract to contain a stringent time-bar clause, limiting a contractor’s time adjustment claim. ASTCC requires the contractor to apply ‘immediately’ and DZ3910 provides a time-bar of 20 working days or as soon as practicable. None of the contracts clarify whether their timing requirements take precedence over the prevention principle, or over any other ground for claiming a time adjustment. The effect of DZ3910’s pre-notification clause 5.19.3 is discussed, and an alternative contents structure is recommended for DZ3910, using a project management method.

The relationship between effectiveness and costs measured by a risk-adjusted case-mix system: multicentre study of Catalonian population data bases

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Flor-Serra Ferran

2009-06-01

Full Text Available Abstract Background The main objective of this study is to measure the relationship between morbidity, direct health care costs and the degree of clinical effectiveness (resolution of health centres and health professionals by the retrospective application of Adjusted Clinical Groups in a Spanish population setting. The secondary objectives are to determine the factors determining inadequate correlations and the opinion of health professionals on these instruments. Methods/Design We will carry out a multi-centre, retrospective study using patient records from 15 primary health care centres and population data bases. The main measurements will be: general variables (age and sex, centre, service [family medicine, paediatrics], and medical unit, dependent variables (mean number of visits, episodes and direct costs, co-morbidity (Johns Hopkins University Adjusted Clinical Groups Case-Mix System and effectiveness. The totality of centres/patients will be considered as the standard for comparison. The efficiency index for visits, tests (laboratory, radiology, others, referrals, pharmaceutical prescriptions and total will be calculated as the ratio: observed variables/variables expected by indirect standardization. The model of cost/patient/year will differentiate fixed/semi-fixed (visits costs of the variables for each patient attended/year (N = 350,000 inhabitants. The mean relative weights of the cost of care will be obtained. The effectiveness will be measured using a set of 50 indicators of process, efficiency and/or health results, and an adjusted synthetic index will be constructed (method: percentile 50. The correlation between the efficiency (relative-weights and synthetic (by centre and physician indices will be established using the coefficient of determination. The opinion/degree of acceptance of physicians (N = 1,000 will be measured using a structured questionnaire including various dimensions. Statistical analysis: multiple regression

Behavioural adjustment in response to increased predation risk: a study in three duck species.

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Cédric Zimmer

Full Text Available Predation directly triggers behavioural decisions designed to increase immediate survival. However, these behavioural modifications can have long term costs. There is therefore a trade-off between antipredator behaviours and other activities. This trade-off is generally considered between vigilance and only one other behaviour, thus neglecting potential compensations. In this study, we considered the effect of an increase in predation risk on the diurnal time-budget of three captive duck species during the wintering period. We artificially increased predation risk by disturbing two groups of 14 mallard and teals at different frequencies, and one group of 14 tufted ducks with a radio-controlled stressor. We recorded foraging, vigilance, preening and sleeping durations the week before, during and after disturbance sessions. Disturbed groups were compared to an undisturbed control group. We showed that in all three species, the increase in predation risk resulted in a decrease in foraging and preening and led to an increase in sleeping. It is worth noting that contrary to common observations, vigilance did not increase. However, ducks are known to be vigilant while sleeping. This complex behavioural adjustment therefore seems to be optimal as it may allow ducks to reduce their predation risk. Our results highlight the fact that it is necessary to encompass the whole individual time-budget when studying behavioural modifications under predation risk. Finally, we propose that studies of behavioural time-budget changes under predation risk should be included in the more general framework of the starvation-predation risk trade-off.

Sleep disorders increase the risk of burning mouth syndrome: a retrospective population-based cohort study.

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Lee, Chun-Feng; Lin, Kuan-Yu; Lin, Ming-Chia; Lin, Cheng-Li; Chang, Shih-Ni; Kao, Chia-Hung

2014-11-01

Sleep disorders (SD), including apnea and nonapnea, and burning mouth syndrome (BMS) have been mutually associated with systemic diseases. Based on our research, the association between BMS and SD has not been elucidated. We determined whether SD patients have an increased risk of BMS. We used information from health insurance claims obtained from the Taiwanese National Health Insurance (NHI) program. We identified patients newly diagnosed with sleep apnea syndrome between 1998 and 2001 as the apnea SD cohort, and newly diagnosed patients with nonapnea SD as the nonapnea SD cohort. The non-SD cohort was 1:2 frequency matched the case group according to sex, age, and index year. We analyzed the risks of BMS by using Cox proportional hazards regression models. Compared with the non-SD cohort, both of the apnea SD (adjusted HR = 2.56, 95% CI = 1.30-5.05) and nonapnea SD (adjusted HR = 2.89, 95% CI = 2.51-3.34) were associated with a significantly higher risk of BMS. The hazard ratio (HR) increased with increased age in the apnea SD cohort and in the nonapnea SD cohort compared with patients younger than 40 years of age. Female apnea SD patients (IRR = 4.63, 95% CI = 3.82-5.61) had a higher risk of developing BMS than did male patients (IRR = 1.76, 95% CI = 1.39-2.24). Based on our research, SD might increase the risk of BMS. Copyright © 2014 Elsevier B.V. All rights reserved.

Is an unfavourable cardiovascular risk profile a risk factor for vasomotor menopausal symptoms? Results of a population-based cohort study.

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van den Berg, M J; Herber-Gast, G C M; van der Schouw, Y T

2015-08-01

Evidence suggests an association between vasomotor menopausal symptoms (VMSs), i.e. hot flushes and night sweats, and cardiovascular disease. However, the causal pathway is unclear. We investigated whether an unfavourable cardiovascular risk profile is a risk factor for VMS later in life. Retrospective cohort study. Women aged 50-70 from the general population. The Prospect-European Prospective Investigation into Cancer and Nutrition (Prospect-EPIC) cohort is a population-based cohort of women who enrolled between 1993 and 1997. Follow-up questionnaires were sent at 5-year intervals for 15 years. Women who returned the third questionnaire, answered questions regarding lifetime VMS and did not report VMS prior to baseline were included in this study (n = 1295). At baseline, the Framingham Risk Score (FRS) was determined. We used logistic regression analysis to calculate odds ratios (ORs) for the association between baseline FRS and incident VMS. Incident VMS. At baseline (mean age ± standard deviation, 52.2 ± 3.6 years), 21.2% had a FRS > 10%. During follow-up, 40.2% of women reported the onset of VMS. Adjusted for body mass index, physical activity, education and alcohol consumption, each point increase in FRS was associated with a decreased incidence of VMS [OR, 0.94 (95% CI, 0.91-0.97)]. Additional adjustment for menopausal status attenuated the OR to null [OR, 0.98 (95% CI, 0.95-1.01)]. None of the separate FRS variables were associated with VMS after adjustment for age. In our cohort, an unfavourable cardiovascular risk profile was not associated with VMS, and therefore we found no evidence for the involvement of a vascular mechanism in the etiology of VMS. © 2014 Royal College of Obstetricians and Gynaecologists.

The adjusted Global AntiphosPholipid Syndrome Score (aGAPSS) for risk stratification in young APS patients with acute myocardial infarction.

Science.gov (United States)

Radin, M; Schreiber, K; Costanzo, P; Cecchi, I; Roccatello, D; Baldovino, S; Bazzan, M; Cuadrado, M J; Sciascia, S

2017-08-01

Young adults with acute myocardial infarction are a critical group to examine for the purpose of risk factor stratification and modification. In this study we aimed to assess the clinical utility of the adjusted Global AntiphosPholipid Syndrome Score (aGAPSS) for the risk stratification of acute myocardial infarction in a cohort of young patients with antiphospholipid syndrome (APS). The analysis included 83 consecutive APS patients (≤50years old) who presented with arterial or venous thromboembolic events. Data on cardiovascular risk factors and antiphospholipid antibodies (aPL) positivity were retrospectively collected. The aGAPSS was calculated by adding the points corresponding to the risk factors, based on a linear transformation derived from the ß-regression coefficient as follows: 3 for hyperlipidaemia, 1 for arterial hypertension, 5 for aCL IgG/IgM, 4 for anti-b2 glycoprotein I IgG/IgM and 4 for LA. Higher aGAPSS values were observed in patients with acute myocardial infarction when compared to the others [mean aGAPSS 11.9 (S.D. 4.15, range 4-18) Vs. mean aGAPSS 9.2 (S.D. 5.1, range 1-17); T test: psyndrome compared to patients with a history of peripheral or cerebrovascular arterial thrombotic events [mean aGAPSS 11.9 (S.D. 4.15, range 4-18) Vs. mean aGAPSS 6.7 (S.D. 5.7, range 1-17); T test: P<0.005]. The aGAPSS is based upon a quantitative score and could aid risk stratifying APS patients younger than 50years for the likelihood of developing coronary thrombotic events and may guide pharmacological treatment for high-risk patients. Copyright © 2017 Elsevier B.V. All rights reserved.

Does Risk-Adjusted Payment Influence Primary Care Providers' Decision on Where to Set Up Practices?

DEFF Research Database (Denmark)

Dietrichson, Jens; Anell, Anders; Dackehag, Margareta

Providing equal access to health care is an important objective in most health care systems. It is especially pertinent in systems like the Swedish primary care market, where providers are free to establish themselves in any part of the country. To improve equity in access to care, 15 out 21 county...... of private primary care centers in areas with unfavorable socioeconomic and demographic characteristics. More generally, this result indicates that risk-adjusted capitation can significantly affect private providers’ establishment decisions....

Case-Mix for Performance Management: A Risk Algorithm Based on ICD-10-CM.

Science.gov (United States)

Gao, Jian; Moran, Eileen; Almenoff, Peter L

2018-06-01

Accurate risk adjustment is the key to a reliable comparison of cost and quality performance among providers and hospitals. However, the existing case-mix algorithms based on age, sex, and diagnoses can only explain up to 50% of the cost variation. More accurate risk adjustment is desired for provider performance assessment and improvement. To develop a case-mix algorithm that hospitals and payers can use to measure and compare cost and quality performance of their providers. All 6,048,895 patients with valid diagnoses and cost recorded in the US Veterans health care system in fiscal year 2016 were included in this study. The dependent variable was total cost at the patient level, and the explanatory variables were age, sex, and comorbidities represented by 762 clinically homogeneous groups, which were created by expanding the 283 categories from Clinical Classifications Software based on ICD-10-CM codes. The split-sample method was used to assess model overfitting and coefficient stability. The predictive power of the algorithms was ascertained by comparing the R, mean absolute percentage error, root mean square error, predictive ratios, and c-statistics. The expansion of the Clinical Classifications Software categories resulted in higher predictive power. The R reached 0.72 and 0.52 for the transformed and raw scale cost, respectively. The case-mix algorithm we developed based on age, sex, and diagnoses outperformed the existing case-mix models reported in the literature. The method developed in this study can be used by other health systems to produce tailored risk models for their specific purpose.

Smoking and subsequent risk of leukemia in Japan: The Japan Public Health Center-based Prospective Study.

Science.gov (United States)

Ugai, Tomotaka; Matsuo, Keitaro; Sawada, Norie; Iwasaki, Motoki; Yamaji, Taiki; Shimazu, Taichi; Sasazuki, Shizuka; Inoue, Manami; Tsugane, Shoichiro

2017-07-01

Cigarette smoking has been reported to be associated with an increased risk of leukemia. Most epidemiological evidence on the association between cigarette smoking and leukemia risk is from studies conducted in Western populations, however, and evidence from Asian populations is scarce. We conducted a large-scale population-based cohort study of 96,992 Japanese subjects (46,493 men and 50,499 women; age 40-69 years at baseline) with an average 18.3 years of follow-up, during which we identified 90 cases of acute myeloid leukemia (AML), 19 of acute lymphoblastic leukemia (ALL), and 28 of chronic myeloid leukemia (CML). Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using a Cox regression model adjusted for potential confounders. When we adjusted for age, sex, and study area, our findings showed no significant association or increasing dose-response relationship between risk of AML and cigarette smoking overall. However, after further adjustment for body mass index and occupation, current smokers with more than 30 pack-years of cigarette smoking had a significantly increased risk of AML compared to never smokers among men (HR 2.21; 95% CI, 1.01-4.83). This increased risk was not clear among women. Our results suggest that cigarette smoking increases the risk of AML in Japanese men. The associations of smoking with AML among women, and with CML and ALL among men and women, should be assessed in future studies. Copyright © 2017 The Authors. Production and hosting by Elsevier B.V. All rights reserved.

The Use of the Kurtosis-Adjusted Cumulative Noise Exposure Metric in Evaluating the Hearing Loss Risk for Complex Noise.

Science.gov (United States)

Xie, Hong-Wei; Qiu, Wei; Heyer, Nicholas J; Zhang, Mei-Bian; Zhang, Peng; Zhao, Yi-Ming; Hamernik, Roger P

2016-01-01

To test a kurtosis-adjusted cumulative noise exposure (CNE) metric for use in evaluating the risk of hearing loss among workers exposed to industrial noises. Specifically, to evaluate whether the kurtosis-adjusted CNE (1) provides a better association with observed industrial noise-induced hearing loss, and (2) provides a single metric applicable to both complex (non-Gaussian [non-G]) and continuous or steady state (Gaussian [G]) noise exposures for predicting noise-induced hearing loss (dose-response curves). Audiometric and noise exposure data were acquired on a population of screened workers (N = 341) from two steel manufacturing plants located in Zhejiang province and a textile manufacturing plant located in Henan province, China. All the subjects from the two steel manufacturing plants (N = 178) were exposed to complex noise, whereas the subjects from textile manufacturing plant (N = 163) were exposed to a G continuous noise. Each subject was given an otologic examination to determine their pure-tone HTL and had their personal 8-hr equivalent A-weighted noise exposure (LAeq) and full-shift noise kurtosis statistic (which is sensitive to the peaks and temporal characteristics of noise exposures) measured. For each subject, an unadjusted and kurtosis-adjusted CNE index for the years worked was created. Multiple linear regression analysis controlling for age was used to determine the relationship between CNE (unadjusted and kurtosis adjusted) and the mean HTL at 3, 4, and 6 kHz (HTL346) among the complex noise-exposed group. In addition, each subject's HTLs from 0.5 to 8.0 kHz were age and sex adjusted using Annex A (ISO-1999) to determine whether they had adjusted high-frequency noise-induced hearing loss (AHFNIHL), defined as an adjusted HTL shift of 30 dB or greater at 3.0, 4.0, or 6.0 kHz in either ear. Dose-response curves for AHFNIHL were developed separately for workers exposed to G and non-G noise using both unadjusted and adjusted CNE as the exposure

Myastenia and risk of cancer

DEFF Research Database (Denmark)

Pedersen, Emil Arnspang; Pottegård, Anton; Hallas, Jesper

2014-01-01

BACKGROUND AND PURPOSE: To evaluate the association between having non-thymoma myasthenia and the risk of extra-thymic cancer in a population-based setting. METHODS: A nationwide case-control study was conducted in Denmark based on medical registries. The study included all cases with a first time...... diagnosis of cancer during 2000-2009. Each case was matched by birth year and gender with eight population controls using risk set sampling. Subjects with myasthenia were identified through a validated register-based algorithm. Conditional logistic regression was used to compute crude and adjusted odds...... risk of overall cancer (OR 1.1; 95% CI 0.9-1.4). Adjusted ORs for major cancer sites were also close to unity, whereas an elevated risk of lymphomas was observed (OR 2.0; 95% CI 0.8-5.5). Early-onset myasthenia was associated with a slightly increased OR for overall cancer (1.5; 95% CI 1...

The effect of community-acquired bacteraemia on return to workforce, risk of sick leave, permanent disability pension and death: a Danish population-based cohort study.

Science.gov (United States)

Dalager-Pedersen, Michael; Koch, Kristoffer; Thomsen, Reimar Wernich; Schønheyder, Henrik Carl; Nielsen, Henrik

2014-01-29

Little is known about the prognosis of community-acquired bacteraemia (CAB) in workforce adults. We assessed return to workforce, risk for sick leave, disability pension and mortality within 1 year after CAB in workforce adults compared with blood culture-negative controls and population controls. Population-based cohort study. North Denmark, 1996-2011. We used population-based healthcare registries to identify all patients aged 20-58 years who had first-time blood cultures obtained within 48 h of medical hospital admission, and who were part of the workforce (450 bacteraemia exposed patients and 6936 culture-negative control patients). For each bacteraemia patient, we included up to 10 matched population controls. Return to workforce, risk of sick leave, permanent disability pension and mortality within 1 year after bacteraemia. Regression analyses were used to compute adjusted relative risks (RRs) with 95% CIs. One year after admission, 78% of patients with CAB, 85.7% of culture-negative controls and 96.8% of population controls were alive and in the workforce, and free from sick leave or disability pension. Compared with culture-negative controls, bacteraemia was associated with an increased risk for long-term sick leave (4-week duration, 40.2% vs 23.9%, adjusted RR, 1.51; CI 1.34 to 1.70) and an increased risk for mortality (30-day mortality, 4% vs 1.4%, adjusted RR, 2.34, CI 1.22 to 4.50; 1-year mortality, 8% vs 3.9%, adjusted RR, 1.73; CI 1.18 to 2.55). Bacteraemia patients had a risk for disability pension similar to culture-negative controls (2.7% vs 2.6%, adjusted RR, 0.99, CI 0.48 to 2.02) but greater than population controls (adjusted RR, 5.20; 95% CI 2.16 to 12.50). CAB is associated with long duration of sick leave and considerable mortality in working-age adults when compared with blood culture-negative controls, and an increased 1-year risk for disability pension when compared with population controls.

Infective Endocarditis and Cancer Risk: A Population-Based Cohort Study.

Science.gov (United States)

Sun, Li-Min; Wu, Jung-Nan; Lin, Cheng-Li; Day, Jen-Der; Liang, Ji-An; Liou, Li-Ren; Kao, Chia-Hung

2016-03-01

This study investigated the possible relationship between endocarditis and overall and individual cancer risk among study participants in Taiwan.We used data from the National Health Insurance program of Taiwan to conduct a population-based, observational, and retrospective cohort study. The case group consisted of 14,534 patients who were diagnosed with endocarditis between January 1, 2000 and December 31, 2010. For the control group, 4 patients without endocarditis were frequency matched to each endocarditis patient according to age, sex, and index year. Competing risks regression analysis was conducted to determine the effect of endocarditis on cancer risk.A large difference was noted in Charlson comorbidity index between endocarditis and nonendocarditis patients. In patients with endocarditis, the risk for developing overall cancer was significant and 119% higher than in patients without endocarditis (adjusted subhazard ratio = 2.19, 95% confidence interval = 1.98-2.42). Regarding individual cancers, in addition to head and neck, uterus, female breast and hematological malignancies, the risks of developing colorectal cancer, and some digestive tract cancers were significantly higher. Additional analyses determined that the association of cancer with endocarditis is stronger within the 1st 5 years after endocarditis diagnosis.This population-based cohort study found that patients with endocarditis are at a higher risk for colorectal cancer and other cancers in Taiwan. The risk was even higher within the 1st 5 years after endocarditis diagnosis. It suggested that endocarditis is an early marker of colorectal cancer and other cancers. The underlying mechanisms must still be explored and may account for a shared risk factor of infection in both endocarditis and malignancy.

The Impact of Disability and Social Determinants of Health on Condition-Specific Readmissions beyond Medicare Risk Adjustments: A Cohort Study.

Science.gov (United States)

Meddings, Jennifer; Reichert, Heidi; Smith, Shawna N; Iwashyna, Theodore J; Langa, Kenneth M; Hofer, Timothy P; McMahon, Laurence F

2017-01-01

Readmission rates after pneumonia, heart failure, and acute myocardial infarction hospitalizations are risk-adjusted for age, gender, and medical comorbidities and used to penalize hospitals. To assess the impact of disability and social determinants of health on condition-specific readmissions beyond current risk adjustment. Retrospective cohort study of Medicare patients using 1) linked Health and Retirement Study-Medicare claims data (HRS-CMS) and 2) Healthcare Cost and Utilization Project State Inpatient Databases (Florida, Washington) linked with ZIP Code-level measures from the Census American Community Survey (ACS-HCUP). Multilevel logistic regression models assessed the impact of disability and selected social determinants of health on readmission beyond current risk adjustment. Outcomes measured were readmissions ≤30 days after hospitalizations for pneumonia, heart failure, or acute myocardial infarction. HRS-CMS models included disability measures (activities of daily living [ADL] limitations, cognitive impairment, nursing home residence, home healthcare use) and social determinants of health (spouse, children, wealth, Medicaid, race). ACS-HCUP model measures were ZIP Code-percentage of residents ≥65 years of age with ADL difficulty, spouse, income, Medicaid, and patient-level and hospital-level race. For pneumonia, ≥3 ADL difficulties (OR 1.61, CI 1.079-2.391) and prior home healthcare needs (OR 1.68, CI 1.204-2.355) increased readmission in HRS-CMS models (N = 1631); ADL difficulties (OR 1.20, CI 1.063-1.352) and 'other' race (OR 1.14, CI 1.001-1.301) increased readmission in ACS-HCUP models (N = 27,297). For heart failure, children (OR 0.66, CI 0.437-0.984) and wealth (OR 0.53, CI 0.349-0.787) lowered readmission in HRS-CMS models (N = 2068), while black (OR 1.17, CI 1.056-1.292) and 'other' race (OR 1.14, CI 1.036-1.260) increased readmission in ACS-HCUP models (N = 37,612). For acute myocardial infarction, nursing home status

Mucosal healing and the risk of ischemic heart disease or atrial fibrillation in patients with celiac disease; a population-based study.

Directory of Open Access Journals (Sweden)

Benjamin Lebwohl

Full Text Available Patients with celiac disease (CD, characterized histologically by villous atrophy (VA of the small intestine, have an increased risk of ischemic heart disease (IHD and atrial fibrillation (AF, risks that persist for years after commencing the gluten-free diet. It is unknown whether persistent VA on follow-up biopsy, rather than mucosal healing, affects the risk of IHD or AF.We identified patients with histologic evidence of CD diagnosed at all 28 pathology departments in Sweden. Among patients who underwent a follow-up small intestinal biopsy, we compared patients with persistent VA to those who showed histologic improvement, with regard to the development of IHD (angina pectoris or myocardial infarction or AF.Among patients with CD and a follow-up biopsy (n = 7,440, the median age at follow-up biopsy was 25 years, with 1,063 (14% patients who were ≥ 60 years at the time of follow-up biopsy. Some 196 patients developed IHD and 205 patients developed AF. After adjusting for age, gender, duration of CD, calendar period, and educational attainment, there was no significant effect of persistent VA on IHD (adjusted HR 0.97; 95%CI 0.73-1.30. Adjusting for diabetes had a negligible effect (adjusted HR 0.98; 95%CI 0.73-1.31. There was no significant association between persistent VA and the risk of AF (adjusted HR 0.98; 95%CI 0.74-1.30.In this population-based study of patients with CD, persistent VA on follow-up biopsy was not associated with an increased risk of IHD or AF. Failed mucosal healing does not influence the risk of these cardiac events.

Active epilepsy prevalence, the treatment gap, and treatment gap risk profile in eastern China: A population-based study.

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Ding, Xiaoyan; Zheng, Yang; Guo, Yi; Shen, Chunhong; Wang, Shan; Chen, Feng; Yan, Shengqiang; Ding, Meiping

2018-01-01

We measured the prevalence of active epilepsy and investigated the treatment gap and treatment gap risk profile in eastern China. This was a cross-sectional population-based survey conducted in Zhejiang, China, from October 2013 to March 2014. A total 54,976 people were selected using multi-stage cluster sampling. A two-stage questionnaire-based process was used to identify patients with active epilepsy and to record their demographic, socioeconomic, and epilepsy-related features. Logistic regression analysis was used to analyze risk factors of the treatment gap in eastern China, as adjusted for age and sex. We interviewed 50,035 people; 118 had active epilepsy (2.4‰), among which the treatment gap was 58.5%. In multivariate analysis, failure to receive appropriate antiepileptic treatment was associated with higher seizure frequency of 12-23 times per year (adjusted odds ratio=6.874; 95% confidence interval [CI]=2.372-19.918), >24 times per year (adjusted odds ratio=19.623; 95% CI=4.999-77.024), and a lack of health insurance (adjusted odds ratio=7.284; 95% CI=1.321-40.154). Eastern China has relatively lower prevalence of active epilepsy and smaller treatment gap. Interventions aimed at reducing seizure frequency, improving the health insurance system should be investigated as potential targets to further bridge the treatment gap. Copyright © 2017 Elsevier Inc. All rights reserved.

Screening techniques, sustainability and risk adjusted returns. : - A quantitative study on the Swedish equity funds market

OpenAIRE

Ögren, Tobias; Forslund, Petter

2017-01-01

Previous studies have primarily compared the performance of sustainable equity funds and non-sustainable equity funds. A meta-analysis over 85 different studies in the field concludes that there is no statistically significant difference in risk-adjusted returns when comparing sustainable funds and non-sustainable funds. This study is thus an extension on previous studies where the authors have chosen to test the two most common sustainability screening techniques to test if there is a differ...

A risk-model for hospital mortality among patients with severe sepsis or septic shock based on German national administrative claims data.

Science.gov (United States)

Schwarzkopf, Daniel; Fleischmann-Struzek, Carolin; Rüddel, Hendrik; Reinhart, Konrad; Thomas-Rüddel, Daniel O

2018-01-01

Sepsis is a major cause of preventable deaths in hospitals. Feasible and valid methods for comparing quality of sepsis care between hospitals are needed. The aim of this study was to develop a risk-adjustment model suitable for comparing sepsis-related mortality between German hospitals. We developed a risk-model using national German claims data. Since these data are available with a time-lag of 1.5 years only, the stability of the model across time was investigated. The model was derived from inpatient cases with severe sepsis or septic shock treated in 2013 using logistic regression with backward selection and generalized estimating equations to correct for clustering. It was validated among cases treated in 2015. Finally, the model development was repeated in 2015. To investigate secular changes, the risk-adjusted trajectory of mortality across the years 2010-2015 was analyzed. The 2013 deviation sample consisted of 113,750 cases; the 2015 validation sample consisted of 134,851 cases. The model developed in 2013 showed good validity regarding discrimination (AUC = 0.74), calibration (observed mortality in 1st and 10th risk-decile: 11%-78%), and fit (R2 = 0.16). Validity remained stable when the model was applied to 2015 (AUC = 0.74, 1st and 10th risk-decile: 10%-77%, R2 = 0.17). There was no indication of overfitting of the model. The final model developed in year 2015 contained 40 risk-factors. Between 2010 and 2015 hospital mortality in sepsis decreased from 48% to 42%. Adjusted for risk-factors the trajectory of decrease was still significant. The risk-model shows good predictive validity and stability across time. The model is suitable to be used as an external algorithm for comparing risk-adjusted sepsis mortality among German hospitals or regions based on administrative claims data, but secular changes need to be taken into account when interpreting risk-adjusted mortality.

77 FR 53059 - Risk-Based Capital Guidelines: Market Risk

Science.gov (United States)

2012-08-30

...'' framework that includes (1) Risk-based capital requirements for credit risk, market risk, and operational... default and credit quality migration risk for non-securitization credit products. With respect to... securitization positions, the revisions assign a specific risk- weighting factor based on the credit rating of a...

Risk of anxiety and depressive disorders in patients with myocardial infarction: A nationwide population-based cohort study.

Science.gov (United States)

Feng, Hsin-Pei; Chien, Wu-Chien; Cheng, Wei-Tung; Chung, Chi-Hsiang; Cheng, Shu-Meng; Tzeng, Wen-Chii

2016-08-01

Anxiety and depressive symptoms are associated with adverse cardiovascular events after an acute myocardial infarction (MI). However, most studies focusing on anxiety or depression have used rating scales or self-report methods rather than clinical diagnosis. This study aimed to investigate the association between psychiatrist-diagnosed psychiatric disorders and cardiovascular prognosis.We sampled data from the National Health Insurance Research Database; 1396 patients with MI were recruited as the study cohort and 13,960 patients without MI were recruited as the comparison cohort. Cox proportional hazard regression models were used to examine the effect of MI on the risk of anxiety and depressive disorders.During the first 2 years of follow-up, patients with MI exhibited a significantly higher risk of anxiety disorders (adjusted hazard ratio [HR] = 5.06, 95% confidence interval [CI]: 4.61-5.54) and depressive disorders (adjusted HR = 7.23, 95% CI: 4.88-10.88) than those without MI did. Greater risk for anxiety and depressive disorders was observed among women and patients aged 45 to 64 years following an acute MI. Patients with post-MI anxiety had a 9.37-fold (95% CI: 4.45-19.70) higher risk of recurrent MI than those without MI did after adjustment for age, sex, socioeconomic status, and comorbidities.This nationwide population-based cohort study provides evidence that MI increases the risk of anxiety and depressive disorders during the first 2 years post-MI, and post-MI anxiety disorders are associated with a higher risk of recurrent MI.

12 CFR Appendix A to Part 225 - Capital Adequacy Guidelines for Bank Holding Companies: Risk-Based Measure

Science.gov (United States)

2010-01-01

... adjusted for capital purposes in accordance with the instructions to the Consolidated Financial Statements... guidelines apply on a consolidated basis to any bank holding company with consolidated assets of $500 million or more. The risk-based guidelines also apply on a consolidated basis to any bank holding company...

Risk factors for fracture in elderly men: a population-based prospective study

DEFF Research Database (Denmark)

Nielsen, Morten Frost; Abrahamsen, Bo; Masud, T

2012-01-01

.30-3.09) and pulmonary illness (1.90; 1.03-3.53) were associated with increased risk of osteoporotic fractures in adjusted models. CONCLUSION: These results underline the importance of assessment of dizziness, falls and those with a family history of hip fracture. Frequent urination and erectile dysfunction were......Risk factors for fractures were assessed in a random sample of 4,696 elderly men followed for 5.4 years. Results highlighted the importance of assessment of falls and dizziness as well as novel risk factors including frequent urination and erectile dysfunction. INTRODUCTION: Knowledge about risk...... in the forearm). Cox proportional hazard regression models were used to evaluate risk factors for any and osteoporotic fractures. The following variables were found to be associated with increased risk of any fracture in adjusted models family history of a hip fracture (HR; 95%CI: 1.56; 1.05-2.33), falls (2...

Risk-based safety indicators

International Nuclear Information System (INIS)

Sedlak, J.

2001-12-01

The report is structured as follows: 1. Risk-based safety indicators: Typology of risk-based indicators (RBIs); Tools for defining RBIs; Requirements for the PSA model; Data sources for RBIs; Types of risks monitored; RBIs and operational safety indicators; Feedback from operating experience; PSO model modification for RBIs; RBI categorization; RBI assessment; RBI applications; Suitable RBI applications. 2. Proposal for risk-based indicators: Acquiring information from operational experience; Method of acquiring safety relevance coefficients for the systems from a PSA model; Indicator definitions; On-line indicators. 3. Annex: Application of RBIs worldwide. (P.A.)

Occupational exposure and ovarian cancer risk.

Science.gov (United States)

Le, Nhu D; Leung, Andy; Brooks-Wilson, Angela; Gallagher, Richard P; Swenerton, Kenneth D; Demers, Paul A; Cook, Linda S

2014-07-01

Relatively little work has been done concerning occupational risk factors in ovarian cancer. Although studies conducted in occupational settings have reported positive associations, their usefulness is generally limited by the lack of information on important confounders. In a population-based case-control study, we assessed risk for developing epithelial ovarian cancer (EOC) associated with occupational exposure while accounting for important confounders. Participants were identified through provincial population-based registries. Lifetime occupational history and information on potential confounding factors were obtained through a self-administered questionnaire. Unconditional logistic regression and the likelihood ratio test were used to assess EOC risk with each occupation (or industry), relative to all other occupations (or industries), adjusting for potential confounders including body mass index, oral contraceptive use, menopausal hormone therapy, parity, age at first childbirth, age at menarche, age at menopause, family history of breast and ovarian cancer in mother and sister(s), tubal ligation, partial oophorectomy, and hysterectomy. Occupations and industries were coded according to the Canadian Standard Occupational Classification (SOC) and Standard Industrial Classification (SIC). Significant excess risk was observed for several groups of teaching occupations, including SOC 27, teaching and related (adjusted OR 1.77, 95% CI 1.15-2.81) and SOC 279, other teaching and related (adjusted OR 3.11, 95% CI 1.35-8.49). Significant excess was also seen for a four-digit occupational group SOC 4131, bookkeepers and accounting clerks (adjusted OR 2.80, 95% CI 1.30-6.80). Industrial sub-groups showing significant excess risk included SIC 65, other retail stores (adjusted OR 2.19, 95 % CI 1.16-4.38); SIC 85, educational service (adjusted OR 1.45, 95% CI 1.00-2.13); and SIC 863, non-institutional health services (adjusted OR 2.54, 95% CI 1.13-6.52). Our study found

The Risks and Rewards of Value-Based Reimbursement.

Science.gov (United States)

Henkel, Robert J; Maryland, Patricia A

2015-01-01

As healthcare systems across the country shift to value-based care, they face an enormous challenge. Not only must they reimagine how they identify, engage, and manage the care of patients, they also need to determine new ways of engaging and aligning physicians and other caregivers in creating better-coordinated care across the continuum. This article explores how healthcare systems making the transition from volume to value can maximize their reward while managing their risk. As the largest not-for-profit healthcare system in the United States and the largest Catholic healthcare system in the world, Ascension is committed to making its own transition, marked by broad-based innovation. We call this goal the Quadruple Aim: improving health outcomes, patient experiences, and provider experiences while lowering the overall cost of care. Healthcare systems and providers have many value-based models to choose from, including pay for performance (P4P), shared savings, bundled payments, shared risk, global capitation, and provider-sponsored health plans. Analysis of these options should include an evaluation of market readiness (i.e., the ability of a health system to align with the needs of employers or commercial insurers in a given market). Healthcare systems also must be prepared to invest in resources that facilitate effective transitions and continuity of care--for example, care management. In addition, they need to recognize that as they focus on wellness, inpatient volumes will decline, requiring cost-structure adjustments and added ancillary services to compensate for this decline. Some healthcare systems are even exploring the possibility of becoming their own payer, taking on more risk and responsibility for the health of patients and populations.

Area-level poverty and preterm birth risk: A population-based multilevel analysis

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DeFranco, Emily A; Lian, Min; Muglia, Louis A; Schootman, Mario

2008-01-01

Background Preterm birth is a complex disease with etiologic influences from a variety of social, environmental, hormonal, genetic, and other factors. The purpose of this study was to utilize a large population-based birth registry to estimate the independent effect of county-level poverty on preterm birth risk. To accomplish this, we used a multilevel logistic regression approach to account for multiple co-existent individual-level variables and county-level poverty rate. Methods Population-based study utilizing Missouri's birth certificate database (1989–1997). We conducted a multilevel logistic regression analysis to estimate the effect of county-level poverty on PTB risk. Of 634,994 births nested within 115 counties in Missouri, two levels were considered. Individual-level variables included demographics factors, prenatal care, health-related behavioral risk factors, and medical risk factors. The area-level variable included the percentage of the population within each county living below the poverty line (US census data, 1990). Counties were divided into quartiles of poverty; the first quartile (lowest rate of poverty) was the reference group. Results PTB rate of PTB poverty and increased through the 4th quartile (4.9%), p poverty was significantly associated with PTB risk. PTB risk (poverty, adjusted odds ratio (adjOR) 1.18 (95% CI 1.03, 1.35), with a similar effect at earlier gestational ages (birth, above other underlying risk factors. Although the risk increase is modest, it affects a large number of pregnancies. PMID:18793437

STUDY ON THE ACCOUNTING OF ADJUSTMENTS FOR RECEIVABLES DEPRECIATION IN OPERATIONS WITH CLIENTS

Directory of Open Access Journals (Sweden)

ILIE RĂSCOLEAN

2015-12-01

Full Text Available The present work approaches an important topic for credit institutions: limiting the credit risk and determining the prudential value adjustments for the depreciation of client credits, and their reflection in the accounting statements. The Chart of Accounts applicable to credit institutions includes class-two accounts Operations with clients and expenses and revenues accounts, which help record the adjustments for receivables depreciation in operations with clients. To constitute, diminish or annul depreciations, credit institutions have the obligation to assure the classification of their credits based on classification categories according to three criteria: financial performance, debt service and initiation of juridical procedures. By the present study, we present the way the credit portfolio is structured according to the criteria mentioned and the reflection in accounting of the prudential adjustments of value. The article ends with the authors’ conclusions regarding the specificity of the way of classification of the credits according to risk categories in agreement to the evolution of the class determination criteria.

Cadmium exposure and endometrial cancer risk: A large midwestern U.S. population-based case-control study.

Directory of Open Access Journals (Sweden)

Jane A McElroy

Full Text Available Estrogen-mimicking chemicals, such as cadmium, may be associated with increased susceptibility to hormone-dependent cancers, though supporting data are sparse, particularly for endometrial cancer. The Health and Environmental Exposure Research (HEER study worked with the Arkansas Central Cancer Registry, Iowa Cancer Registry and Missouri Cancer Registry to obtain names of women diagnosed with endometrial cancer who were willing to be contacted for participation in our case control study. Voter registration lists from Iowa and Missouri were used to randomly select similarly aged women as represented in the case population. Participants were interviewed by telephone to obtain information on known or suspected endometrial risk factors. Urine kits were sent to participants for home collection and returned for analysis. Our case-control study consisted of 631 incident cases of endometrial cancer diagnosed from January 2010 to October 2012 and 879 age-matched population-based controls, ages 18-81 years (mean age 65 years. We quantified cadmium amounts in urine and standardized these values through creatinine adjustment. Using data from all survey completers, we developed a multivariable model for endometrial cancer. Creatinine-adjusted cadmium concentration was added to this model. Odds ratio (OR and 95% confidence intervals (CIs for endometrial cancer were calculated. After multivariable adjustment, higher creatinine-adjusted cadmium exposure was associated with a statistically significant increase of endometrial cancer risk (OR: 1.22; 95% CI: 1.03-1.44. Our results provide evidence that cadmium may increase the risk of endometrial cancer, possibly through estrogenic effects.

Alternative Strategies to Achieve Cardiovascular Mortality Goals in China and India: A Microsimulation of Target- Versus Risk-Based Blood Pressure Treatment.

Science.gov (United States)

Basu, Sanjay; Yudkin, John S; Sussman, Jeremy B; Millett, Christopher; Hayward, Rodney A

2016-03-01

The World Health Organization aims to reduce mortality from chronic diseases including cardiovascular disease (CVD) by 25% by 2025. High blood pressure is a leading CVD risk factor. We sought to compare 3 strategies for treating blood pressure in China and India: a treat-to-target (TTT) strategy emphasizing lowering blood pressure to a target, a benefit-based tailored treatment (BTT) strategy emphasizing lowering CVD risk, or a hybrid strategy currently recommended by the World Health Organization. We developed a microsimulation model of adults aged 30 to 70 years in China and in India to compare the 2 treatment approaches across a 10-year policy-planning horizon. In the model, a BTT strategy treating adults with a 10-year CVD event risk of ≥ 10% used similar financial resources but averted ≈ 5 million more disability-adjusted life-years in both China and India than a TTT approach based on current US guidelines. The hybrid strategy in the current World Health Organization guidelines produced no substantial benefits over TTT. BTT was more cost-effective at $205 to $272/disability-adjusted life-year averted, which was $142 to $182 less per disability-adjusted life-year than TTT or hybrid strategies. The comparative effectiveness of BTT was robust to uncertainties in CVD risk estimation and to variations in the age range analyzed, the BTT treatment threshold, or rates of treatment access, adherence, or concurrent statin therapy. In model-based analyses, a simple BTT strategy was more effective and cost-effective than TTT or hybrid strategies in reducing mortality. © 2016 American Heart Association, Inc.

A STUDY ON THE RISK-ADJUSTED PERFORMANCE OF MUTUAL FUNDS INDUSTRY IN INDIA

Directory of Open Access Journals (Sweden)

Shivangi Agarwal

2017-04-01

Full Text Available Investing through mutual funds has gained interest in recent years as it offers optimal risk adjusted returns to investors. The Indian market is no exception and has witnessed a multifold growth in mutual funds over the years. As of 2016, the Indian market is crowded with over two thousand mutual fund schemes, each promising higher returns compared to their peers. This comes as a challenge for an ordinary investor to select the best portfolio to invest making it critical to analyse the performance of these funds. While understanding and analysing the historical performance of mutual funds do not guarantee future performance, however, this may give an idea of how the fund is likely to perform in different market conditions. In this research we address multiple research issues. These include measuring the performance of selected mutual schemes on the basis of risk and return and compare the performance of these selected schemes with benchmark index to see whether the scheme is outperforming or underperforming the benchmark. We also rank funds on the basis of performance and suggest strategies to invest in a mutual fund and therefore, our findings have significant relevance for investing public.

Mucosal Healing and the Risk of Ischemic Heart Disease or Atrial Fibrillation in Patients with Celiac Disease; A Population-Based Study

Science.gov (United States)

Lebwohl, Benjamin; Emilsson, Louise; Fröbert, Ole; Einstein, Andrew J.; Green, Peter H. R.; Ludvigsson, Jonas F.

2015-01-01

Background Patients with celiac disease (CD), characterized histologically by villous atrophy (VA) of the small intestine, have an increased risk of ischemic heart disease (IHD) and atrial fibrillation (AF), risks that persist for years after commencing the gluten-free diet. It is unknown whether persistent VA on follow-up biopsy, rather than mucosal healing, affects the risk of IHD or AF. Methods We identified patients with histologic evidence of CD diagnosed at all 28 pathology departments in Sweden. Among patients who underwent a follow-up small intestinal biopsy, we compared patients with persistent VA to those who showed histologic improvement, with regard to the development of IHD (angina pectoris or myocardial infarction) or AF. Results Among patients with CD and a follow-up biopsy (n = 7,440), the median age at follow-up biopsy was 25 years, with 1,063 (14%) patients who were ≥60 years at the time of follow-up biopsy. Some 196 patients developed IHD and 205 patients developed AF. After adjusting for age, gender, duration of CD, calendar period, and educational attainment, there was no significant effect of persistent VA on IHD (adjusted HR 0.97; 95%CI 0.73–1.30). Adjusting for diabetes had a negligible effect (adjusted HR 0.98; 95%CI 0.73–1.31). There was no significant association between persistent VA and the risk of AF (adjusted HR 0.98; 95%CI 0.74–1.30). Conclusions In this population-based study of patients with CD, persistent VA on follow-up biopsy was not associated with an increased risk of IHD or AF. Failed mucosal healing does not influence the risk of these cardiac events. PMID:25635403

Evaluating variation in use of definitive therapy and risk-adjusted prostate cancer mortality in England and the USA.

Science.gov (United States)

Sachdeva, Ashwin; van der Meulen, Jan H; Emberton, Mark; Cathcart, Paul J

2015-02-24

Prostate cancer mortality (PCM) in the USA is among the lowest in the world, whereas PCM in England is among the highest in Europe. This paper aims to assess the association of variation in use of definitive therapy on risk-adjusted PCM in England as compared with the USA. Observational study. Cancer registry data from England and the USA. Men diagnosed with non-metastatic prostate cancer (PCa) in England and the USA between 2004 and 2008. Competing-risks survival analyses to estimate subhazard ratios (SHR) of PCM adjusted for age, ethnicity, year of diagnosis, Gleason score (GS) and clinical tumour (cT) stage. 222,163 men were eligible for inclusion. Compared with American patients, English patients were more likely to present at an older age (70-79 years: England 44.2%, USA 29.3%, pUSA 8.6%, pUSA 11.2%, pUSA 77%, pUSA. This difference may be explained by less frequent use of definitive therapy in England. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Balancing the risks and benefits of drinking water disinfection: disability adjusted life-years on the scale.

Science.gov (United States)

Havelaar, A H; De Hollander, A E; Teunis, P F; Evers, E G; Van Kranen, H J; Versteegh, J F; Van Koten, J E; Slob, W

2000-04-01

To evaluate the applicability of disability adjusted life-years (DALYs) as a measure to compare positive and negative health effects of drinking water disinfection, we conducted a case study involving a hypothetical drinking water supply from surface water. This drinking water supply is typical in The Netherlands. We compared the reduction of the risk of infection with Cryptosporidium parvum by ozonation of water to the concomitant increase in risk of renal cell cancer arising from the production of bromate. We applied clinical, epidemiologic, and toxicologic data on morbidity and mortality to calculate the net health benefit in DALYs. We estimated the median risk of infection with C. parvum as 10(-3)/person-year. Ozonation reduces the median risk in the baseline approximately 7-fold, but bromate is produced in a concentration above current guideline levels. However, the health benefits of preventing gastroenteritis in the general population and premature death in patients with acquired immunodeficiency syndrome outweigh health losses by premature death from renal cell cancer by a factor of > 10. The net benefit is approximately 1 DALY/million person-years. The application of DALYs in principle allows us to more explicitly compare the public health risks and benefits of different management options. In practice, the application of DALYs may be hampered by the substantial degree of uncertainty, as is typical for risk assessment.

COX-2 rs689466, rs5275, and rs20417 polymorphisms and risk of head and neck squamous cell carcinoma: a meta-analysis of adjusted and unadjusted data

International Nuclear Information System (INIS)

Leng, Wei-Dong; Wen, Xiu-Jie; Kwong, Joey S. W.; Huang, Wei; Chen, Jian-Gang; Zeng, Xian-Tao

2016-01-01

Numerous case–control studies have been performed to investigate the association between three cyclooxygenase-2 (COX-2) polymorphisms (rs20417 (−765G > C), rs689466 (−1195G > A), and rs5275 (8473 T > C)) and the risk of head and neck squamous cell carcinoma (HNSCC). However, the results were inconsistent. Therefore, we conducted this meta-analysis to investigate the association. We searched in PubMed, Embase, and Web of Science up to January 20, 2015 (last updated on May 12, 2016). Two independent reviewers extracted the data. Odds ratios (ORs) with their 95 % confidence intervals (CIs) were used to assess the association. All statistical analyses were performed using the Review Manager (RevMan) 5.2 software. Finally 8 case–control studies were included in this meta-analysis. For unadjusted data, an association with increased risk was observed in three genetic models in COX-2 rs689466 polymorphism; however, COX-2 rs5275 and rs20417 polymorphisms were not related to HNSCC risk in this study. The pooled results from adjusted data all revealed non-significant association between these three polymorphisms and risk of HNSCC. We also found a similar result in the subgroup analyses, based on both unadjusted data and adjusted data. Current results suggest that COX-2 rs689466, rs5275, and rs20417 polymorphisms are not associated with HNSCC. Further large and well-designed studies are necessary to validate this association

Risk of Nongenitourinary Cancers in Patients With Spinal Cord Injury: A Population-based Cohort Study.

Science.gov (United States)

Kao, Chia-Hong; Sun, Li-Min; Chen, Yueh-Sheng; Lin, Cheng-Li; Liang, Ji-An; Kao, Chia-Hung; Weng, Ming-Wei

2016-01-01

Little information is available regarding the risk of nongenitourinary (GU) cancers in patients with spinal cord injury (SCI). The authors conducted a nationwide population-based study to investigate whether a higher risk of non-GU cancer is seen among patients with SCI.Data retrieved from the National Health Insurance Research Database of Taiwan were used in this study. A total of 41,900 patients diagnosed with SCI between 2000 and 2011 were identified from the National Health Insurance Research Database and comprised the SCI cohort. Each of these patients was randomly frequency matched with 4 people from the general population (without SCI) according to age, sex, comorbidities, and index year. Cox proportional hazards regression analysis was used to calculate adjusted hazard ratios and 95% confidence intervals and determine how SCI affected non-GU cancer risk.No significant difference in overall non-GU cancer risk was observed between the SCI and control groups. The patients with SCI exhibited a significantly higher risk of developing esophageal, liver, and hematologic malignancies compared with those without SCI. By contrast, the SCI cohort had a significantly lower risk of colorectal cancer compared with the non-SCI cohort (adjusted hazard ratio = 0.80, 95% confidence interval = 0.69-0.93). Additional stratified analyses by sex, age, and follow-up duration revealed various correlations between SCI and non-GU cancer risk.The patients with SCI exhibited higher risk of esophageal, liver, and hematologic malignancies but a lower risk of colorectal cancer compared with those without SCI. The diverse patterns of cancer risk among the patients with SCI may be related to the complications of chronic SCI.

Method Based on Confidence Radius to Adjust the Location of Mobile Terminals

DEFF Research Database (Denmark)

García-Fernández, Juan Antonio; Jurado-Navas, Antonio; Fernández-Navarro, Mariano

2017-01-01

The present paper details a technique for adjusting in a smart manner the position estimates of any user equipment given by different geolocation/positioning methods in a wireless radiofrequency communication network based on different strategies (observed time difference of arrival , angle of ar...

Risk of affective disorders following prenatal exposure to severe life events: a Danish population-based cohort study.

LENUS (Irish Health Repository)

Khashan, Ali S

2012-01-31

OBJECTIVE: To examine the effect of prenatal exposure to severe life events on risk of affective disorders in the offspring. METHODS: In a cohort of 1.1 million Danish births from May 1978 until December 1997, mothers were considered exposed if one (or more) of their close relatives died or was diagnosed with serious illness up to 6 months before conception or during pregnancy. Offspring were followed up from their 10th birthday until their death, migration, onset of affective disorder or 31 December 2007; hospital admissions were identified by linkage to the Central Psychiatric Register. Log-linear Poisson regression was used for data analysis. RESULTS: The risk of affective disorders was increased in male offspring whose mothers were exposed to severe life events during the second trimester (adjusted RR 1.55 [95% CI 1.05-2.28]). There was an increased risk of male offspring affective disorders in relation to maternal exposure to death of a relative in the second trimester (adjusted RR 1.74 [95% CI 1.06-2.84]) or serious illness in a relative before pregnancy (adjusted RR 1.44 [95% CI 1.02-2.05]). There was no evidence for an association between prenatal exposure to severe life events and risk of female offspring affective disorders. CONCLUSIONS: Our population-based study suggests that prenatal maternal exposure to severe life events may increase the risk of affective disorders in male offspring. These findings are consistent with studies of populations exposed to famine and earthquake disasters which indicate that prenatal environment may influence the neurodevelopment of the unborn child.

Risk-based cost-benefit analysis for evaluating microbial risk mitigation in a drinking water system.

Science.gov (United States)

Bergion, Viktor; Lindhe, Andreas; Sokolova, Ekaterina; Rosén, Lars

2018-04-01

Waterborne outbreaks of gastrointestinal diseases can cause large costs to society. Risk management needs to be holistic and transparent in order to reduce these risks in an effective manner. Microbial risk mitigation measures in a drinking water system were investigated using a novel approach combining probabilistic risk assessment and cost-benefit analysis. Lake Vomb in Sweden was used to exemplify and illustrate the risk-based decision model. Four mitigation alternatives were compared, where the first three alternatives, A1-A3, represented connecting 25, 50 and 75%, respectively, of on-site wastewater treatment systems in the catchment to the municipal wastewater treatment plant. The fourth alternative, A4, represented installing a UV-disinfection unit in the drinking water treatment plant. Quantitative microbial risk assessment was used to estimate the positive health effects in terms of quality adjusted life years (QALYs), resulting from the four mitigation alternatives. The health benefits were monetised using a unit cost per QALY. For each mitigation alternative, the net present value of health and environmental benefits and investment, maintenance and running costs was calculated. The results showed that only A4 can reduce the risk (probability of infection) below the World Health Organization guidelines of 10 -4 infections per person per year (looking at the 95th percentile). Furthermore, all alternatives resulted in a negative net present value. However, the net present value would be positive (looking at the 50 th percentile using a 1% discount rate) if non-monetised benefits (e.g. increased property value divided evenly over the studied time horizon and reduced microbial risks posed to animals), estimated at 800-1200 SEK (€100-150) per connected on-site wastewater treatment system per year, were included. This risk-based decision model creates a robust and transparent decision support tool. It is flexible enough to be tailored and applied to local

Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study

Science.gov (United States)

Robinson, Emily J; Power, Geraldine S; Nolan, Jerry; Soar, Jasmeet; Spearpoint, Ken; Gwinnutt, Carl; Rowan, Kathryn M

2016-01-01

Background Internationally, hospital survival is lower for patients admitted at weekends and at night. Data from the UK National Cardiac Arrest Audit (NCAA) indicate that crude hospital survival was worse after in-hospital cardiac arrest (IHCA) at night versus day, and at weekends versus weekdays, despite similar frequency of events. Objective To describe IHCA demographics during three day/time periods—weekday daytime (Monday to Friday, 08:00 to 19:59), weekend daytime (Saturday and Sunday, 08:00 to 19:59) and night-time (Monday to Sunday, 20:00 to 07:59)—and to compare the associated rates of return of spontaneous circulation (ROSC) for >20 min (ROSC>20 min) and survival to hospital discharge, adjusted for risk using previously developed NCAA risk models. To consider whether any observed difference could be attributed to differences in the case mix of patients resident in hospital and/or the administered care. Methods We performed a prospectively defined analysis of NCAA data from 27 700 patients aged ≥16 years receiving chest compressions and/or defibrillation and attended by a hospital-based resuscitation team in response to a resuscitation (2222) call in 146 UK acute hospitals. Results Risk-adjusted outcomes (OR (95% CI)) were worse (p20 min 0.88 (0.81 to 0.95); hospital survival 0.72 (0.64 to 0.80)), and night-time (ROSC>20 min 0.72 (0.68 to 0.76); hospital survival 0.58 (0.54 to 0.63)) compared with weekday daytime. The effects were stronger for non-shockable than shockable rhythms, but there was no significant interaction between day/time of arrest and age, or day/time of arrest and arrest location. While many daytime IHCAs involved procedures, restricting the analyses to IHCAs in medical admissions with an arrest location of ward produced results that are broadly in line with the primary analyses. Conclusions IHCAs attended by the hospital-based resuscitation team during nights and weekends have substantially worse outcomes than during

Multidirectional flexible force sensors based on confined, self-adjusting carbon nanotube arrays

Science.gov (United States)

Lee, J.-I.; Pyo, Soonjae; Kim, Min-Ook; Kim, Jongbaeg

2018-02-01

We demonstrate a highly sensitive force sensor based on self-adjusting carbon nanotube (CNT) arrays. Aligned CNT arrays are directly synthesized on silicon microstructures by a space-confined growth technique which enables a facile self-adjusting contact. To afford flexibility and softness, the patterned microstructures with the integrated CNTs are embedded in polydimethylsiloxane structures. The sensing mechanism is based on variations in the contact resistance between the facing CNT arrays under the applied force. By finite element analysis, proper dimensions and positions for each component are determined. Further, high sensitivities up to 15.05%/mN of the proposed sensors were confirmed experimentally. Multidirectional sensing capability could also be achieved by designing multiple sets of sensing elements in a single sensor. The sensors show long-term operational stability, owing to the unique properties of the constituent CNTs, such as outstanding mechanical durability and elasticity.

Calculation of risk-based detection limits for radionuclides in the liquid effluents from Korean nuclear power plants

International Nuclear Information System (INIS)

Cheong, Jae Hak

2017-01-01

In order to review if present detection limits of radionuclides in liquid effluent from nuclear power plants are effective enough to warrant compliance with regulatory discharge limits, a risk-based approach is developed to derive a new detection limit for each radionuclide based on radiological criteria. Equations and adjustment factors are also proposed to discriminate the validity of the detection limits for multiple radionuclides in the liquid effluent with or without consideration of the nuclide composition. From case studies to three nuclear power plants in Korea with actual operation data from 2006 to 2015, the present detection limits have turned out to be effective for Hanul Unit 1 but may not be sensitive enough for Kori Unit 1 (8 out of 14 radionuclides) and Wolsong Unit 1 (9 out of 42 radionuclides). However, it is shown that the present detection limits for the latter two nuclear power plants can be justified, if credit is given to the radionuclide composition. Otherwise, consideration should be given to adjustment of the present detection limits. The risk-based approach of this study can be used to determine the validity of established detection limits of a specific nuclear power plant. (author)

Time synchronization algorithm of distributed system based on server time-revise and workstation self-adjust

International Nuclear Information System (INIS)

Zhou Shumin; Sun Yamin; Tang Bin

2007-01-01

In order to enhance the time synchronization quality of the distributed system, a time synchronization algorithm of distributed system based on server time-revise and workstation self-adjust is proposed. The time-revise cycle and self-adjust process is introduced in the paper. The algorithm reduces network flow effectively and enhances the quality of clock-synchronization. (authors)

Color adjustable LED driver design based on PWM

Science.gov (United States)

Du, Yiying; Yu, Caideng; Que, Longcheng; Zhou, Yun; Lv, Jian

2012-10-01

Light-emitting diode (LED) is a liquid cold source light source that rapidly develops in recent years. The merits of high brightness efficiency, long duration, high credibility and no pollution make it satisfy our demands for consumption and natural life, and gradually replace the traditional lamp-house-incandescent light and fluorescent light. However, because of the high cost and unstable drive circuit, the application range is restricted. To popularize the applications of the LED, we focus on improving the LED driver circuit to change this phenomenon. Basing on the traditional LED drive circuit, we adopt pre-setup constant current model and introduce pulse width modulation (PWM) control method to realize adjustable 256 level-grays display. In this paper, basing on human visual characteristics and the traditional PWM control method, we propose a new PWM control timing clock to alter the duty cycle of PWM signal to realize the simple gamma correction. Consequently, the brightness can accord with our visual characteristics.

Willingness to pay for a quality-adjusted life year: an evaluation of attitudes towards risk and preferences

OpenAIRE

Martín-Fernández, Jesus; Polentinos-Castro, Elena; del Cura-González, Ma Isabel; Ariza-Cardiel, Gloria; Abraira, Victor; Gil-LaCruz, Ana Isabel; García-Pérez, Sonia

2014-01-01

Background This paper examines the Willingness to Pay (WTP) for a quality-adjusted life year (QALY) expressed by people who attended the healthcare system as well as the association of attitude towards risk and other personal characteristics with their response. Methods Health-state preferences, measured by EuroQol (EQ-5D-3L), were combined with WTP for recovering a perfect health state. WTP was assessed using close-ended, iterative bidding, contingent valuation method. Data on demographic an...

Risk-based configuration control

International Nuclear Information System (INIS)

Szikszai, T.

1997-01-01

The presentation discusses the following issues: The Configuration Control; The Risk-based Configuration Control (during power operation mode, and during shutdown mode). PSA requirements. Use of Risk-based Configuration Control System. Configuration Management (basic elements, benefits, information requirements)

A population-based study of race-specific risk for placental abruption

Directory of Open Access Journals (Sweden)

Stamilio David M

2008-09-01

Full Text Available Abstract Background Efforts to elucidate risk factors for placental abruption are imperative due to the severity of complications it produces for both mother and fetus, and its contribution to preterm birth. Ethnicity-based differences in risk of placental abruption and preterm birth have been reported. We tested the hypotheses that race, after adjusting for other factors, is associated with the risk of placental abruption at specific gestational ages, and that there is a greater contribution of placental abruption to the increased risk of preterm birth in Black mothers, compared to White mothers. Methods We conducted a population-based cohort study using the Missouri Department of Health's maternally-linked database of all births in Missouri (1989–1997 to assess racial effects on placental abruption and the contribution of placental abruption to preterm birth, at different gestational age categories (n = 664,303. Results Among 108,806 births to Black mothers and 555,497 births to White mothers, 1.02% (95% CI 0.96–1.08 of Black births were complicated by placental abruption, compared to 0.71% (95% CI 0.69–0.73 of White births (aOR 1.32, 95% CI 1.22–1.43. The magnitude of risk of placental abruption for Black mothers, compared to White mothers, increased with younger gestational age categories. The risk of placental abruption resulting in term and extreme preterm births ( Conclusion Black women have an increased risk of placental abruption compared to White women, even when controlling for known coexisting risk factors. This risk increase is greatest at the earliest preterm gestational ages when outcomes are the poorest. The relative contribution of placental abruption to term births was greater in Black women, whereas the relative contribution of placental abruption to preterm birth was greater in White women.

Why and when is ethnic harassment a risk for immigrant adolescents' school adjustment? understanding the processes and conditions.

Science.gov (United States)

Bayram Özdemir, Sevgi; Stattin, Håkan

2014-08-01

Ethnically harassed immigrant youth are at risk for experiencing a wide range of school adjustment problems. However, it is still unclear why and under what conditions experiencing ethnic harassment leads to school adjustment difficulties. To address this limitation in the literature, we examined two important questions. First, we investigated whether self-esteem and/or depressive symptoms would mediate the associations between ethnic harassment and poor school adjustment among immigrant youth. Second, we examined whether immigrant youths' perception of school context would play a buffering role in the pathways between ethnic harassment and school adjustment difficulties. The sample (n = 330; M age = 14.07, SD = .90; 49% girls at T1) was drawn from a longitudinal study in Sweden. The results revealed that experiencing ethnic harassment led to a decrease in immigrant youths' self-esteem over time, and that youths' expectations of academic failure increased. Further, youths' relationships with their teachers and their perceptions of school democracy moderated the mediation processes. Specifically, when youth had poor relationships with their teachers or perceived their school context as less democratic, being exposed to ethnic harassment led to a decrease in their self-esteem. In turn, they reported low school satisfaction and perceived themselves as being unsuccessful in school. Such indirect effects were not observed when youth had high positive relationships with their teachers or perceived their school as offering a democratic environment. These findings highlight the importance of understanding underlying processes and conditions in the examination of the effects of ethnic devaluation experiences in order to reach a more comprehensive understanding of immigrant youths' school adjustment.

Smoking and the Risk of Hospitalization for Symptomatic Diverticular Disease: A Population-Based Cohort Study from Sweden.

Science.gov (United States)

Humes, David J; Ludvigsson, Jonas F; Jarvholm, Bengt

2016-02-01

Current studies reporting on the risk of smoking and development of symptomatic diverticular disease have reported conflicting results. The aim of this study was to investigate the association between smoking and symptomatic diverticular disease. This is a cohort study : Information was derived from the Swedish Construction Workers Cohort 1971-1993. Patients were selected from construction workers in Sweden. The primary outcome measured was the development of symptomatic diverticular disease and complicated diverticular disease (abscess and perforation) as identified in the Swedish Hospital Discharge Register. Adjusted relative risks of symptomatic diverticular disease according to smoking status were estimated by using negative binomial regression analysis. In total, the study included 232,685 men and 14,592 women. During follow-up, 3891 men and 318 women had a diagnosis of later symptomatic diverticular disease. In men, heavy smokers (≥15 cigarettes a day) had a 1.6-fold increased risk of developing symptomatic diverticular disease compared with nonsmokers (adjusted relative risk, 1.56; 95% CI, 1.42-1.72). There was evidence of a dose-response relationship, because moderate and ex-smokers had a 1.4- and 1.2-fold increased risk compared with nonsmokers (adjusted relative risk, 1.39; 95% CI, 1.27-1.52 and adjusted relative risk, 1.14; 95% CI, 1.04-1.27). These relationships were similar in women, but the risk estimates were less precise owing to smaller numbers. Male ever-smokers had a 2.7-fold increased risk of developing complicated diverticular disease (perforation/abscess) compared with nonsmokers (adjusted relative risks, 2.73; 95% CI, 1.69-4.41). We were unable to account for other confounding variables such as comorbidity, prescription medication, or lifestyle factors. Smoking is associated with symptomatic diverticular disease in both men and women and with an increased risk of developing complicated diverticular disease.

Association between metabolic syndrome and bone fracture risk: A community-based study using a fracture risk assessment tool.

Science.gov (United States)

Yu, Chia-Ying; Chen, Fang-Ping; Chen, Li-Wei; Kuo, Sheng-Fong; Chien, Rong-Nan

2017-12-01

Osteoporosis and metabolic syndrome (MS) share similar risk factors. Previous studies of association between bone marrow density (BMD) and MS are controversial. Moreover, some studies revealed that MS is associated with BMD but not with bone fracture. In clinical practice, patients pay more attention to bone fracture risk than BMD values. Hence, this study aimed to evaluate the association between MS and the 10-year bone fracture risk probability using a fracture risk assessment tool (FRAX) from community-based data. From March 2014 to August 2015, 2689 participants (897 men and 1792 women) were enrolled in this study. Inflammatory cytokines, such as tumor necrosis factor alpha and C-reactive protein, and adipokines were included for analysis.The mean age was 60.2 ± 10.7 years in men and 58.9 ± 9.6 years in women. The percentage of MS was 27.6% in men and 27.9% in women. Participants were divided into 2 groups, those with or without MS. Compared with women without MS, women with MS had a higher rate of fracture risk (22.8% vs 16.3%, P = .001). In contrast, men with MS had a lower rate of fracture risk then men without MS (5.6% vs 12.3%, P = .004). However, MS loss the association with a high bone fracture risk in men based on multivariate logistical regression analysis, after adjusting for confounding factor of body mass index (BMI). Conclusively, the result of regression analysis between MS and the bone fracture risk may be different in men and women, and BMI was an important confounding factor to interfere with the regression analysis. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

New ventures require accurate risk analyses and adjustments.

Science.gov (United States)

Eastaugh, S R

2000-01-01

For new business ventures to succeed, healthcare executives need to conduct robust risk analyses and develop new approaches to balance risk and return. Risk analysis involves examination of objective risks and harder-to-quantify subjective risks. Mathematical principles applied to investment portfolios also can be applied to a portfolio of departments or strategic business units within an organization. The ideal business investment would have a high expected return and a low standard deviation. Nonetheless, both conservative and speculative strategies should be considered in determining an organization's optimal service line and helping the organization manage risk.

Screening Models for Cardiac Risk Evaluation in Emergency Abdominal Surgery. I. Evaluation of the Intraoperative Period Risk based on Data from the Preoperative Period

Directory of Open Access Journals (Sweden)

Mikhail Matveev

2008-04-01

Full Text Available A classification of intraoperative cardio-vascular complications (CVC was performed, based on data from 466 patients subjected to emergency surgery, due to severe abdominal surgical diseases or traumas, in accordance with the severe criteria of ACC/AHA for CVC in noncardiac surgery. There were 370 intraoperative CVC registered, distributed as follows: groups with low risk (148, moderate risk (200, and high risk (22. Patient groups were formed, according to the CVC risk level, during the intraoperative period, for which the determinant factor for the group distribution of patients was the complication with the highest risk. Individual data was collected for each patient, based on 65 indices: age, physical status, diseases, surgical interventions, anaesthesiological information, intra and postoperative cardio-vascular complications, disease outcome, causes of death, cardiovascular disease anamnesis, anamnesis of all other nonsurgical diseases present, laboratory results, results from all imaging and instrumental examinations, etc. On the basis of these indices, a new distribution of the risk factors was implemented, into groups with different levels of risk of CVC during intraoperative period. This result is a solid argument, substantiating the proposal to introduce these adjustments for determining the severity of CVC in the specific conditions of emergency abdominal surgery.

Risk-based regulation: Challenges and opportunities

International Nuclear Information System (INIS)

Bari, R.A.

1995-01-01

Over the last twenty years, man has witnessed a gradual but steady movement toward increased usage of risk-based methods and results in the regulatory process. The ''risk perspective'' as a supportive view to existing (non-risk-based or deterministic) information used in decision making has a firm foothold now in most countries that regulate nuclear power. Furthermore, in the areas outside the nuclear power field, such as health risk assessment, risk-based information is used increasingly to make decisions on potential impacts of chemical, biological, and radiological exposures. Some of the principal concepts and issues that are pertinent to risk-based regulation are reviewed. There is a growing interest in most countries in the use of risk-based methods and results to facilitate decision-making associated with regulatory processes. A summary is presented of the challenges and opportunities related to expanded use of risk-based regulation

Building Adjustable Pre-storm Reservoir Flood-control Release Rules

Science.gov (United States)

Yang, Shun-Nien; Chang, Li-Chiu; Chang, Fi-John; Hsieh, Cheng-Daw

2017-04-01

Typhoons hit Taiwan several times every year, which could cause serious flood disasters. Because mountainous terrains and steep landforms can rapidly accelerate the speed of flood flow during typhoon events, rivers cannot be a stable source of water supply. Reservoirs become the most effective floodwater storage facilities for alleviating flood damages in Taiwan. The pre-storm flood-control release can significantly increase reservoir storage capacity available to store floodwaters for reducing downstream flood damage, while the uncertainties of total forecasted rainfalls are very high in different stages of an oncoming typhoon, which may cause the risk of water shortage in the future. This study proposes adjustable pre-storm reservoir flood-control release rules in three designed operating stages with various hydrological conditions in the Feitsui Reservoir, a pivot reservoir for water supply to Taipei metropolitan in Taiwan, not only to reduce the risk of reservoir flood control and downstream flooding but also to consider water supply. The three operating stages before an oncoming typhoon are defined upon the timings when: (1) typhoon news is issued (3-7days before typhoon hit); (2) the sea warning is issued (2-4 days before typhoon hit); and (3) the land warning is issued (1-2 days before typhoon hit). We simulate 95 historical typhoon events with 3000 initial water levels and build some pre-storm flood-control release rules to adjust the amount of pre-release based on the total forecasted rainfalls at different operating stages. A great number of simulations (68.4 millions) are conducted to extract their major consequences and then build the adjustable pre-storm reservoir flood-control release rules. Accordingly, given a total forecasted rainfall and a water level, reservoir decision makers can easily identify the corresponding rule to tell the amount of pre-release in any stage. The results show that the proposed adjustable pre-release rules can effectively

Risk of tinnitus in patients with sleep apnea: A nationwide, population-based, case-control study.

Science.gov (United States)

Koo, Malcolm; Hwang, Juen-Haur

2017-09-01

To investigate the risk of tinnitus in patients with sleep disturbance or sleep apnea. Case control study. We identified 21,798 middle-aged and elderly patients with otolaryngologist-diagnosed tinnitus between January 1, 2000, and December 31, 2012, from the Longitudinal Health Insurance Database 2000 of the Taiwan National Health Insurance Research Database. A total of 108,990 controls were also identified from the same database based on frequency-matching on 10-year age interval, sex, and year of index date of the cases. Diagnoses of sleep disturbance (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] codes 780.50, 780.52, 307.4) and sleep apnea (ICD-9-CM codes 780.51, 780.53, 780.57) in the cases and controls prior to the index date were assessed. The risks of tinnitus in patients with sleep disturbance and sleep apnea were separately evaluated with multivariate logistic regression analyses. The mean age of the total 130,788 patients was 59.8 years, and 47% of them were males. The risk of tinnitus was higher in patients with sleep disturbance compared to those without the condition (adjusted odds ratio [OR] = 1.13, 95% confidence interval [CI] [95% CI] = 1.11-1.17), and the risk of tinnitus was higher in patients with sleep apnea compared to those without the condition (adjusted OR = 1.36, 95% CI = 1.16-1.60). In this population-based, case-control study, the risk of tinnitus was found to be significantly higher among middle-aged and elderly Taiwanese patients with sleep disturbances, especially with sleep apnea. 3b. Laryngoscope, 127:2171-2175, 2017. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Menstrual and reproductive factors and type 2 diabetes risk: the Japan Public Health Center-based Prospective Study.

Science.gov (United States)

Nanri, Akiko; Mizoue, Tetsuya; Noda, Mitsuhiko; Goto, Atsushi; Sawada, Norie; Tsugane, Shoichiro

2018-04-18

Menstrual and reproductive factors, including age at menarche, parity, and breastfeeding, have been linked to type 2 diabetes risk. We prospectively investigated the association between these factors and type 2 diabetes risk in a large Japanese cohort. Participants were 37,511 women aged 45-75 years who participated in the baseline (1990-1993), second (1995-1998), and third surveys (2000-2003) of the Japan Public Health Center-based Prospective Study and who had no history of diabetes at the second survey. Menstrual and reproductive history was ascertained using questionnaires at the baseline and second surveys. Odds ratios of self-reported, physician-diagnosed type 2 diabetes over the 5-year period from the second survey were estimated using logistic regression. At the third survey, 513 new cases of type 2 diabetes were self-reported. The odds ratios of type 2 diabetes tended to increase with the number of parity, after adjustment for covariates other than body mass index (P for trend = 0.029). The multivariable-adjusted odds ratios (95% confidence interval) of type 2 diabetes for women with ≥3 births was 1.56 (0.96-2.53) compared to those who were nulliparous. The association between parity and type 2 diabetes risk was attenuated after additional adjustment for body mass index (P for trend = 0.12). No factors other than parity were significantly associated with type 2 diabetes risk. Higher parity may be associated with increased risk of type 2 diabetes among Japanese women, partly through increasing body weight. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Comparing treatment effects after adjustment with multivariable Cox proportional hazards regression and propensity score methods

NARCIS (Netherlands)

Martens, Edwin P; de Boer, Anthonius; Pestman, Wiebe R; Belitser, Svetlana V; Stricker, Bruno H Ch; Klungel, Olaf H

PURPOSE: To compare adjusted effects of drug treatment for hypertension on the risk of stroke from propensity score (PS) methods with a multivariable Cox proportional hazards (Cox PH) regression in an observational study with censored data. METHODS: From two prospective population-based cohort

Specifications for adjusted cross section and covariance libraries based upon CSEWG fast reactor and dosimetry benchmarks

International Nuclear Information System (INIS)

Weisbin, C.R.; Marable, J.H.; Collins, P.J.; Cowan, C.L.; Peelle, R.W.; Salvatores, M.

1979-06-01

The present work proposes a specific plan of cross section library adjustment for fast reactor core physics analysis using information from fast reactor and dosimetry integral experiments and from differential data evaluations. This detailed exposition of the proposed approach is intended mainly to elicit review and criticism from scientists and engineers in the research, development, and design fields. This major attempt to develop useful adjusted libraries is based on the established benchmark integral data, accurate and well documented analysis techniques, sensitivities, and quantified uncertainties for nuclear data, integral experiment measurements, and calculational methodology. The adjustments to be obtained using these specifications are intended to produce an overall improvement in the least-squares sense in the quality of the data libraries, so that calculations of other similar systems using the adjusted data base with any credible method will produce results without much data-related bias. The adjustments obtained should provide specific recommendations to the data evaluation program to be weighed in the light of newer measurements, and also a vehicle for observing how the evaluation process is converging. This report specifies the calculational methodology to be used, the integral experiments to be employed initially, and the methods and integral experiment biases and uncertainties to be used. The sources of sensitivity coefficients, as well as the cross sections to be adjusted, are detailed. The formulae for sensitivity coefficients for fission spectral parameters are developed. A mathematical formulation of the least-square adjustment problem is given including biases and uncertainties in methods

76 FR 1889 - Risk-Based Capital Guidelines: Market Risk

Science.gov (United States)

2011-01-11

... ``three-pillar'' framework that includes (i) risk-based capital requirements for credit risk, market risk... incremental risk capital requirement to capture default and credit quality migration risk for non... (advanced approaches rules) (collectively, the credit risk capital rules) \\8\\ by requiring any bank subject...

Associations between screen-based sedentary behavior and cardiovascular disease risk factors in Korean youth.

Science.gov (United States)

Byun, Wonwoo; Dowda, Marsha; Pate, Russell R

2012-04-01

The purposes of this study were to: 1) describe the patterns of screen-based sedentary behaviors, and 2) examine the association between screen-based sedentary behavior and cardiovascular disease (CVD) risk factors in representative Korean children and adolescents, aged 12 to 18 yr, in the Korean National Health and Nutrition Examination Survey. Screen-based sedentary behavior was measured using self-report questionnaires that included items for time spent watching TV and playing PC/video games. Physical activity was measured using items for frequency and duration of moderate-to-vigorous physical activity (MVPA). CVD risk factors such as body mass index (BMI), waist circumference, LDL cholesterol, HDL cholesterol, total cholesterol, triglycerides, glucose, systolic blood pressure, and diastolic blood pressure were measured. Boys spent more time playing PC/video games, and girls spent more time watching TV. After adjusting for age, gender, annual household income, and MVPA, an additional hour of watching TV was significantly associated with the risk of overweight (OR 1.17 [95% CI 1.03-1.33]), high abdominal adiposity (OR 1.27 [1.06-1.51]), and low HDL cholesterol (OR 1.27 [1.10-1.47]). An additional hour spent playing PC/video games also increased the risk of high abdominal adiposity (OR 1.20 [1.03-1.40]). Prospective observations and interventions are needed to determine causal relationships between screen-based sedentary behavior and CVD risk profiles in Korean youth.

Spoken language identification based on the enhanced self-adjusting extreme learning machine approach

Science.gov (United States)

Tiun, Sabrina; AL-Dhief, Fahad Taha; Sammour, Mahmoud A. M.

2018-01-01

Spoken Language Identification (LID) is the process of determining and classifying natural language from a given content and dataset. Typically, data must be processed to extract useful features to perform LID. The extracting features for LID, based on literature, is a mature process where the standard features for LID have already been developed using Mel-Frequency Cepstral Coefficients (MFCC), Shifted Delta Cepstral (SDC), the Gaussian Mixture Model (GMM) and ending with the i-vector based framework. However, the process of learning based on extract features remains to be improved (i.e. optimised) to capture all embedded knowledge on the extracted features. The Extreme Learning Machine (ELM) is an effective learning model used to perform classification and regression analysis and is extremely useful to train a single hidden layer neural network. Nevertheless, the learning process of this model is not entirely effective (i.e. optimised) due to the random selection of weights within the input hidden layer. In this study, the ELM is selected as a learning model for LID based on standard feature extraction. One of the optimisation approaches of ELM, the Self-Adjusting Extreme Learning Machine (SA-ELM) is selected as the benchmark and improved by altering the selection phase of the optimisation process. The selection process is performed incorporating both the Split-Ratio and K-Tournament methods, the improved SA-ELM is named Enhanced Self-Adjusting Extreme Learning Machine (ESA-ELM). The results are generated based on LID with the datasets created from eight different languages. The results of the study showed excellent superiority relating to the performance of the Enhanced Self-Adjusting Extreme Learning Machine LID (ESA-ELM LID) compared with the SA-ELM LID, with ESA-ELM LID achieving an accuracy of 96.25%, as compared to the accuracy of SA-ELM LID of only 95.00%. PMID:29672546

Spoken language identification based on the enhanced self-adjusting extreme learning machine approach.

Science.gov (United States)

Albadr, Musatafa Abbas Abbood; Tiun, Sabrina; Al-Dhief, Fahad Taha; Sammour, Mahmoud A M

2018-01-01

Spoken Language Identification (LID) is the process of determining and classifying natural language from a given content and dataset. Typically, data must be processed to extract useful features to perform LID. The extracting features for LID, based on literature, is a mature process where the standard features for LID have already been developed using Mel-Frequency Cepstral Coefficients (MFCC), Shifted Delta Cepstral (SDC), the Gaussian Mixture Model (GMM) and ending with the i-vector based framework. However, the process of learning based on extract features remains to be improved (i.e. optimised) to capture all embedded knowledge on the extracted features. The Extreme Learning Machine (ELM) is an effective learning model used to perform classification and regression analysis and is extremely useful to train a single hidden layer neural network. Nevertheless, the learning process of this model is not entirely effective (i.e. optimised) due to the random selection of weights within the input hidden layer. In this study, the ELM is selected as a learning model for LID based on standard feature extraction. One of the optimisation approaches of ELM, the Self-Adjusting Extreme Learning Machine (SA-ELM) is selected as the benchmark and improved by altering the selection phase of the optimisation process. The selection process is performed incorporating both the Split-Ratio and K-Tournament methods, the improved SA-ELM is named Enhanced Self-Adjusting Extreme Learning Machine (ESA-ELM). The results are generated based on LID with the datasets created from eight different languages. The results of the study showed excellent superiority relating to the performance of the Enhanced Self-Adjusting Extreme Learning Machine LID (ESA-ELM LID) compared with the SA-ELM LID, with ESA-ELM LID achieving an accuracy of 96.25%, as compared to the accuracy of SA-ELM LID of only 95.00%.

Demography-adjusted tests of neutrality based on genome-wide SNP data

KAUST Repository

Rafajlović, Marina

2014-08-01

Tests of the neutral evolution hypothesis are usually built on the standard model which assumes that mutations are neutral and the population size remains constant over time. However, it is unclear how such tests are affected if the last assumption is dropped. Here, we extend the unifying framework for tests based on the site frequency spectrum, introduced by Achaz and Ferretti, to populations of varying size. Key ingredients are the first two moments of the site frequency spectrum. We show how these moments can be computed analytically if a population has experienced two instantaneous size changes in the past. We apply our method to data from ten human populations gathered in the 1000 genomes project, estimate their demographies and define demography-adjusted versions of Tajima\\'s D, Fay & Wu\\'s H, and Zeng\\'s E. Our results show that demography-adjusted test statistics facilitate the direct comparison between populations and that most of the differences among populations seen in the original unadjusted tests can be explained by their underlying demographies. Upon carrying out whole-genome screens for deviations from neutrality, we identify candidate regions of recent positive selection. We provide track files with values of the adjusted and unadjusted tests for upload to the UCSC genome browser. © 2014 Elsevier Inc.

Type, number or both? A population-based matched case-control study on the risk of fall injuries among older people and number of medications beyond fall-inducing drugs.

Directory of Open Access Journals (Sweden)

Lucie Laflamme

Full Text Available Drug use is a modifiable risk factor for fall-related injuries in older people. Whereas the injurious effect of polypharmacy is established, that of low numbers of medications has not been fully ascertained. Neither do we know whether it is the number per se or the type of medications that actually matters. We assessed this question for fall injuries leading to hospitalization.National register-based, population-based, matched case-control study.Community dwellers aged 65+ years living in Sweden between March 2006 and December 2009.Cases (n = 64,399 were identified in the national inpatient register and four controls per case were randomly matched by gender, date of birth and residential area. The association between number of prescribed medications, assessed through linkage with the Swedish prescribed drug register, and the risk of injurious falls was estimated with odds ratios with 95% confidence intervals using conditional logistic regression, adjusted for demographic and health status.The number of medications was associated with an increased risk of fall injury in a dose-response fashion, even after adjustment for marital status, comorbidity and number of fall-risk-inducing drugs (FRIDs. Using ten or more medications was associated with an almost two-fold higher risk (adjusted OR: 1.76, 95% CI: 1.66 to 1.88. When stratified by use (or not of at least one FRID, the association weakened slightly among both non-users (adjusted OR: 1.50, 95% CI: 1.34 to 1.67 and users (adjusted OR: 1.67, 95% CI: 1.58 to 1.77.In older people, not only large but also small numbers of medications may affect the risk for them to sustain injurious falls. Although the mechanisms lying behind this are complex, the finding challenges the prevention strategies targeting either specific types of medications (FRIDs or high numbers of them.

Type, number or both? A population-based matched case-control study on the risk of fall injuries among older people and number of medications beyond fall-inducing drugs.

Science.gov (United States)

Laflamme, Lucie; Monárrez-Espino, Joel; Johnell, Kristina; Elling, Berty; Möller, Jette

2015-01-01

Drug use is a modifiable risk factor for fall-related injuries in older people. Whereas the injurious effect of polypharmacy is established, that of low numbers of medications has not been fully ascertained. Neither do we know whether it is the number per se or the type of medications that actually matters. We assessed this question for fall injuries leading to hospitalization. National register-based, population-based, matched case-control study. Community dwellers aged 65+ years living in Sweden between March 2006 and December 2009. Cases (n = 64,399) were identified in the national inpatient register and four controls per case were randomly matched by gender, date of birth and residential area. The association between number of prescribed medications, assessed through linkage with the Swedish prescribed drug register, and the risk of injurious falls was estimated with odds ratios with 95% confidence intervals using conditional logistic regression, adjusted for demographic and health status. The number of medications was associated with an increased risk of fall injury in a dose-response fashion, even after adjustment for marital status, comorbidity and number of fall-risk-inducing drugs (FRIDs). Using ten or more medications was associated with an almost two-fold higher risk (adjusted OR: 1.76, 95% CI: 1.66 to 1.88). When stratified by use (or not) of at least one FRID, the association weakened slightly among both non-users (adjusted OR: 1.50, 95% CI: 1.34 to 1.67) and users (adjusted OR: 1.67, 95% CI: 1.58 to 1.77). In older people, not only large but also small numbers of medications may affect the risk for them to sustain injurious falls. Although the mechanisms lying behind this are complex, the finding challenges the prevention strategies targeting either specific types of medications (FRIDs) or high numbers of them.

An Efficient Bundle Adjustment Model Based on Parallax Parametrization for Environmental Monitoring

Science.gov (United States)

Chen, R.; Sun, Y. Y.; Lei, Y.

2017-12-01

With the rapid development of Unmanned Aircraft Systems (UAS), more and more research fields have been successfully equipped with this mature technology, among which is environmental monitoring. One difficult task is how to acquire accurate position of ground object in order to reconstruct the scene more accurate. To handle this problem, we combine bundle adjustment method from Photogrammetry with parallax parametrization from Computer Vision to create a new method call APCP (aerial polar-coordinate photogrammetry). One impressive advantage of this method compared with traditional method is that the 3-dimensional point in space is represented using three angles (elevation angle, azimuth angle and parallax angle) rather than the XYZ value. As the basis for APCP, bundle adjustment could be used to optimize the UAS sensors' pose accurately, reconstruct the 3D models of environment, thus serving as the criterion of accurate position for monitoring. To verity the effectiveness of the proposed method, we test on several UAV dataset obtained by non-metric digital cameras with large attitude angles, and we find that our methods could achieve 1 or 2 times better efficiency with no loss of accuracy than traditional ones. For the classical nonlinear optimization of bundle adjustment model based on the rectangular coordinate, it suffers the problem of being seriously dependent on the initial values, making it unable to converge fast or converge to a stable state. On the contrary, APCP method could deal with quite complex condition of UAS when conducting monitoring as it represent the points in space with angles, including the condition that the sequential images focusing on one object have zero parallax angle. In brief, this paper presents the parameterization of 3D feature points based on APCP, and derives a full bundle adjustment model and the corresponding nonlinear optimization problems based on this method. In addition, we analyze the influence of convergence and

Is Weight-Based Adjustment of Automatic Exposure Control Necessary for the Reduction of Chest CT Radiation Dose?

Energy Technology Data Exchange (ETDEWEB)

Prakash, Priyanka; Kalra, Mannudeep K.; Gilman, Matthew D.; Shepard, Jo Anne O.; Digumarthy, Subba R. [Massachusetts General Hospital and Harvard Medical School, Boston (United States)

2010-02-15

To assess the effects of radiation dose reduction in the chest CT using a weight-based adjustment of the automatic exposure control (AEC) technique. With Institutional Review Board Approval, 60 patients (mean age, 59.1 years; M:F = 35:25) and 57 weight-matched patients (mean age, 52.3 years, M:F = 25:32) were scanned using a weight-adjusted AEC and nonweight- adjusted AEC, respectively on a 64-slice multidetector CT with a 0.984:1 pitch, 0.5 second rotation time, 40 mm table feed/rotation, and 2.5 mm section thickness. Patients were categorized into 3 weight categories; < 60 kg (n = 17), 60-90 kg (n = 52), and > 90 kg (n = 48). Patient weights, scanning parameters, CT dose index volumes (CTDIvol) and dose length product (DLP) were recorded, while effective dose (ED) was estimated. Image noise was measured in the descending thoracic aorta. Data were analyzed using a standard statistical package (SAS/STAT) (Version 9.1, SAS institute Inc, Cary, NC). Compared to the non-weight-adjusted AEC, the weight-adjusted AEC technique resulted in an average decrease of 29% in CTDIvol and a 27% effective dose reduction (p < 0.0001). With weight-adjusted AEC, the CTDIvol decreased to 15.8, 15.9, and 27.3 mGy for the < 60, 60-90 and > 91 kg weight groups, respectively, compared to 20.3, 27.9 and 32.8 mGy, with non-weight adjusted AEC. No significant difference was observed for objective image noise between the chest CT acquired with the non-weight-adjusted (15.0 {+-} 3.1) and weight-adjusted (16.1 {+-} 5.6) AEC techniques (p > 0.05). The results of this study suggest that AEC should be tailored according to patient weight. Without weight-based adjustment of AEC, patients are exposed to a 17 - 43% higher radiation-dose from a chest CT.

Profile of congenital heart disease and correlation to risk adjustment for surgery; an echocardiographic study

International Nuclear Information System (INIS)

Akhtar, K.; Ahmed, W.

2008-01-01

To determine the pattern and profile of Congenital Heart Diseases (CHD) in paediatric patients (age 1 day to 18 years) presenting to a paediatric tertiary referral centre and its correlation to risk adjustment for surgery for congenital heart disease. Over a period of 6 months, 1149 cases underwent 2-D echocardiography. It was a non-probability purposive sampling. This study showed 25% of all referrals had normal hearts. A male preponderance (38%) was observed from 1 year to 5 years age group. Nineteen percent of the cases were categorized as cyanotic CHD with the remaining as acyanotic variety. Tetralogy of Fallot (TOF) represented 10%, Ventricular Septal Defects (VSD) 24%, followed by Patent Ductus Arteriosus (PDA) and Atrial Septal Defect (ASD), which comprised 6.6% and 6.5% respectively. VSD was the most common association in patients with more complex CHD (10%) followed by PDA in 3% and ASD in 1.2% of the cases. Most of the cases were category 2 in the RACHS-1 scoring system. VSD and TOF formed the major groups of cases profiled. Most of the cases recommended for surgery for congenital heart disease belonged to the risk category 2 (28.1%) followed by the risk category 1 (12.7%) of the RACHS-1 scoring system. (author)

Cerebral Perfusion and the Risk of Dementia: A Population-Based Study.

Science.gov (United States)

Wolters, Frank J; Zonneveld, Hazel I; Hofman, Albert; van der Lugt, Aad; Koudstaal, Peter J; Vernooij, Meike W; Ikram, M Arfan

2017-08-22

Cerebral hypoperfusion has previously been associated with mild cognitive impairment and dementia in various cross-sectional studies, but whether hypoperfusion precedes neurodegeneration is unknown. We prospectively determined the association of cerebral perfusion with subsequent cognitive decline and development of dementia. Between 2005 and 2012, we measured cerebral blood flow by 2-dimensional phase-contrast magnetic resonance imaging in participants of the population-based Rotterdam Study without dementia. We determined the association of cerebral perfusion (mL/100mL/min) with risk of dementia (until 2015) using a Cox model, adjusting for age, sex, demographics, cardiovascular risk factors, and apolipoprotein E genotype. We repeated analyses for Alzheimer disease and accounting for stroke. We used linear regression to determine change in cognitive performance during 2 consecutive examination rounds in relation to perfusion. Finally, we investigated whether associations were modified by baseline severity of white matter hyperintensities. Of 4759 participants (median age 61.3 years, 55.2% women) with a median follow-up of 6.9 years, 123 participants developed dementia (97 Alzheimer disease). Lower cerebral perfusion was associated with higher risk of dementia (adjusted hazard ratio, 1.31; 95% confidence interval per standard deviation decrease, 1.07-1.61), similar for Alzheimer disease only, and unaltered by accounting for stroke. Risk of dementia with hypoperfusion was higher with increasing severity of white matter hyperintensities (with severe white matter hyperintensities; hazard ratio, 1.54; 95% confidence interval, 1.11-2.14). At cognitive reexamination after on average 5.7 years, lower baseline perfusion was associated with accelerated decline in cognition (global cognition: β=-0.029, P =0.003), which was similar after excluding those with incident dementia, and again most profound in individuals with higher volume of white matter hyperintensities ( P

RiskREP: Risk-Based Security Requirements Elicitation and Prioritization

OpenAIRE

Herrmann, Andrea; Morali, A.; Etalle, Sandro; Wieringa, Roelf J.; Niedrite, Laila; Strazdina, Renate; Wangler, Benkt

2011-01-01

Companies are under pressure to be in control of their assets but at the same time they must operate as efficiently as possible. This means that they aim to implement “good-enough security‿ but need to be able to justify their security investment plans. In this paper, we present a Risk-Based Requirements Prioritization method (RiskREP) that extends misuse case-based methods with IT architecture based risk assessment and countermeasure definition and prioritization. Countermeasure prioritizati...

12 CFR 567.6 - Risk-based capital credit risk-weight categories.

Science.gov (United States)

2010-01-01

... 12 Banks and Banking 5 2010-01-01 2010-01-01 false Risk-based capital credit risk-weight... CAPITAL Regulatory Capital Requirements § 567.6 Risk-based capital credit risk-weight categories. (a) Risk...)(2) of this section), plus risk-weighted recourse obligations, direct credit substitutes, and certain...

Risk-adjusted impact of administrative costs on the distribution of terminal wealth for long-term investment.

Science.gov (United States)

Guillén, Montserrat; Jarner, Søren Fiig; Nielsen, Jens Perch; Pérez-Marín, Ana M

2014-01-01

The impact of administrative costs on the distribution of terminal wealth is approximated using a simple formula applicable to many investment situations. We show that the reduction in median returns attributable to administrative fees is usually at least twice the amount of the administrative costs charged for most investment funds, when considering a risk-adjustment correction over a reasonably long-term time horizon. The example we present covers a number of standard cases and can be applied to passive investments, mutual funds, and hedge funds. Our results show investors the potential losses they face in performance due to administrative costs.

Risk-based maintenance-Techniques and applications

International Nuclear Information System (INIS)

Arunraj, N.S.; Maiti, J.

2007-01-01

Plant and equipment, however well designed, will not remain safe or reliable if it is not maintained. The general objective of the maintenance process is to make use of the knowledge of failures and accidents to achieve the possible safety with the lowest possible cost. The concept of risk-based maintenance was developed to inspect the high-risk components usually with greater frequency and thoroughness and to maintain in a greater manner, to achieve tolerable risk criteria. Risk-based maintenance methodology provides a tool for maintenance planning and decision making to reduce the probability of failure of equipment and the consequences of failure. In this paper, the risk analysis and risk-based maintenance methodologies were identified and classified into suitable classes. The factors affecting the quality of risk analysis were identified and analyzed. The applications, input data and output data were studied to understand their functioning and efficiency. The review showed that there is no unique way to perform risk analysis and risk-based maintenance. The use of suitable techniques and methodologies, careful investigation during the risk analysis phase, and its detailed and structured results are necessary to make proper risk-based maintenance decisions

Sorting Out the Health Risk in California's State-Based Marketplace.

Science.gov (United States)

Bindman, Andrew B; Hulett, Denis; Gilmer, Todd P; Bertko, John

2016-02-01

To characterize the health risk of enrollees in California's state-based insurance marketplace (Covered California) by metal tier, region, month of enrollment, and plan. 2014 Open-enrollment data from Covered California linked with 2012 hospitalization and emergency department (ED) visit records from statewide all-payer administrative databases. Chronic Illness and Disability Payment System (CDPS) health risk scores derived from an individual's age and sex from the enrollment file and the diagnoses captured in the hospitalization and ED records. CDPS scores were standardized by setting the average to 1.00. Among the 1,286,089 enrollees, 120,573 (9.4 percent) had at least one ED visit and/or a hospitalization in 2012. Higher risk enrollees chose plans with greater actuarial value. The standardized CDPS health risk score was 11 percent higher in the first month of enrollment (1.08; 99 percent CI: 1.07-1.09) than the last month (0.97; 99 percent CI: 0.97-0.97). Four of the 12 plans enrolled 91 percent of individuals; their average health risk scores were each within 3 percent of the marketplace's statewide average. Providing health plans with a means to assess the health risk of their year 1 enrollees allowed them to anticipate whether they would receive or contribute payments to a risk-adjustment pool. After receiving these findings as a part of their negotiations with Covered California, health plans covering the majority of enrollees decreased their initially proposed 2015 rates, saving consumers tens of millions of dollars in potential premiums. © Health Research and Educational Trust.

Risk based surveillance for vector borne diseases

DEFF Research Database (Denmark)

Bødker, Rene

of samples and hence early detection of outbreaks. Models for vector borne diseases in Denmark have demonstrated dramatic variation in outbreak risk during the season and between years. The Danish VetMap project aims to make these risk based surveillance estimates available on the veterinarians smart phones...... in Northern Europe. This model approach may be used as a basis for risk based surveillance. In risk based surveillance limited resources for surveillance are targeted at geographical areas most at risk and only when the risk is high. This makes risk based surveillance a cost effective alternative...... sample to a diagnostic laboratory. Risk based surveillance models may reduce this delay. An important feature of risk based surveillance models is their ability to continuously communicate the level of risk to veterinarians and hence increase awareness when risk is high. This is essential for submission...

Case‐mix adjustment in non‐randomised observational evaluations: the constant risk fallacy

OpenAIRE

Nicholl, Jon

2007-01-01

Observational studies comparing groups or populations to evaluate services or interventions usually require case‐mix adjustment to account for imbalances between the groups being compared. Simulation studies have, however, shown that case‐mix adjustment can make any bias worse.

Biomonitoring-based risk assessment for hexabromocyclododecane (HBCD).

Science.gov (United States)

Aylward, Lesa L; Hays, Sean M

2011-06-01

Hexabromocyclododecane (HBCD) is a brominated flame retardant compound that has been the subject of recent interest and risk assessment efforts due to its detection in a variety of environmental media and in human biological matrices. Because the exposure pathways for HBCD may be varied and exposure estimation uncertain, biomonitoring for HBCD in humans shows promise as a means of reflecting integrated human exposures to HBCD with lower uncertainty than through estimation of external exposures via multiple pathways. Data from numerous biomonitoring studies of HBCD over the past decade indicate that the central tendency of lipid-adjusted serum and human milk concentrations is approximately 1ng/g lipid, with upper bound levels of approximately 20 ng/g lipid. Recent risk assessment evaluations from Health Canada and the European Union have identified points of departure of 10 and 20mg/kg day, respectively, from rat repeated dose studies. The corresponding measured or estimated lipid-adjusted tissue concentrations in the laboratory animals at these points of departure range from 120,000 to 190,000 ng/g lipid. In comparison to these concentrations, the biomonitored human serum and milk concentrations indicate margins of exposure (MOEs) of 6000 to more than 100,000, which are greatly in excess of target MOE values. The use of internal dose measures (both from measurements of tissue concentrations in animal toxicology studies and from human biomonitoring studies) provides risk managers with highly relevant exposure information that is less uncertain than estimated external doses. Copyright © 2011 Elsevier GmbH. All rights reserved.

Risk-adjusted survival for adults following in-hospital cardiac arrest by day of week and time of day: observational cohort study.

Science.gov (United States)

Robinson, Emily J; Smith, Gary B; Power, Geraldine S; Harrison, David A; Nolan, Jerry; Soar, Jasmeet; Spearpoint, Ken; Gwinnutt, Carl; Rowan, Kathryn M

2016-11-01

Internationally, hospital survival is lower for patients admitted at weekends and at night. Data from the UK National Cardiac Arrest Audit (NCAA) indicate that crude hospital survival was worse after in-hospital cardiac arrest (IHCA) at night versus day, and at weekends versus weekdays, despite similar frequency of events. To describe IHCA demographics during three day/time periods-weekday daytime (Monday to Friday, 08:00 to 19:59), weekend daytime (Saturday and Sunday, 08:00 to 19:59) and night-time (Monday to Sunday, 20:00 to 07:59)-and to compare the associated rates of return of spontaneous circulation (ROSC) for >20 min (ROSC>20 min) and survival to hospital discharge, adjusted for risk using previously developed NCAA risk models. To consider whether any observed difference could be attributed to differences in the case mix of patients resident in hospital and/or the administered care. We performed a prospectively defined analysis of NCAA data from 27 700 patients aged ≥16 years receiving chest compressions and/or defibrillation and attended by a hospital-based resuscitation team in response to a resuscitation (2222) call in 146 UK acute hospitals. Risk-adjusted outcomes (OR (95% CI)) were worse (p20 min 0.88 (0.81 to 0.95); hospital survival 0.72 (0.64 to 0.80)), and night-time (ROSC>20 min 0.72 (0.68 to 0.76); hospital survival 0.58 (0.54 to 0.63)) compared with weekday daytime. The effects were stronger for non-shockable than shockable rhythms, but there was no significant interaction between day/time of arrest and age, or day/time of arrest and arrest location. While many daytime IHCAs involved procedures, restricting the analyses to IHCAs in medical admissions with an arrest location of ward produced results that are broadly in line with the primary analyses. IHCAs attended by the hospital-based resuscitation team during nights and weekends have substantially worse outcomes than during weekday daytimes. Organisational or care differences at

Model of personalised risk assessment of phytoestrogen intake based on 11 SNP in ESR1 and ESR2 genes

Directory of Open Access Journals (Sweden)

Radoslav Zidek

2016-12-01

Full Text Available Phytoestrogens can induce biological responses in vertebrates by mimicking or modulating the action or production of endogenous hormones, and because of their structural similarity with estradiol they have the ability to cause estrogenic or anti-estrogenic effects. Risk assessment of phytoestrogens intake may therefore provide important information useful in the adjustment of nutrients composition, as one of nutrigenomics approaches. Proper risk assessment is an essential part of good nutrient composition. The current risk assessment procedures does use an additive effect of genes, but the accumulation of relevant factors do not count with the distribution of risk in the European population. A combination of approaches based on genetic score, along with the use of the data bases like 1000 genomes and dbSNP is a powerful tool for population risk modelling that would provide reasonable results without needs of as testing a representative number of individual genetic profiles.

Localization of an Underwater Control Network Based on Quasi-Stable Adjustment

Science.gov (United States)

Chen, Xinhua; Zhang, Hongmei; Feng, Jie

2018-01-01

There exists a common problem in the localization of underwater control networks that the precision of the absolute coordinates of known points obtained by marine absolute measurement is poor, and it seriously affects the precision of the whole network in traditional constraint adjustment. Therefore, considering that the precision of underwater baselines is good, we use it to carry out quasi-stable adjustment to amend known points before constraint adjustment so that the points fit the network shape better. In addition, we add unconstrained adjustment for quality control of underwater baselines, the observations of quasi-stable adjustment and constrained adjustment, to eliminate the unqualified baselines and improve the results’ accuracy of the two adjustments. Finally, the modified method is applied to a practical LBL (Long Baseline) experiment and obtains a mean point location precision of 0.08 m, which improves by 38% compared with the traditional method. PMID:29570627

Adjustments of microwave-based measurements on coal moisture using natural radioactivity techniques

Energy Technology Data Exchange (ETDEWEB)

Prieto-Fernandez, I.; Luengo-Garcia, J.C.; Alonso-Hidalgo, M.; Folgueras-Diaz, B. [University of Oviedo, Gijon (Spain)

2006-01-07

The use of nonconventional on-line measurements of moisture and ash content in coal is presented. The background research is briefly reviewed. The possibilities of adjusting microwave-based moisture measurements using natural radioactive techniques, and vice versa, are proposed. The results obtained from the simultaneous analysis of moisture and ash content as well as the correlation improvements are shown.

Is Weight-Based Adjustment of Automatic Exposure Control Necessary for the Reduction of Chest CT Radiation Dose?

Science.gov (United States)

Prakash, Priyanka; Gilman, Matthew D.; Shepard, Jo-Anne O.; Digumarthy, Subba R.

2010-01-01

Objective To assess the effects of radiation dose reduction in the chest CT using a weight-based adjustment of the automatic exposure control (AEC) technique. Materials and Methods With Institutional Review Board Approval, 60 patients (mean age, 59.1 years; M:F = 35:25) and 57 weight-matched patients (mean age, 52.3 years, M:F = 25:32) were scanned using a weight-adjusted AEC and non-weight-adjusted AEC, respectively on a 64-slice multidetector CT with a 0.984:1 pitch, 0.5 second rotation time, 40 mm table feed/rotation, and 2.5 mm section thickness. Patients were categorized into 3 weight categories; 90 kg (n = 48). Patient weights, scanning parameters, CT dose index volumes (CTDIvol) and dose length product (DLP) were recorded, while effective dose (ED) was estimated. Image noise was measured in the descending thoracic aorta. Data were analyzed using a standard statistical package (SAS/STAT) (Version 9.1, SAS institute Inc, Cary, NC). Results Compared to the non-weight-adjusted AEC, the weight-adjusted AEC technique resulted in an average decrease of 29% in CTDIvol and a 27% effective dose reduction (p 91 kg weight groups, respectively, compared to 20.3, 27.9 and 32.8 mGy, with non-weight-adjusted AEC. No significant difference was observed for objective image noise between the chest CT acquired with the non-weight-adjusted (15.0 ± 3.1) and weight-adjusted (16.1 ± 5.6) AEC techniques (p > 0.05). Conclusion The results of this study suggest that AEC should be tailored according to patient weight. Without weight-based adjustment of AEC, patients are exposed to a 17 - 43% higher radiation-dose from a chest CT. PMID:20046494

Droop Control with an Adjustable Complex Virtual Impedance Loop based on Cloud Model Theory

DEFF Research Database (Denmark)

Li, Yan; Shuai, Zhikang; Xu, Qinming

2016-01-01

Droop control framework with an adjustable virtual impedance loop is proposed in this paper, which is based on the cloud model theory. The proposed virtual impedance loop includes two terms: a negative virtual resistor and an adjustable virtual inductance. The negative virtual resistor term...... sometimes. The cloud model theory is applied to get online the changing line impedance value, which relies on the relevance of the reactive power responding the changing line impedance. The verification of the proposed control strategy is done according to the simulation in a low voltage microgrid in Matlab....

Gender adjustment or stratification in discerning upper extremity musculoskeletal disorder risk?

Science.gov (United States)

Silverstein, Barbara; Fan, Z Joyce; Smith, Caroline K; Bao, Stephen; Howard, Ninica; Spielholz, Peregrin; Bonauto, David; Viikari-Juntura, Eira

2009-03-01

The aim was to explore whether "adjustment" for gender masks important exposure differences between men and women in a study of rotator cuff syndrome (RCS) and carpal tunnel syndrome (CTS) and work exposures. This cross-sectional study of 733 subjects in 12 health care and manufacturing workplaces used detailed individual health and work exposure assessment methods. Multiple logistic regression analysis was used to compare gender stratified and adjusted models. Prevalence of RCS and CTS among women was 7.1% and 11.3% respectively, and among men 7.8% and 6.4%. In adjusted (gender, age, body mass index) multivariate analyses of RCS and CTS, gender was not statistically significantly different. For RCS, upper arm flexion >/=45 degrees and forceful pinch increased the odds in the gender-adjusted model (OR 2.66, 95% CI 1.26-5.59) but primarily among women in the stratified analysis (OR 6.68, 95% CI 1.81-24.66 versus OR 1.45, 95% CI 0.53-4.00). For CTS, wrist radial/ulnar deviation >/=4% time and lifting >/=4.5kg >3% time, the adjusted OR was higher for women (OR 4.85, 95% CI 2.12-11.11) and in the gender stratified analyses, the odds were increased for both genders (women OR 5.18, 95% CI 1.70-15.81 and men OR 3.63, 95% CI 1.08-12.18). Gender differences in response to physical work exposures may reflect gender segregation in work and potential differences in pinch and lifting capacity. Reduction in these exposures may reduce prevalence of upper extremity disorders for all workers.

Autoimmune diseases and severe infections as risk factors for schizophrenia: a 30-year population-based register study.

Science.gov (United States)

Benros, Michael E; Nielsen, Philip R; Nordentoft, Merete; Eaton, William W; Dalton, Susanne O; Mortensen, Preben B

2011-12-01

Autoimmune diseases have been associated with an increased risk of schizophrenia. It has been suggested that brain-reactive autoantibodies are part of the mechanisms behind this association. Furthermore, an increased permeability of the blood-brain barrier has been observed during periods of infection and inflammation. The authors therefore investigated whether autoimmune diseases combined with exposures to severe infections may increase the risk of schizophrenia Nationwide population-based registers in Denmark were linked, and the data were analyzed in a cohort study using survival analysis. All analyses were adjusted for calendar year, age, and sex. Incidence rate ratios and accompanying 95% confidence intervals (CIs) as measures of relative risk were used. A prior autoimmune disease increased the risk of schizophrenia by 29% (incidence rate ratio=1.29; 95% CI=1.18-1.41). Any history of hospitalization with infection increased the risk of schizophrenia by 60% (incidence rate ratio=1.60; 95% CI=1.56-1.64). When the two risk factors were combined, the risk of schizophrenia was increased even further (incidence rate ratio=2.25; 95% CI=2.04-2.46). The risk of schizophrenia was increased in a dose-response relationship, where three or more infections and an autoimmune disease were associated with an incidence rate ratio of 3.40 (95% CI=2.91-3.94). The results remained significant after adjusting for substance use disorders and family history of psychiatric disorders. Hospital contact with infection occurred in nearly 24% of individuals prior to a schizophrenia diagnosis. Autoimmune disease and the number of infections requiring hospitalization are risk factors for schizophrenia. The increased risk is compatible with an immunological hypothesis in subgroups of schizophrenia patients.

Calculating disability-adjusted life years (DALY) as a measure of excess cancer risk following radiation exposure

International Nuclear Information System (INIS)

Shimada, K; Kai, M

2015-01-01

This paper has proposed that disability-adjusted life year (DALY) can be used as a measure of radiation health risk. DALY is calculated as the sum of years of life lost (YLL) and years lived with disability (YLD). This multidimensional concept can be expressed as a risk index without a probability measure to avoid the misuse of the current radiation detriment at low doses. In this study, we calculated YLL and YLD using Japanese population data by gender. DALY for all cancers in Japan per 1 Gy per person was 0.84 year in men and 1.34 year in women. The DALY for all cancers in the Japanese baseline was 4.8 in men and 3.5 in women. When we calculated the ICRP detriment from the same data, DALYs for the cancer sites were similar to the radiation detriment in the cancer sites, excluding leukemia, breast and thyroid cancer. These results suggested that the ICRP detriment overestimate the weighting fraction of leukemia risk and underestimate the weighting fraction of breast and thyroid cancer. A big advantage over the ICRP detriment is that DALY can calculate the risk components for non-fatal diseases without the data of lethality. This study showed that DALY is a practical tool that can compare many types of diseases encountered in public health. (paper)

A Comparative Study of CAPM and Seven Factors Risk Adjusted Return Model

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Madiha Riaz Bhatti

2014-12-01

Full Text Available This study is a comparison and contrast of the predictive powers of two asset pricing models: CAPM and seven factor risk-return adjusted model, to explain the cross section of stock rate of returns in the financial sector listed at Karachi Stock Exchange (KSE. To test the models daily returns from January 2013 to February 2014 have been taken and the excess returns of portfolios are regressed on explanatory variables. The results of the tested models indicate that the models are valid and applicable in the financial market of Pakistan during the period under study, as the intercepts are not significantly different from zero. It is consequently established from the findings that all the explanatory variables explain the stock returns in the financial sector of KSE. In addition, the results of this study show that addition of more explanatory variables to the single factor CAPM results in reasonably high values of R2. These results provide substantial support to fund managers, investors and financial analysts in making investment decisions.

A Community-Based Randomized Trial of Hepatitis B Screening Among High-Risk Vietnamese Americans.

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Ma, Grace X; Fang, Carolyn Y; Seals, Brenda; Feng, Ziding; Tan, Yin; Siu, Philip; Yeh, Ming Chin; Golub, Sarit A; Nguyen, Minhhuyen T; Tran, Tam; Wang, Minqi

2017-03-01

To evaluate the effectiveness of a community-based liver cancer prevention program on hepatitis B virus (HBV) screening among low-income, underserved Vietnamese Americans at high risk. We conducted a cluster randomized trial involving 36 Vietnamese community-based organizations and 2337 participants in Pennsylvania, New Jersey, and New York City between 2009 and 2014. We randomly assigned 18 community-based organizations to a community-based multilevel HBV screening intervention (n = 1131). We randomly assigned the remaining 18 community-based organizations to a general cancer education program (n = 1206), which included information about HBV-related liver cancer prevention. We assessed HBV screening rates at 6-month follow-up. Intervention participants were significantly more likely to have undergone HBV screening (88.1%) than were control group participants (4.6%). In a Cochran-Mantel-Haenszel analysis, the intervention effect on screening outcomes remained statistically significant after adjustment for demographic and health care access variables, including income, having health insurance, having a regular health provider, and English proficiency. A community-based, culturally appropriate, multilevel HBV screening intervention effectively increases screening rates in a high-risk, hard-to-reach Vietnamese American population.

Migraine and risk of stroke: a national population-based twin study.

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Lantz, Maria; Sieurin, Johanna; Sjölander, Arvid; Waldenlind, Elisabet; Sjöstrand, Christina; Wirdefeldt, Karin

2017-10-01

Numerous studies have indicated an increased risk for stroke in patients with migraine, especially migraine with aura; however, many studies used self-reported migraine and only a few controlled for familial factors. We aimed to investigate migraine as a risk factor for stroke in a Swedish population-based twin cohort, and whether familial factors contribute to an increased risk. The study population included twins without prior cerebrovascular disease who answered a headache questionnaire during 1998 and 2002 for twins born 1935-58 and during 2005-06 for twins born between 1959 and 1985. Migraine with and without aura and probable migraine was defined by an algorithm mapping on to clinical diagnostic criteria according to the International Classification of Headache Disorders. Stroke diagnoses were obtained from the national patient and cause of death registers. Twins were followed longitudinally, by linkage of national registers, from date of interview until date of first stroke, death, or end of study on 31 Dec 2014. In total, 8635 twins had any migraineous headache, whereof 3553 had migraine with aura and 5082 had non-aura migraineous headache (including migraine without aura and probable migraine), and 44 769 twins had no migraine. During a mean follow-up time of 11.9 years we observed 1297 incident cases of stroke. The Cox proportional hazards model with attained age as underlying time scale was used to estimate hazard ratios with 95% confidence intervals for stroke including ischaemic and haemorrhagic subtypes related to migraine with aura, non-aura migraineous headache, and any migraineous headache. Analyses were adjusted for gender and cardiovascular risk factors. Where appropriate; within-pair analyses were performed to control for confounding by familial factors. The age- and gender-adjusted hazard ratio for stroke related to migraine with aura was 1.27 (95% confidence interval 1.00-1.62), P = 0.05, and 1.07 (95% confidence interval 0.91-1.26), P = 0

[The motive force of evolution based on the principle of organismal adjustment evolution.].

Science.gov (United States)

Cao, Jia-Shu

2010-08-01

From the analysis of the existing problems of the prevalent theories of evolution, this paper discussed the motive force of evolution based on the knowledge of the principle of organismal adjustment evolution to get a new understanding of the evolution mechanism. In the guide of Schrodinger's theory - "life feeds on negative entropy", the author proposed that "negative entropy flow" actually includes material flow, energy flow and information flow, and the "negative entropy flow" is the motive force for living and development. By modifying my own theory of principle of organismal adjustment evolution (not adaptation evolution), a new theory of "regulation system of organismal adjustment evolution involved in DNA, RNA and protein interacting with environment" is proposed. According to the view that phylogenetic development is the "integral" of individual development, the difference of negative entropy flow between organisms and environment is considered to be a motive force for evolution, which is a new understanding of the mechanism of evolution. Based on such understanding, evolution is regarded as "a changing process that one subsystem passes all or part of its genetic information to the next generation in a larger system, and during the adaptation process produces some new elements, stops some old ones, and thereby lasts in the larger system". Some other controversial questions related to evolution are also discussed.

Increased risk of acute angle closure in retinitis pigmentosa: a population-based case-control study.

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Yu-Chieh Ko

Full Text Available To investigate the association between retinitis pigmentosa (RP and acute angle closure during a 15-year follow-up period.Using the Taiwan Longitudinal Health Insurance Database 2000, we identified 382 RP patients based on the diagnostic code of RP (International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM 362.74 made during 1996-2010, excluding subjects under age of 20 years at diagnosis or subjects undergoing lens extraction before the index date. The control group included 3820 randomly selected non-RP subjects matched with the RP patients in age, gender and the index date of diagnosis. The incidence of acute angle closure during the study period was observed based on an ICD-9-CM code of 365.22. Cochran-Mantel-Haenszel test was used to determine the odds ratio (OR of having acute angle closure in RP patients.The mean age at the diagnosis of RP was 51.1 years (standard deviation [SD] 16.7. Acute angle closure occurred in 5 RP patients (1.3% and in 15 controls (0.4%. The mean age with the acute angle closure was 53.3 years (SD 8.0 in RP patients and 64.6 years (SD 8.4 in controls (P = 0.015. After adjusting for age, gender and comorbid disorders, RP patients had 3.64-fold (95% confidence interval [CI], 1.29-10.25, P<0.001 greater odds of having acute angle closure. After stratification for gender and age, the risk of acute angle closure in RP was higher in patients under age of 60 years (adjusted OR 11.84; 95% CI, 2.84-49.48 and male patients (adjusted OR 19.36; 95% CI, 3.43-109.40 (both P = 0.001.RP patients had increased risk of acute angle closure than controls. Contrary to the fact that angle closure disease is more prevalent in elderly females in general population, acute angle closure attack occurred earlier in life and the risk was higher in males among RP patients.

The influence of school-based natural mentoring relationships on school attachment and subsequent adolescent risk behaviors.

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Black, David S; Grenard, Jerry L; Sussman, Steve; Rohrbach, Louise A

2010-10-01

A relatively new area of research suggests that naturally occurring mentoring relationships may influence the development of adolescents by protecting against risk behaviors. Few studies have explored how these relationships function to reduce risk behavior among youth, especially in the school context. Based on previous research and theory, we proposed and tested a mediation model, which hypothesized that school attachment mediated the longitudinal association between school-based natural mentoring relationships and risk behaviors, including eight indicators of substance use and violence. Students (N = 3320) from 65 high schools across eight states completed a self-report questionnaire at baseline and 1-year follow-up. The sample was comprised of youth with an average age of 14.8 years and an almost equal percentage of females (53%) and males from various ethnic backgrounds. Tests for mediation were conducted in Mplus using path analysis with full information maximum likelihood procedures and models adjusted for demographic covariates and baseline level of the dependent variable. Results suggested that natural mentoring relationships had a protective indirect influence on all eight risk behaviors through its positive association on the school attachment mediator. Implications are discussed for strengthening the association between school-based natural mentoring and school attachment to prevent risk behaviors among youth.

Obesity and Cardiovascular Risk: Variations in Visfatin Gene Can Modify the Obesity Associated Cardiovascular Risk. Results from the Segovia Population Based-Study. Spain.

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María Teresa Martínez Larrad

Full Text Available Our aim was to investigate if genetic variations in the visfatin gene (SNPs rs7789066/ rs11977021/rs4730153 could modify the cardiovascular-risk (CV-risk despite the metabolic phenotype (obesity and glucose tolerance. In addition, we investigated the relationship between insulin sensitivity and variations in visfatin gene.A population-based study in rural and urban areas of the Province of Segovia, Spain, was carried out in the period of 2001-2003 years. A total of 587 individuals were included, 25.4% subjects were defined as obese (BMI ≥30 Kg/m2.Plasma visfatin levels were significantly higher in obese subjects with DM2 than in other categories of glucose tolerance. The genotype AA of the rs4730153 SNP was significantly associated with fasting glucose, fasting insulin and HOMA-IR (Homeostasis model assessment-insulin resistance after adjustment for gender, age, BMI and waist circumference. The obese individuals carrying the CC genotype of the rs11977021 SNP showed higher circulating levels of fasting proinsulin after adjustment for the same variables. The genotype AA of the rs4730153 SNP seems to be protective from CV-risk either estimated by Framingham or SCORE charts in general population; and in obese and non-obese individuals. No associations with CV-risk were observed for other studied SNPs (rs11977021/rs7789066.In summary, this is the first study which concludes that the genotype AA of the rs4730153 SNP appear to protect against CV-risk in obese and non-obese individuals, estimated by Framingham and SCORE charts. Our results confirm that the different polymorphisms in the visfatin gene might be influencing the glucose homeostasis in obese individuals.

Risk factors for acute Toxoplasma gondii diseases in Taiwan: a population-based case-control study.

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Ting-Yi Chiang

Full Text Available Although human toxoplasmosis is a notifiable disease in Taiwan since 2007, little is known about its risk factors. This study aimed to investigate the risk factors for acute Toxoplasma gondii diseases in Taiwan. We conducted a nationwide population-based case-control study. Cases of acute human toxoplasmosis notified to the Taiwan Centers for Diseases Control (Taipei, Taiwan during 2008-2013 were compared with controls that were randomly selected from healthy T. gondii-seronegative blood donors who participated in a nationwide T. gondii seroepidemiologic study during 2009-2010. Cases and controls were matched according to age, gender and residency at an 1:8 ratio. Structured questionnaires were used to gather information regarding risk factors. A total of 30 laboratory-confirmed acute T. gondii disease cases and 224 controls were enrolled. The most common clinical manifestation of the cases was flu-like symptoms (n = 20, followed by central nervous system disease (n = 4, ocular diseases (n = 3, abortion (n = 2, and congenital infection (n = 1. Multivariate conditional logistic regression showed that raw clam consumption (adjusted odds ratio [OR] = 3.7; 95% confidence interval [CI] = 1.4-9.9 and having a cat in the household (adjusted OR = 2.9; 95% CI = 1.1-7.9 were two independent risk factors for acute T. gondii disease. We conclude that raw shellfish consumption and domestic cat exposure were risk factors for acquiring acute T. gondii diseases in Taiwan. This finding may guide future research and control policies.

Water risk assessment in China based on the improved Water Risk Filter

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Hong, G.; Yaqin, Q.; Qiong, L.; Cunwen, N.; Na, W.; Jiajia, L.; Jongde, G.; Na, Z.; Xiangyi, D.

2014-09-01

Finding an effective way to deal with the water crisis and the relationship between water and development is a major issue for all levels of government and different economic sectors across the world. Scientific understanding of water risk is the basis for achieving a scientific relationship between water and development, and water risk assessment is currently an important research focus. To effectively deal with the global water crisis, the World Wide Fund for Nature and German Investment and Development Company Limited proposed the concept of water risk and released an online Water Risk Filter in March 2012, which has been applied to at least 85 countries. To comprehensively and accurately reflect the situation of water risk in China, this study adjusts the water risk assessment indicators in the Water Risk Filter, taking the actual situation in China and the difficulty of obtaining the information about the indicators into account, and proposes an index system for water risk evaluation for China which consists of physical risk, regulatory risk and reputational risk. The improved Water Risk Filter is further used to assess the sources and causes of the water risks in 10 first-class and seven second-class water resource areas (WRAs). The results indicate that the water risk for the whole country is generally medium and low, while those for different regions in the country vary greatly, and those for southern regions are generally lower than those for northern regions. Government regulatory and policy implementation as well as media supervision in northern regions should be strengthened to reduce the water risk. The research results may provide decision support and references for both governments and industrial enterprises in identifying water risks, formulating prevention and control policies, and improving water resources management in China.

Water risk assessment in China based on the improved Water Risk Filter

Directory of Open Access Journals (Sweden)

G. Hong

2014-09-01

Full Text Available Finding an effective way to deal with the water crisis and the relationship between water and development is a major issue for all levels of government and different economic sectors across the world. Scientific understanding of water risk is the basis for achieving a scientific relationship between water and development, and water risk assessment is currently an important research focus. To effectively deal with the global water crisis, the World Wide Fund for Nature and German Investment and Development Company Limited proposed the concept of water risk and released an online Water Risk Filter in March 2012, which has been applied to at least 85 countries. To comprehensively and accurately reflect the situation of water risk in China, this study adjusts the water risk assessment indicators in the Water Risk Filter, taking the actual situation in China and the difficulty of obtaining the information about the indicators into account, and proposes an index system for water risk evaluation for China which consists of physical risk, regulatory risk and reputational risk. The improved Water Risk Filter is further used to assess the sources and causes of the water risks in 10 first-class and seven second-class water resource areas (WRAs. The results indicate that the water risk for the whole country is generally medium and low, while those for different regions in the country vary greatly, and those for southern regions are generally lower than those for northern regions. Government regulatory and policy implementation as well as media supervision in northern regions should be strengthened to reduce the water risk. The research results may provide decision support and references for both governments and industrial enterprises in identifying water risks, formulating prevention and control policies, and improving water resources management in China.

Children's adjustment to their divorced parents' new relationships.

Science.gov (United States)

Isaacs, Ar

2002-08-01

With new relationships common after divorce, researchers have tried to determine the factors that predict how well children adjust to their stepfamily. The many potential factors are often grouped into the categories of family process, individual risk and vulnerability, and ecological variables. Family process is concentrated on the impact of disrupted family relationships; positive outcomes are associated with low conflict and authoritative parenting. Individual risk and vulnerability includes attributes of the child and the adults; positive outcomes are associated with children who have an easy temperament. Adolescents and girls may have particular difficulty adjusting. Ecological perspectives include the larger social environment such as peers and school.

Contract Design: Risk Management and Evaluation.

Science.gov (United States)

Mühlbacher, Axel C; Amelung, Volker E; Juhnke, Christin

2018-01-12

Effective risk adjustment is an aspect that is more and more given weight on the background of competitive health insurance systems and vital healthcare systems. The risk structure of the providers plays a vital role in Pay for Performance. A prerequisite for optimal incentive-based service models is a (partial) dependence of the agent's returns on the provider's gain level. Integrated care systems as well as accountable care organisations (ACOs) in the US and similar concepts in other countries are advocated as an effective method of improving the performance of healthcare systems. These systems outline a payment and care delivery model that intends to tie provider reimbursements to predefined quality metrics. By this the total costs of care shall be reduced. Little is known about the contractual design and the main challenges of delegating "accountability" to these new kinds of organisations and/or contracts. The costs of market utilisation are highly relevant for the conception of healthcare contracts; furthermore information asymmetries and contract-specific investments are an obstacle to the efficient operation of ACOs. A comprehensive literature review on methods of designing contracts in Integrated Care was conducted. The research question in this article focuses on how reimbursement strategies, evaluation of measures and methods of risk adjustment can best be integrated in healthcare contracting. Each integrated care contract includes challenges for both payers and providers without having sufficient empirical data on both sides. These challenges are clinical, administrative or financial nature. Risk adjusted contracts ensure that the reimbursement roughly matches the true costs resulting from the morbidity of a population. If reimbursement of care provider corresponds to the actual expenses for an individual/population the problem of risk selection is greatly reduced. The currently used methods of risk adjustment have widely differing model and forecast

A population-based case-control study on statin exposure and risk of acute diverticular disease.

Science.gov (United States)

Sköldberg, Filip; Svensson, Tobias; Olén, Ola; Hjern, Fredrik; Schmidt, Peter T; Ljung, Rickard

2016-01-01

A reduced risk of perforated diverticular disease among individuals with current statin exposure has been reported. The aim of the present study was to investigate whether statins reduce the risk of acute diverticular disease. A nation-wide population-based case-control study was performed, including 13,127 cases hospitalised during 2006-2010 with a first-time diagnosis of colonic diverticular disease, and 128,442 control subjects (matched for sex, age, county of residence and calendar year). Emergency surgery, assumed to be a proxy for complicated diverticulitis, was performed on 906 of the cases during the index admission, with 8818 matched controls. Statin exposure was classified as "current" or "former" if a statin prescription was last dispensed ≤ 125 days or >125 days before index date, respectively. The association between statin exposure and acute diverticular disease was investigated by conditional logistic regression, including models adjusting for country of birth, educational level, marital status, comorbidities, nonsteroidal anti-inflammatory drug/steroid exposure and healthcare utilisation. A total of 1959 cases (14.9%) and 16,456 controls (12.8%) were current statin users (crude OR 1.23 [95% CI 1.17-1.30]; fully adjusted OR 1.00 [0.94-1.06]). One hundred and thirty-two of the cases subjected to surgery (14.6%), and 1441 of the corresponding controls (16.3%) were current statin users (crude OR 0.89 [95% CI 0.73-1.08]; fully adjusted OR 0.70 [0.55-0.89]). The results do not indicate that statins affect the development of symptomatic diverticular disease in general. However, current statin use was associated with a reduced risk of emergency surgery for diverticular disease.

Recipient Age and Mortality Risk after Liver Transplantation: A Population-Based Cohort Study.

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Chen, Hsiu-Pin; Tsai, Yung-Fong; Lin, Jr-Rung; Liu, Fu-Chao; Yu, Huang-Ping

2016-01-01

The aim of the present large population-based cohort study is to explore the risk factors of age-related mortality in liver transplant recipients in Taiwan. Basic information and data on medical comorbidities for 2938 patients who received liver transplants between July 1, 1998, and December 31, 2012, were extracted from the National Health Insurance Research Database on the basis of ICD-9-codes. Mortality risks were analyzed after adjusting for preoperative comorbidities and compared among age cohorts. All patients were followed up until the study endpoint or death. This study finally included 2588 adults and 350 children [2068 (70.4%) male and 870 (29.6%) female patients]. The median age at transplantation was 52 (interquartile range, 43-58) years. Recipients were categorized into the following age cohorts: recipients (≥60 years), especially dialysis patients, have a higher mortality rate, possibly because they have more medical comorbidities. Our findings should make clinicians aware of the need for better risk stratification among elderly liver transplantation candidates.

Predicting Couples’ Happiness Based on Spiritual Intelligence and Lovemaking Styles: The Mediating Role of Marital adjustment

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ZAHRA KERMANI MAMAZANDI

2017-02-01

Full Text Available The purpose of this study was to predict couples’ happiness based on spiritual intelligence and lovemaking styles with the mediating role of marital adjustment. Therefore 360 male and female, married students living in Tehran University dormitory were randomly selected and were asked to answer the items of Sternberg’s Love Questionnaire, King’s Spiritual Intelligence Scale, Oxford’s Happiness Questionnaire and Spanier’s Marital Adjustment Questionnaire. Structural equation modeling (path analysis was used for data analysis. The results  of path analysis showed  that spiritual intelligence and lovemaking styles have direct effects on couples’ happiness, and the spiritual intelligence did not have an indirect effect on couples’ happiness whereas lovemaking styles had indirect effects on couples’ happiness through martial satisfaction. Altogether the results of this research show that marital adjustment has a mediating role in predicting couples’ happiness based on spiritual intelligence and lovemaking styles.

Risk-based and deterministic regulation

International Nuclear Information System (INIS)

Fischer, L.E.; Brown, N.W.

1995-07-01

Both risk-based and deterministic methods are used for regulating the nuclear industry to protect the public safety and health from undue risk. The deterministic method is one where performance standards are specified for each kind of nuclear system or facility. The deterministic performance standards address normal operations and design basis events which include transient and accident conditions. The risk-based method uses probabilistic risk assessment methods to supplement the deterministic one by (1) addressing all possible events (including those beyond the design basis events), (2) using a systematic, logical process for identifying and evaluating accidents, and (3) considering alternative means to reduce accident frequency and/or consequences. Although both deterministic and risk-based methods have been successfully applied, there is need for a better understanding of their applications and supportive roles. This paper describes the relationship between the two methods and how they are used to develop and assess regulations in the nuclear industry. Preliminary guidance is suggested for determining the need for using risk based methods to supplement deterministic ones. However, it is recommended that more detailed guidance and criteria be developed for this purpose

Association of a Dietary Score with Incident Type 2 Diabetes: The Dietary-Based Diabetes-Risk Score (DDS.

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Ligia J Dominguez

Full Text Available Strong evidence supports that dietary modifications may decrease incident type 2 diabetes mellitus (T2DM. Numerous diabetes risk models/scores have been developed, but most do not rely specifically on dietary variables or do not fully capture the overall dietary pattern. We prospectively assessed the association of a dietary-based diabetes-risk score (DDS, which integrates optimal food patterns, with the risk of developing T2DM in the SUN ("Seguimiento Universidad de Navarra" longitudinal study.We assessed 17,292 participants initially free of diabetes, followed-up for a mean of 9.2 years. A validated 136-item FFQ was administered at baseline. Taking into account previous literature, the DDS positively weighted vegetables, fruit, whole cereals, nuts, coffee, low-fat dairy, fiber, PUFA, and alcohol in moderate amounts; while it negatively weighted red meat, processed meats and sugar-sweetened beverages. Energy-adjusted quintiles of each item (with exception of moderate alcohol consumption that received either 0 or 5 points were used to build the DDS (maximum: 60 points. Incident T2DM was confirmed through additional detailed questionnaires and review of medical records of participants. We used Cox proportional hazards models adjusted for socio-demographic and anthropometric parameters, health-related habits, and clinical variables to estimate hazard ratios (HR of T2DM.We observed 143 T2DM confirmed cases during follow-up. Better baseline conformity with the DDS was associated with lower incidence of T2DM (multivariable-adjusted HR for intermediate (25-39 points vs. low (11-24 category 0.43 [95% confidence interval (CI 0.21, 0.89]; and for high (40-60 vs. low category 0.32 [95% CI: 0.14, 0.69]; p for linear trend: 0.019.The DDS, a simple score exclusively based on dietary components, showed a strong inverse association with incident T2DM. This score may be applicable in clinical practice to improve dietary habits of subjects at high risk of T2DM

Prostate cancer mortality reduction by prostate-specific antigen-based screening adjusted for nonattendance and contamination in the European Randomised Study of Screening for Prostate Cancer (ERSPC).

Science.gov (United States)

Roobol, Monique J; Kerkhof, Melissa; Schröder, Fritz H; Cuzick, Jack; Sasieni, Peter; Hakama, Matti; Stenman, Ulf Hakan; Ciatto, Stefano; Nelen, Vera; Kwiatkowski, Maciej; Lujan, Marcos; Lilja, Hans; Zappa, Marco; Denis, Louis; Recker, Franz; Berenguer, Antonio; Ruutu, Mirja; Kujala, Paula; Bangma, Chris H; Aus, Gunnar; Tammela, Teuvo L J; Villers, Arnauld; Rebillard, Xavier; Moss, Sue M; de Koning, Harry J; Hugosson, Jonas; Auvinen, Anssi

2009-10-01

Prostate-specific antigen (PSA) based screening for prostate cancer (PCa) has been shown to reduce prostate specific mortality by 20% in an intention to screen (ITS) analysis in a randomised trial (European Randomised Study of Screening for Prostate Cancer [ERSPC]). This effect may be diluted by nonattendance in men randomised to the screening arm and contamination in men randomised to the control arm. To assess the magnitude of the PCa-specific mortality reduction after adjustment for nonattendance and contamination. We analysed the occurrence of PCa deaths during an average follow-up of 9 yr in 162,243 men 55-69 yr of age randomised in seven participating centres of the ERSPC. Centres were also grouped according to the type of randomisation (ie, before or after informed written consent). Nonattendance was defined as nonattending the initial screening round in ERSPC. The estimate of contamination was based on PSA use in controls in ERSPC Rotterdam. Relative risks (RRs) with 95% confidence intervals (CIs) were compared between an ITS analysis and analyses adjusting for nonattendance and contamination using a statistical method developed for this purpose. In the ITS analysis, the RR of PCa death in men allocated to the intervention arm relative to the control arm was 0.80 (95% CI, 0.68-0.96). Adjustment for nonattendance resulted in a RR of 0.73 (95% CI, 0.58-0.93), and additional adjustment for contamination using two different estimates led to estimated reductions of 0.69 (95% CI, 0.51-0.92) to 0.71 (95% CI, 0.55-0.93), respectively. Contamination data were obtained through extrapolation of single-centre data. No heterogeneity was found between the groups of centres. PSA screening reduces the risk of dying of PCa by up to 31% in men actually screened. This benefit should be weighed against a degree of overdiagnosis and overtreatment inherent in PCa screening.

Psychotropic drugs and the risk of fractures in old age: a prospective population-based study.

Science.gov (United States)

Nurminen, Janne; Puustinen, Juha; Piirtola, Maarit; Vahlberg, Tero; Kivelä, Sirkka-Liisa

2010-07-06

There is evidence that the use of any psychotropic and the concomitant use of two or more benzodiazepines are related to an increased risk of fractures in old age. However, also controversial results exist. The aim was to describe associations between the use of a psychotropic drug, or the concomitant use of two or more of these drugs and the risk of fractures in a population aged 65 years or over. This study was a part of a prospective longitudinal population-based study carried out in the municipality of Lieto, South-Western Finland. The objective was to describe gender-specific associations between the use of one psychotropic drug [benzodiazepine (BZD), antipsychotic (AP) or antidepressant (AD)] or the concomitant use of two or more psychotropic drugs and the risk of fractures in a population 65 years or over. Subjects were participants in the first wave of the Lieto study in 1990-1991, and they were followed up until the end of 1996. Information about fractures confirmed with radiology reports in 1,177 subjects (482 men and 695 women) during the follow-up was collected from medical records. Two follow-up periods (three and six years) were used, and previously found risk factors of fractures were adjusted as confounding factors separately for men and women. The Poisson regression model was used in the analyses. The concomitant use of two or more BZDs and the concomitant use of two or more APs were related to an increased risk of fractures during both follow-up periods after adjusting for confounding factors in men. No similar associations were found in women. The concomitant use of several BZDs and that of several APs are associated with an increase in the risk of fractures in older men. Our findings show only risk relations. We cannot draw the conclusion that these drug combinations are causes of fractures.

24 CFR 5.611 - Adjusted income.

Science.gov (United States)

2010-04-01

... 24 Housing and Urban Development 1 2010-04-01 2010-04-01 false Adjusted income. 5.611 Section 5... Serving Persons with Disabilities: Family Income and Family Payment; Occupancy Requirements for Section 8 Project-Based Assistance Family Income § 5.611 Adjusted income. Adjusted income means annual income (as...

Data analysis-based autonomic bandwidth adjustment in software defined multi-vendor optical transport networks.

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Li, Yajie; Zhao, Yongli; Zhang, Jie; Yu, Xiaosong; Jing, Ruiquan

2017-11-27

Network operators generally provide dedicated lightpaths for customers to meet the demand for high-quality transmission. Considering the variation of traffic load, customers usually rent peak bandwidth that exceeds the practical average traffic requirement. In this case, bandwidth provisioning is unmetered and customers have to pay according to peak bandwidth. Supposing that network operators could keep track of traffic load and allocate bandwidth dynamically, bandwidth can be provided as a metered service and customers would pay for the bandwidth that they actually use. To achieve cost-effective bandwidth provisioning, this paper proposes an autonomic bandwidth adjustment scheme based on data analysis of traffic load. The scheme is implemented in a software defined networking (SDN) controller and is demonstrated in the field trial of multi-vendor optical transport networks. The field trial shows that the proposed scheme can track traffic load and realize autonomic bandwidth adjustment. In addition, a simulation experiment is conducted to evaluate the performance of the proposed scheme. We also investigate the impact of different parameters on autonomic bandwidth adjustment. Simulation results show that the step size and adjustment period have significant influences on bandwidth savings and packet loss. A small value of step size and adjustment period can bring more benefits by tracking traffic variation with high accuracy. For network operators, the scheme can serve as technical support of realizing bandwidth as metered service in the future.

Correlates of sexual-risk behaviors among young black MSM: implications for clinic-based counseling programs.

Science.gov (United States)

Crosby, Richard A; Mena, Leandro; Ricks, JaNelle M

2017-06-01

This study applied an 8-item index of recent sexual-risk behaviors to young Black men who have sex with men (YBMSM) and evaluated the distribution for normality. The distribution was tested for associations with possible antecedents of sexual risk. YBMSM (N = 600), aged 16-29 years, were recruited from a sexually transmitted infection clinic, located in the southern US. Men completed an extensive audio computer-assisted self-interview. Thirteen possible antecedents of sexual risk, as assessed by the index, were selected for analyses. The 8-item index formed a normal distribution with a mean of 4.77 (SD = 1.77). In adjusted analyses, not having completed education beyond high school was associated with less risk, as was having sex with females. Conversely, meeting sex partners online was associated with greater risk, as was reporting that sex partners were drunk during sex. The obtained normal distribution of sexual-risk behaviors suggests a corresponding need to "target and tailor" clinic-based counseling and prevention services for YBMSM. Avoiding sex when partners are intoxicated may be an especially valuable goal of counseling sessions.

Sickness presence, sick leave and adjustment latitude

Directory of Open Access Journals (Sweden)

Joachim Gerich

2014-10-01

Full Text Available Objectives: Previous research on the association between adjustment latitude (defined as the opportunity to adjust work efforts in case of illness and sickness absence and sickness presence has produced inconsistent results. In particular, low adjustment latitude has been identified as both a risk factor and a deterrent of sick leave. The present study uses an alternative analytical strategy with the aim of joining these results together. Material and Methods: Using a cross-sectional design, a random sample of employees covered by the Upper Austrian Sickness Fund (N = 930 was analyzed. Logistic and ordinary least square (OLS regression models were used to examine the association between adjustment latitude and days of sickness absence, sickness presence, and an estimator for the individual sickness absence and sickness presence propensity. Results: A high level of adjustment latitude was found to be associated with a reduced number of days of sickness absence and sickness presence, but an elevated propensity for sickness absence. Conclusions: Employees with high adjustment latitude experience fewer days of health complaints associated with lower rates of sick leave and sickness presence compared to those with low adjustment latitude. In case of illness, however, high adjustment latitude is associated with a higher pro­bability of taking sick leave rather than sickness presence.

Napping and the risk of type 2 diabetes: a population-based prospective study.

Science.gov (United States)

Hublin, Christer; Lehtovirta, Mikko; Partinen, Markku; Koskenvuo, Markku; Kaprio, Jaakko

2016-01-01

Some studies indicate an association between napping and increased risk of type 2 diabetes. We studied this prospectively in a sample representative of general population. A questionnaire was administered to the Finnish Twin Cohort in 1990 (response rate 77%, age 33-60 years). The study population included 12,244 subjects who replied to the question "Do you sleep during the daytime (take naps)?" with five response alternatives ranging from "no need" to "every or almost every day." Information on incident cases of diabetes was obtained by linkage to nationwide registers. Logistic regression models were used to obtain odds ratios (ORs) (95% confidence intervals) for incident type 2 diabetes risk in 1991-2004 by napping category. Adjustments were made for 11 socio-demographic and lifestyle covariates. For subjects aged 33-45 years at baseline, a questionnaire in 2011 provided information on prevalent diabetes. Thirty-four per cent had no need for napping, and 15% did so on ≥3 days weekly. There were 356 incident type 2 diabetes cases during the follow-up. Using the 'no need' category as the reference, the risk of type 2 diabetes was significantly increased only among those napping most frequently [OR 1.86 (1.29-2.67), age- and sex-adjusted]. After adjusting for other covariates, the results were essentially the same, but when adjusted for body mass index, the association decreased (to about 1.3) and was statistically non-significant. Analysis of 2011 self-reported type 2 diabetes was in line with the register data. Frequent napping is associated with future risk of type 2 diabetes. This association is largely explained by obesity. Copyright © 2015 Elsevier B.V. All rights reserved.

Secrets of Success in a Landscape of Fear: Urban Wild Boar Adjust Risk Perception and Tolerate Disturbance

Directory of Open Access Journals (Sweden)

Milena Stillfried

2017-12-01

Full Text Available In urban areas with a high level of human disturbance, wildlife has to adjust its behavior to deal with the so called “landscape of fear.” This can be studied in risk perception during movement in relation to specific habitat types, whereby individuals trade-off between foraging and disturbance. Due to its high behavioral plasticity and increasing occurrence in urban environments, wild boar (Sus scrofa is an excellent model organism to study adjustment to urbanization. With the help of GPS tracking, space use of 11 wild boar from Berlin's metropolitan region was analyzed: we aimed at understanding how animals adjust space use to deal with the landscape of fear in urban areas compared to rural areas. We compared use vs. availability with help of generalized linear mixed models. First, we studied landscape types selected by rural vs. urban wild boar, second, we analyzed distances of wild boar locations to each of the landscape types. Finally, we mapped the resulting habitat selection probability to predict hotspots of human-wildlife conflicts. A higher tolerance to disturbance in urban wild boar was shown by a one third shorter flight distance and by an increased re-use of areas close to the trap. Urban wild boar had a strong preference for natural landscapes such as swamp areas, green areas and deciduous forests, and areas with high primary productivity, as indicated by high NDVI (normalized difference vegetation index values. The areas selected by urban wild boar were often located closely to roads and houses. The spatial distribution maps show that a large area of Berlin would be suitable for urban wild boar but not their rural conspecifics, with the most likely reason being a different perception of anthropogenic disturbance. Wild boar therefore showed considerable behavioral plasticity suitable to adjust to human-dominated environments in a potentially evolutionarily adaptive manner.

Fibromyalgia and Risk of Dementia-A Nationwide, Population-Based, Cohort Study.

Science.gov (United States)

Tzeng, Nian-Sheng; Chung, Chi-Hsiang; Liu, Feng-Cheng; Chiu, Yu-Hsiang; Chang, Hsin-An; Yeh, Chin-Bin; Huang, San-Yuan; Lu, Ru-Band; Yeh, Hui-Wen; Kao, Yu-Chen; Chiang, Wei-Shan; Tsao, Chang-Hui; Wu, Yung-Fu; Chou, Yu-Ching; Lin, Fu-Huang; Chien, Wu-Chien

2018-02-01

Fibromyalgia is a syndrome of chronic pain and other symptoms and is associated with patient discomfort and other diseases. This nationwide matched-cohort population-based study aimed to investigate the association between fibromyalgia and the risk of developing dementia, and to clarify the association between fibromyalgia and dementia. A total of 41,612 patients of age ≥50 years with newly diagnosed fibromyalgia between January 1, and December 31, 2000 were selected from the National Health Insurance Research Database of Taiwan, along with 124,836 controls matched for sex and age. After adjusting for any confounding factors, Fine and Gray competing risk analysis was used to compare the risk of developing dementia during the 10 years of follow-up. Of the study subjects, 1,704 from 41,612 fibromyalgia patients (21.23 per 1,000 person-years) developed dementia when compared to 4,419 from 124,836 controls (18.94 per 1,000 person-years). Fine and Gray competing risk analysis revealed that the study subjects were more likely to develop dementia (hazard ratio: 2.29, 95% CI: 2.16-2.42; P dementia in this study. The study subjects with fibromyalgia had a 2.77-fold risk of dementia in comparison to the control group. Therefore, further studies are needed to elucidate the underlying mechanisms of the association between fibromyalgia and the risk of dementia. Copyright © 2018 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.

Risk-based methodology for USNRC inspections

International Nuclear Information System (INIS)

Wong, S.M.; Holahan, G.M.; Chung, J.W.; Johnson, M.R.

1995-01-01

This paper describes the development and trial applications of a risk-based methodology to enhance the inspection processes for US nuclear power plants. Objectives of risk-based methods to complement prescriptive engineering approaches in US Nuclear Regulatory Commission (USNRC) inspection programs are presented. Insights from time-dependent risk profiles of plant configurational from Individual Plant Evaluation (IPE) studies were integrated to develop a framework for optimizing inspection efforts in NRC regulatory initiatives. Lessons learned from NRC pilot applications of the risk-based methodology for evaluation of the effectiveness of operational risk management programs at US nuclear power plant sites are also discussed

Risk-based SMA for Cubesats

Science.gov (United States)

Leitner, Jesse

2016-01-01

This presentation conveys an approach for risk-based safety and mission assurance applied to cubesats. This presentation accompanies a NASA Goddard standard in development that provides guidance for building a mission success plan for cubesats based on the risk tolerance and resources available.

Use of organic nitrates and the risk of hip fracture: a population-based case-control study.

Science.gov (United States)

Pouwels, Sander; Lalmohamed, Arief; van Staa, Tjeerd; Cooper, Cyrus; Souverein, Patrick; Leufkens, Hubertus G; Rejnmark, Lars; de Boer, Anthonius; Vestergaard, Peter; de Vries, Frank

2010-04-01

Use of organic nitrates has been associated with increased bone mineral density. Moreover, a large Danish case-control study reported a decreased fracture risk. However, the association with duration of nitrate use, dose frequency, and impact of discontinuation has not been extensively studied. Our objective was to evaluate the association between organic nitrates and hip fracture risk. A case-control study was conducted using the Dutch PHARMO Record Linkage System (1991-2002, n = 6,763 hip fracture cases and 26,341 controls). Cases had their first admission for hip fracture, whereas controls had not sustained any fracture after enrollment. Current users of organic nitrates were patients who had received a prescription within 90 d before the index date. The analyses were adjusted for disease and drug history. Current use of nitrates was not associated with a decreased risk of hip fracture [adjusted odds ratio (OR) = 0.93; 95% confidence interval (CI) = 0.83-1.04]. Those who used as-needed medication only had a lower risk of hip fracture (adjusted OR = 0.83; 95% CI = 0.63-1.08) compared with users of maintenance medication only (adjusted OR = 1.17; 95% CI = 0.97-1.40). No association was found between duration of nitrate use and fracture risk. Our overall analyses showed that risk of a hip fracture was significantly lower among users of as-needed organic nitrates, when compared with users of maintenance medication. Our analyses of hip fracture risks with duration of use did not further support a beneficial effect of organic nitrates on hip fracture, although residual confounding may have masked beneficial effects.

Postmenopausal Estrogen Therapy and Risk of Gallstone Disease

DEFF Research Database (Denmark)

Simonsen, Maja Hellfritzsch; Erichsen, Rune; Frøslev, Trine

2013-01-01

BACKGROUND: Female gender and increasing age are key risk factors for gallstone disease; therefore, postmenopausal women are at high risk. Estrogen increases cholesterol saturation of bile and may further increase gallstone risk, but population-based evidence is sparse. OBJECTIVE: Our objective......, and parity. RESULTS: We identified 16,386 cases with gallstone disease and 163,860 controls. A total of 1,425 cases (8.7 %) and 8,930 controls (5.4 %) were current estrogen users, yielding an adjusted OR for gallstone disease of 1.74 (95 % CI 1.64-1.85) compared with non-users. The corresponding adjusted...

Antenatal steroids and risk of bronchopulmonary dysplasia: a lack of effect or a case of over-adjustment?

Science.gov (United States)

Gagliardi, Luigi; Bellù, Roberto; Rusconi, Franca; Merazzi, Daniele; Mosca, Fabio

2007-07-01

Although antenatal steroids reduce risk factors for bronchopulmonary dysplasia (BPD) in preterm infants, their effect on BPD is conflicting. We hypothesised that the lack of protective effect found in some studies could derive from over-adjustment during analysis, caused by controlling for factors intermediate in the causal pathway between treatment and outcome. We prospectively studied a cohort of infants 23-32 weeks gestation steroids. In univariable analysis, steroids were not significantly protective against BPD; some intermediate factors (mechanical ventilation, greater severity of illness as measured by Clinical Risk Index for Babies score, patent ductus arteriosus) were significantly positively associated with (i.e. were risk factors for) BPD (OR = 11.0, 1.55, 4.42, respectively, all P steroids (OR = 0.58, 0.92, and 0.58, respectively, all P steroid-treated infants had a lower risk of BPD (OR 0.59 [95% CI 0.36, 0.97], P = 0.036); male sex (OR = 2.08), late-onset sepsis (OR = 4.26), and birthweight (OR = 0.63 for 100 g increase) were also associated with BPD, all P effect of steroids disappeared; ventilation (OR = 3.03), increased illness severity (OR = 1.11), and patent ductus arteriosus (OR = 1.90) were significant risk factors. This study suggests that including variables that are potential mediators in the causal chain can obscure the ability to detect a protective effect of treatment. We observed such a phenomenon in our analyses of the relationship between antenatal steroids and BPD, suggesting that steroid effect is partly mediated through a reduction in the classical risk factors.

C-reactive protein, insulin resistance and risk of cardiovascular disease: a population-based study

DEFF Research Database (Denmark)

Hansen, T.W.; Olsen, M.H.; Rasmussen, S.

2008-01-01

BACKGROUND: C-reactive protein (CRP), a marker of inflammation, and insulin resistance (IR), a metabolic disorder, are closely related. CRP and IR have both been identified as significant risk factors of cardiovascular disease (CVD) after adjustment for conventional CVD risk factors...

Prevalence and risk factors associated with dry eye symptoms: a population based study in Indonesia

Science.gov (United States)

Lee, A J; Lee, J; Saw, S-M; Gazzard, G; Koh, D; Widjaja, D; Tan, D T H

2002-01-01

Aim: To determine the prevalence and identify associated risk factors for dry eye syndrome in a population in Sumatra, Indonesia. Methods: A one stage cluster sampling procedure was conducted to randomly select 100 households in each of the five rural villages and one provincial town of the Riau province, Indonesia, from April to June 2001. Interviewers collected demographic, lifestyle, and medical data from 1058 participants aged 21 years or over. Symptoms of dry eye were assessed using a six item validated questionnaire. Presence of one or more of the six dry eye symptoms often or all the time was analysed. Presence of pterygium was documented. Results: Prevalence of one or more of the six dry eye symptoms often or all the time adjusted for age was 27.5% (95% confidence interval (CI) 24.8 to 30.2). After adjusting for all significant variables, independent risk factors for dry eye were pterygium (p<0.001, multivariate odds ratio (OR) 1.8; 95% CI 1.4 to 2.5) and a history of current cigarette smoking (p=0.05, multivariate OR 1.5; 95% CI 1.0 to 2.2). Conclusions: This population based study provides prevalence rates of dry eye symptoms in a tropical developing nation. From our findings, pterygium is a possible independent risk factor for dry eye symptoms. PMID:12446361

Consumption-based Equity Valuation

DEFF Research Database (Denmark)

Bach, Christian; Christensen, Peter Ove

2013-01-01

the performance of the model with several implementations of standard valuation models, both in terms of absolute valuation errors, and in terms of the returns on simple investment strategies based on the differences between model and market prices in the respective valuation models. The CCAPM-based valuation...... model performs substantially better than the best performing standard valuation model when comparing absolute valuation errors. Both types of models are able to identify investment strategies with subsequent excess returns but also in this setting, the CCAPM-based valuation model outperforms...... residual income for risk in the numerator rather than through a risk-adjusted cost of equity in the denominator. The risk-adjustments are derived based on assumptions about the time-series properties of residual income returns and aggregate consumption rather than on historical stock returns. We compare...

Risk-adjusted econometric model to estimate postoperative costs: an additional instrument for monitoring performance after major lung resection.

Science.gov (United States)

Brunelli, Alessandro; Salati, Michele; Refai, Majed; Xiumé, Francesco; Rocco, Gaetano; Sabbatini, Armando

2007-09-01

The objectives of this study were to develop a risk-adjusted model to estimate individual postoperative costs after major lung resection and to use it for internal economic audit. Variable and fixed hospital costs were collected for 679 consecutive patients who underwent major lung resection from January 2000 through October 2006 at our unit. Several preoperative variables were used to develop a risk-adjusted econometric model from all patients operated on during the period 2000 through 2003 by a stepwise multiple regression analysis (validated by bootstrap). The model was then used to estimate the postoperative costs in the patients operated on during the 3 subsequent periods (years 2004, 2005, and 2006). Observed and predicted costs were then compared within each period by the Wilcoxon signed rank test. Multiple regression and bootstrap analysis yielded the following model predicting postoperative cost: 11,078 + 1340.3X (age > 70 years) + 1927.8X cardiac comorbidity - 95X ppoFEV1%. No differences between predicted and observed costs were noted in the first 2 periods analyzed (year 2004, $6188.40 vs $6241.40, P = .3; year 2005, $6308.60 vs $6483.60, P = .4), whereas in the most recent period (2006) observed costs were significantly lower than the predicted ones ($3457.30 vs $6162.70, P model may be used as a methodologic template for economic audit in our specialty and complement more traditional outcome measures in the assessment of performance.

Social and Emotional Adjustment of Siblings of Children with Autism

Science.gov (United States)

Pilowsky, Tammy; Yirmiya, Nurit; Doppelt, Osnat; Gross-Tsur, Varda; Shalev, Ruth S.

2004-01-01

Background: Social and emotional adjustment of siblings of children with autism was examined, to explore their risk or resilience to effects of genetic liability and environmental factors involved in having a sibling with autism. Method: Social-emotional adjustment, behavior problems, socialization skills, and siblings' relationships were compared…

Oxytocin during labour and risk of severe postpartum haemorrhage: a population-based, cohort-nested case–control study

Science.gov (United States)

Belghiti, Jérémie; Kayem, Gilles; Dupont, Corinne; Rudigoz, René-Charles; Bouvier-Colle, Marie-Hélène

2011-01-01

Objectives Postpartum haemorrhage (PPH) is a major cause of maternal mortality and morbidity worldwide. Experimental studies support the hypothesis that oxytocin administration during labour, a common although not evidence-based practice, may increase the risk of atonic PPH. The clinical studies, however, are inconclusive. The objectives of this study was to investigate the association between the level of oxytocin exposure during labour and the risk of severe PPH and to explore whether the prophylactic use of oxytocin after birth modifies this association. Design Population-based, cohort-nested case–control study. Setting 106 French hospitals from December 2004 through November 2006. Participants Women with term singleton vaginal deliveries, after an uncomplicated pregnancy. Cases were 1483 women with severe PPH, defined by peripartum change in haemoglobin of ≥4 g/dl or need for blood transfusion. Controls were 1758 women from a random sample of parturients without PPH. Main outcome measures The independent association between the level of oxytocin during labour and the risk of severe PPH was tested and quantified with ORs through two-level multivariable logistic regression modelling. Results Oxytocin was administered during labour to 73% of cases and 61% of controls (crude OR: 1.7, 95% CI 1.5 to 2.0). After adjustment for all potential confounders, oxytocin during labour was associated with a significantly higher risk of severe PPH (adjusted OR: 1.8, 95% CI 1.3 to 2.6) in women who did not receive prophylactic oxytocin after delivery; the OR for haemorrhage increased from 1 to 5 according to the level of oxytocin exposure. In women who had prophylactic oxytocin after delivery, this association was significant only for the highest exposure categories. Conclusions Oxytocin during labour appears to be an independent risk factor for severe PPH. The results emphasise the need for guidelines clarifying the evidence-based indications for this procedure and the

Clinical outcomes in low risk coronary artery disease patients treated with different limus-based drug-eluting stents--a nationwide retrospective cohort study using insurance claims database.

Directory of Open Access Journals (Sweden)

Chao-Lun Lai

Full Text Available The clinical outcomes of different limus-based drug-eluting stents (DES in a real-world setting have not been well defined. The aim of this study was to investigate the clinical outcomes of three different limus-based DES, namely sirolimus-eluting stent (SES, Endeavor zotarolimus-eluting stent (E-ZES and everolimus-eluting stent (EES, using a national insurance claims database. We identified all patients who received implantation of single SES, E-ZES or EES between January 1, 2007 and December 31, 2009 from the National Health Insurance claims database, Taiwan. Follow-up was through December 31, 2011 for all selected clinical outcomes. The primary end-point was all-cause mortality. Secondary end-points included acute coronary events, heart failure needing hospitalization, and cerebrovascular disease. Cox regression model adjusting for baseline characteristics was used to compare the relative risks of different outcomes among the three different limus-based DES. Totally, 6584 patients were evaluated (n=2142 for SES, n=3445 for E-ZES, and n=997 for EES. After adjusting for baseline characteristics, we found no statistically significant difference in the risk of all-cause mortality in three DES groups (adjusted hazard ratio [HR]: 1.14, 95% confidence interval [CI]: 0.94-1.38, p=0.20 in E-ZES group compared with SES group; adjusted HR: 0.77, 95% CI: 0.54-1.10, p=0.15 in EES group compared with SES group. Similarly, we found no difference in the three stent groups in risks of acute coronary events, heart failure needing hospitalization, and cerebrovascular disease. In conclusion, we observed no difference in all-cause mortality, acute coronary events, heart failure needing hospitalization, and cerebrovascular disease in patients treated with SES, E-ZES, and EES in a real-world population-based setting in Taiwan.

Statin use and risk of prostate cancer: a Danish population-based case-control study, 1997-2010.

Science.gov (United States)

Jespersen, Christina G; Nørgaard, Mette; Friis, Søren; Skriver, Charlotte; Borre, Michael

2014-02-01

Conflicting evidence has suggested that statins possess chemopreventive properties against prostate cancer (PCa). Therefore, we examined the association between statin use and risk of PCa in a Denmark-based case-control study. We identified 42,480 patients diagnosed with incident PCa during 1997-2010 from a national cancer registry. Five age-matched population controls (n=212,400) were selected for each case using risk-set sampling. Statin use from 1996 to the index date was obtained from the National Prescription Registry. Odds ratios (ORs) adjusted for age, comorbidity, non-steroidal anti-inflammatory drug use, and educational level for PCa associated with statin use, were computed using conditional logistic regression. Analyses were stratified by duration of statin use (0-1, 2-4, 5-9, or ≥10 years), stage of PCa (localized or advanced), and type of statin used (lipophilic or hydrophilic). In total, 7915 patients (19%) and 39,384 controls (19%) redeemed statin prescriptions prior to the index date. Overall, statin users had a 6% lower risk of PCa compared with non-users [adjusted OR (ORa), 0.94; 95% confidence interval (CI), 0.91-0.97]. Risk estimates did not differ substantially by duration or type of statin used. Slightly larger statin use-associated risk reductions were observed for advanced PCa (ORa, 0.90; 95% CI, 0.85-0.96) and with statin use ≥10 years (ORa, 0.78; 95% CI, 0.65-0.95). Statin use was associated with a risk reduction overall (6%) and, specifically with advanced PCa (10%). Differences in diagnostic measures and residual confounding by socioeconomic parameters may have influenced our results. Copyright © 2013 Elsevier Ltd. All rights reserved.

Subthreshold-swing-adjustable tunneling-field-effect-transistor-based random-access memory for nonvolatile operation

Science.gov (United States)

Huh, In; Cheon, Woo Young; Choi, Woo Young

2016-04-01

A subthreshold-swing-adjustable tunneling-field-effect-transistor-based random-access memory (SAT RAM) has been proposed and fabricated for low-power nonvolatile memory applications. The proposed SAT RAM cell demonstrates adjustable subthreshold swing (SS) depending on stored information: small SS in the erase state ("1" state) and large SS in the program state ("0" state). Thus, SAT RAM cells can achieve low read voltage (Vread) with a large memory window in addition to the effective suppression of ambipolar behavior. These unique features of the SAT RAM are originated from the locally stored charge, which modulates the tunneling barrier width (Wtun) of the source-to-channel tunneling junction.

Prevalence of gastro-esophageal reflux disease and its risk factors in a community-based population in southern India.

Science.gov (United States)

Wang, Hai-Yun; Leena, Kondarapassery Balakumaran; Plymoth, Amelie; Hergens, Maria-Pia; Yin, Li; Shenoy, Kotacherry Trivikrama; Ye, Weimin

2016-03-15

The prevalence of gastro-esophageal reflux disease (GERD) varies widely around the world. This study aimed to investigate the prevalence and risk factors of GERD in a general population of southern India. An interview-based observational study was carried out in southern India during 2010 and early 2011 using a GERD questionnaire (GerdQ). In total 1072 participants were enrolled using a multi-stage cluster sampling method. Presence of GERD was defined as a score of ≥ 8. Logistic regression models were used to derive odds ratios (ORs) with 95 % confidence intervals (CIs). The prevalence of GERD was 22.2 % (238/1072) in southern India, and was more common among older subjects and men. Overweight and obese subjects had a dose-dependent increased risk of GERD, compared to those with body mass index less than 25 (multivariate-adjusted OR = 1.4, 95 % CI 1.0-2.0; OR = 2.3, 95 % CI 1.3-4.1, respectively). People residing in urban community were more vulnerable to GERD than those in rural community (multivariate-adjusted OR = 1.8, 95 % CI 1.3-2.5). Similarly, those with a lower educational level appeared to have an increased risk of GERD. Further, those with a habit of pan masala chewing were more likely to develop GERD compared with those abstained from the habit (multivariate-adjusted OR = 2.0, 95 % CI 1.2-3.2). GERD is highly prevalent in southern India. Increasing age and BMI, an urban environment, lower educational level, and pan masala chewing appear to be risk factors of GERD symptoms for the studied population.

HOW INTERNAL RISK - BASED AUDIT APPRAISES THE EVALUATION OF RISKS MANAGEMENT

Directory of Open Access Journals (Sweden)

N. Dorosh

2017-09-01

Full Text Available The article deals with the nature and function of the internal risk-based audit process approach to create patterns of risks and methods of evaluation. Deals with the relationship between the level of maturity of the risk of the company and the method of risk-based internal audit. it was emphasized that internal auditing provides an independent and objective opinion to an organization’s management as to whether its risks are being managed to acceptable levels.

Adjustments of the Pesticide Risk Index Used in Environmental Policy in Flanders.

Science.gov (United States)

Fevery, Davina; Peeters, Bob; Lenders, Sonia; Spanoghe, Pieter

2015-01-01

Indicators are used to quantify the pressure of pesticides on the environment. Pesticide risk indicators typically require weighting environmental exposure by a no effect concentration. An indicator based on spread equivalents (ΣSeq) is used in environmental policy in Flanders (Belgium). The pesticide risk for aquatic life is estimated by weighting active ingredient usage by the ratio of their maximum allowable concentration and their soil halflife. Accurate estimates of total pesticide usage in the region are essential in such calculations. Up to 2012, the environmental impact of pesticides was estimated on sales figures provided by the Federal Government. Since 2013, pesticide use is calculated based on results from the Farm Accountancy Data Network (FADN). The estimation of pesticide use was supplemented with data for non-agricultural use based on sales figures of amateur use provided by industry and data obtained from public services. The Seq-indicator was modified to better reflect reality. This method was applied for the period 2009-2012 and showed differences between estimated use and sales figures of pesticides. The estimated use of pesticides based on accountancy data is more accurate compared to sales figures. This approach resulted in a better view on pesticide use and its respective environmental impact in Flanders.

Adjustments of the Pesticide Risk Index Used in Environmental Policy in Flanders.

Directory of Open Access Journals (Sweden)

Davina Fevery

Full Text Available Indicators are used to quantify the pressure of pesticides on the environment. Pesticide risk indicators typically require weighting environmental exposure by a no effect concentration. An indicator based on spread equivalents (ΣSeq is used in environmental policy in Flanders (Belgium. The pesticide risk for aquatic life is estimated by weighting active ingredient usage by the ratio of their maximum allowable concentration and their soil halflife. Accurate estimates of total pesticide usage in the region are essential in such calculations. Up to 2012, the environmental impact of pesticides was estimated on sales figures provided by the Federal Government. Since 2013, pesticide use is calculated based on results from the Farm Accountancy Data Network (FADN. The estimation of pesticide use was supplemented with data for non-agricultural use based on sales figures of amateur use provided by industry and data obtained from public services. The Seq-indicator was modified to better reflect reality. This method was applied for the period 2009-2012 and showed differences between estimated use and sales figures of pesticides. The estimated use of pesticides based on accountancy data is more accurate compared to sales figures. This approach resulted in a better view on pesticide use and its respective environmental impact in Flanders.

Risk-adjustment models for heart failure patients' 30-day mortality and readmission rates: the incremental value of clinical data abstracted from medical charts beyond hospital discharge record.

Science.gov (United States)

Lenzi, Jacopo; Avaldi, Vera Maria; Hernandez-Boussard, Tina; Descovich, Carlo; Castaldini, Ilaria; Urbinati, Stefano; Di Pasquale, Giuseppe; Rucci, Paola; Fantini, Maria Pia

2016-09-06

Hospital discharge records (HDRs) are routinely used to assess outcomes of care and to compare hospital performance for heart failure. The advantages of using clinical data from medical charts to improve risk-adjustment models remain controversial. The aim of the present study was to evaluate the additional contribution of clinical variables to HDR-based 30-day mortality and readmission models in patients with heart failure. This retrospective observational study included all patients residing in the Local Healthcare Authority of Bologna (about 1 million inhabitants) who were discharged in 2012 from one of three hospitals in the area with a diagnosis of heart failure. For each study outcome, we compared the discrimination of the two risk-adjustment models (i.e., HDR-only model and HDR-clinical model) through the area under the ROC curve (AUC). A total of 1145 and 1025 patients were included in the mortality and readmission analyses, respectively. Adding clinical data significantly improved the discrimination of the mortality model (AUC = 0.84 vs. 0.73, p < 0.001), but not the discrimination of the readmission model (AUC = 0.65 vs. 0.63, p = 0.08). We identified clinical variables that significantly improved the discrimination of the HDR-only model for 30-day mortality following heart failure. By contrast, clinical variables made little contribution to the discrimination of the HDR-only model for 30-day readmission.

Psychologic adjustment to irreversible vision loss in adults: a systematic review.

Science.gov (United States)

Senra, Hugo; Barbosa, Fernando; Ferreira, Patrícia; Vieira, Cristina R; Perrin, Paul B; Rogers, Heather; Rivera, Diego; Leal, Isabel

2015-04-01

To summarize relevant evidence investigating the psychologic adjustment to irreversible vision loss (IVL) in adults. Irreversible vision loss entails a challenging medical condition in which rehabilitation outcomes are strongly dependent on the patient's psychologic adjustment to illness and impairment. So far, no study has systematically reviewed the psychologic adjustment to IVL in adults. We reviewed all articles examining the psychologic adjustment to IVL in adults. We included articles published in English in peer-reviewed journals. We performed a keyword literature search using 4 databases (PubMed, EBSCO, Cochrane Library, and Science Direct) for all years through July 2014. We assessed risk of bias of selected studies using the RTI Item Bank for Assessing Risk of Bias and Confounding for Observational Studies of Interventions or Exposures and the Cochrane risk of bias tool for randomized controlled trials. Of a total of 3948 citations retrieved, we selected 52 eligible studies published between 1946 and 2014. The majority of studies were observational and cross-sectional in nature. Our review suggests that high levels of depression occur during the adjustment to IVL. Better adjustment to IVL was associated with greater acceptance of vision loss and use of instrumental coping, good social support, positivity, and use of assistive aids. The overall findings indicate that IVL often has negative effects on patients' quality of life and mental health and that such effects tend to remain over time. Specific factors and variables associated with the adjustment to IVL need to be clarified through further in-depth and longitudinal research. Copyright © 2015 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.

Theory of Work Adjustment Personality Constructs.

Science.gov (United States)

Lawson, Loralie

1993-01-01

To measure Theory of Work Adjustment personality and adjustment style dimensions, content-based scales were analyzed for homogeneity and successively reanalyzed for reliability improvement. Three sound scales were developed: inflexibility, activeness, and reactiveness. (SK)

Clearing margin system in the futures markets—Applying the value-at-risk model to Taiwanese data

Science.gov (United States)

Chiu, Chien-Liang; Chiang, Shu-Mei; Hung, Jui-Cheng; Chen, Yu-Lung

2006-07-01

This article sets out to investigate if the TAIFEX has adequate clearing margin adjustment system via unconditional coverage, conditional coverage test and mean relative scaled bias to assess the performance of three value-at-risk (VaR) models (i.e., the TAIFEX, RiskMetrics and GARCH-t). For the same model, original and absolute returns are compared to explore which can accurately capture the true risk. For the same return, daily and tiered adjustment methods are examined to evaluate which corresponds to risk best. The results indicate that the clearing margin adjustment of the TAIFEX cannot reflect true risks. The adjustment rules, including the use of absolute return and tiered adjustment of the clearing margin, have distorted VaR-based margin requirements. Besides, the results suggest that the TAIFEX should use original return to compute VaR and daily adjustment system to set clearing margin. This approach would improve the funds operation efficiency and the liquidity of the futures markets.

Contract Design: Risk Management and Evaluation

Directory of Open Access Journals (Sweden)

Axel C. Mühlbacher

2018-01-01

Full Text Available Introduction: Effective risk adjustment is an aspect that is more and more given weight on the background of competitive health insurance systems and vital healthcare systems. The risk structure of the providers plays a vital role in Pay for Performance. A prerequisite for optimal incentive-based service models is a (partial dependence of the agent’s returns on the provider’s gain level. Integrated care systems as well as accountable care organisations (ACOs in the US and similar concepts in other countries are advocated as an effective method of improving the performance of healthcare systems. These systems outline a payment and care delivery model that intends to tie provider reimbursements to predefined quality metrics. By this the total costs of care shall be reduced.  Methods: Little is known about the contractual design and the main challenges of delegating “accountability” to these new kinds of organisations and/or contracts. The costs of market utilisation are highly relevant for the conception of healthcare contracts; furthermore information asymmetries and contract-specific investments are an obstacle to the efficient operation of ACOs. A comprehensive literature review on methods of designing contracts in Integrated Care was conducted. The research question in this article focuses on how reimbursement strategies, evaluation of measures and methods of risk adjustment can best be integrated in healthcare contracting.  Results: Each integrated care contract includes challenges for both payers and providers without having sufficient empirical data on both sides. These challenges are clinical, administrative or financial nature. Risk adjusted contracts ensure that the reimbursement roughly matches the true costs resulting from the morbidity of a population. If reimbursement of care provider corresponds to the actual expenses for an individual/population the problem of risk selection is greatly reduced. The currently used methods

RISK LOAN PORTFOLIO OPTIMIZATION MODEL BASED ON CVAR RISK MEASURE

Directory of Open Access Journals (Sweden)

Ming-Chang LEE

2015-07-01

Full Text Available In order to achieve commercial banks liquidity, safety and profitability objective requirements, loan portfolio risk analysis based optimization decisions are rational allocation of assets.  The risk analysis and asset allocation are the key technology of banking and risk management.  The aim of this paper, build a loan portfolio optimization model based on risk analysis.  Loan portfolio rate of return by using Value-at-Risk (VaR and Conditional Value-at-Risk (CVaR constraint optimization decision model reflects the bank's risk tolerance, and the potential loss of direct control of the bank.  In this paper, it analyze a general risk management model applied to portfolio problems with VaR and CVaR risk measures by using Using the Lagrangian Algorithm.  This paper solves the highly difficult problem by matrix operation method.  Therefore, the combination of this paper is easy understanding the portfolio problems with VaR and CVaR risk model is a hyperbola in mean-standard deviation space.  It is easy calculation in proposed method.

Risk Aversion is Associated with Decision Making among Community-Based Older Persons.

Science.gov (United States)

Boyle, Patricia A; Yu, Lei; Buchman, Aron S; Bennett, David A

2012-01-01

Risk aversion is associated with many important decisions among younger and middle aged persons, but the association of risk aversion with decision making has not been well studied among older persons who face some of the most significant decisions of their lives. Using data from 606 community-dwelling older persons without dementia from the Rush Memory and Aging Project, an ongoing longitudinal epidemiologic study of aging, we examined the association of risk aversion with decision making. Risk aversion was measured using standard behavioral economics questions in which participants were asked to choose between a certain monetary payment ($15) versus a gamble in which they could gain more than $15 or gain nothing; potential gamble gains ranged from $20 to $300 with the gain amounts varied randomly over questions. Decision making was measured using a 12 item version of the Decision Making Competence Assessment Tool. In a linear regression model adjusted for age, sex, education, and income, greater risk aversion was associated with poorer decision making [estimate = -1.03, standard error (SE) = 0.35, p = 0.003]. Subsequent analyses showed that the association of risk aversion with decision making persisted after adjustment for global cognitive function as well as executive and non-executive cognitive abilities. Similar to findings from studies of younger persons, risk aversion is associated with poorer decision making among older persons who face a myriad of complex and influential decisions.

Population-Based Estimates of Decreases in Quality-Adjusted Life Expectancy Associated with Unhealthy Body Mass Index.

Science.gov (United States)

Jia, Haomiao; Zack, Matthew M; Thompson, William W

2016-01-01

Being classified as outside the normal range for body mass index (BMI) has been associated with increased risk for chronic health conditions, poor health-related quality of life (HRQOL), and premature death. To assess the impact of BMI on HRQOL and mortality, we compared quality-adjusted life expectancy (QALE) by BMI levels. We obtained HRQOL data from the 1993-2010 Behavioral Risk Factor Surveillance System and life table estimates from the National Center for Health Statistics national mortality files to estimate QALE among U.S. adults by BMI categories: underweight (BMI overweight (BMI 25.0-29.9 kg/m(2)), obese (BMI 30.0-34.9 kg/m(2)), and severely obese (BMI ≥35.0 kg/m(2)). In 2010 in the United States, the highest estimated QALE for adults at 18 years of age was 54.1 years for individuals classified as normal weight. The two lowest QALE estimates were for those classified as either underweight (48.9 years) or severely obese (48.2 years). For individuals who were overweight or obese, the QALE estimates fell between those classified as either normal weight (54.1 years) or severely obese (48.2 years). The difference in QALE between adults classified as normal weight and those classified as either overweight or obese was significantly higher among women than among men, irrespective of race/ethnicity. Using population-based data, we found significant differences in QALE loss by BMI category. These findings are valuable for setting national and state targets to reduce health risks associated with severe obesity, and could be used for cost-effectiveness evaluations of weight-reduction interventions.

Transmission History Based Distributed Adaptive Contention Window Adjustment Algorithm Cooperating with Automatic Rate Fallback for Wireless LANs

Science.gov (United States)

Ogawa, Masakatsu; Hiraguri, Takefumi; Nishimori, Kentaro; Takaya, Kazuhiro; Murakawa, Kazuo

This paper proposes and investigates a distributed adaptive contention window adjustment algorithm based on the transmission history for wireless LANs called the transmission-history-based distributed adaptive contention window adjustment (THAW) algorithm. The objective of this paper is to reduce the transmission delay and improve the channel throughput compared to conventional algorithms. The feature of THAW is that it adaptively adjusts the initial contention window (CWinit) size in the binary exponential backoff (BEB) algorithm used in the IEEE 802.11 standard according to the transmission history and the automatic rate fallback (ARF) algorithm, which is the most basic algorithm in automatic rate controls. This effect is to keep CWinit at a high value in a congested state. Simulation results show that the THAW algorithm outperforms the conventional algorithms in terms of the channel throughput and delay, even if the timer in the ARF is changed.

Evidence-based ergonomics education: Promoting risk factor awareness among office computer workers.

Science.gov (United States)

Mani, Karthik; Provident, Ingrid; Eckel, Emily

2016-01-01

Work-related musculoskeletal disorders (WMSDs) related to computer work have become a serious public health concern. Literature revealed a positive association between computer use and WMSDs. The purpose of this evidence-based pilot project was to provide a series of evidence-based educational sessions on ergonomics to office computer workers to enhance the awareness of risk factors of WMSDs. Seventeen office computer workers who work for the National Board of Certification in Occupational Therapy volunteered for this project. Each participant completed a baseline and post-intervention ergonomics questionnaire and attended six educational sessions. The Rapid Office Strain Assessment and an ergonomics questionnaire were used for data collection. The post-intervention data revealed that 89% of participants were able to identify a greater number of risk factors and answer more questions correctly in knowledge tests of the ergonomics questionnaire. Pre- and post-intervention comparisons showed changes in work posture and behaviors (taking rest breaks, participating in exercise, adjusting workstation) of participants. The findings have implications for injury prevention in office settings and suggest that ergonomics education may yield positive knowledge and behavioral changes among computer workers.

Antihypertensive agents and risk of Parkinson's disease, essential tremor and dementia: a population-based prospective study (NEDICES).

Science.gov (United States)

Louis, Elan D; Benito-León, Julián; Bermejo-Pareja, Félix

2009-01-01

Recent interest in antihypertensive agents, especially calcium channel blockers, has been sparked by the notion that these medications may be neuroprotective. A modest literature, with mixed results, has examined whether these medications might lower the odds or risk of Parkinson's disease (PD) or dementia. There are no data for essential tremor (ET). To examine the association between antihypertensive use (defined broadly and by individual subclasses) and ET, PD and dementia. For each disorder, we used cross-sectional data (association with prevalent disease) and prospective data (association with incident disease). Prospective population-based study in Spain enrolling 5,278 participants at baseline. Use of antihypertensive medications (aside from beta-blockers) was similar in prevalent ET cases and controls. Baseline use of antihypertensive agents was not associated with reduced risk of incident ET. Antihypertensive medication use was not associated with prevalent or incident PD. Calcium channel blocker use was marginally reduced in prevalent dementia cases (OR(adjusted) = 0.63, p = 0.06) but was not associated with reduced risk of incident dementia (RR(adjusted) = 1.02, p = 0.95). We did not find evidence of a protective effect of antihypertensive medications in these three neurodegenerative disorders. Copyright 2009 S. Karger AG, Basel.

Risk factors and between-hospital variation of caesarean section in Denmark

DEFF Research Database (Denmark)

Wehberg, Sonja; Guldberg, Rikke; Gradel, Kim Oren

2018-01-01

OBJECTIVES: The aim of this study was to estimate the effects of risk factors on elective and emergency caesarean section (CS) and to estimate the between-hospital variation of risk-adjusted CS proportions. DESIGN: Historical registry-based cohort study. SETTINGS AND PARTICIPANTS: The study......, for example, body mass index, parity, age and size of maternity unit and (2) risk-adjusted proportions of elective and emergency CS to evaluate between-hospital variation. RESULTS: The CS proportion was stable at 20%-21%, but showed wide variation between units, even in adjusted models. Large units performed...... CSs and one unit fewer CSs than expected. CONCLUSION: The main risk factors for elective CS were breech presentation and previous CS; for emergency CS they were breech presentation and cephalopelvic disproportion. The proportions of CS were stable during the study period. We found variation in risk...

HIV quality report cards: impact of case-mix adjustment and statistical methods.

Science.gov (United States)

Ohl, Michael E; Richardson, Kelly K; Goto, Michihiko; Vaughan-Sarrazin, Mary; Schweizer, Marin L; Perencevich, Eli N

2014-10-15

There will be increasing pressure to publicly report and rank the performance of healthcare systems on human immunodeficiency virus (HIV) quality measures. To inform discussion of public reporting, we evaluated the influence of case-mix adjustment when ranking individual care systems on the viral control quality measure. We used data from the Veterans Health Administration (VHA) HIV Clinical Case Registry and administrative databases to estimate case-mix adjusted viral control for 91 local systems caring for 12 368 patients. We compared results using 2 adjustment methods, the observed-to-expected estimator and the risk-standardized ratio. Overall, 10 913 patients (88.2%) achieved viral control (viral load ≤400 copies/mL). Prior to case-mix adjustment, system-level viral control ranged from 51% to 100%. Seventeen (19%) systems were labeled as low outliers (performance significantly below the overall mean) and 11 (12%) as high outliers. Adjustment for case mix (patient demographics, comorbidity, CD4 nadir, time on therapy, and income from VHA administrative databases) reduced the number of low outliers by approximately one-third, but results differed by method. The adjustment model had moderate discrimination (c statistic = 0.66), suggesting potential for unadjusted risk when using administrative data to measure case mix. Case-mix adjustment affects rankings of care systems on the viral control quality measure. Given the sensitivity of rankings to selection of case-mix adjustment methods-and potential for unadjusted risk when using variables limited to current administrative databases-the HIV care community should explore optimal methods for case-mix adjustment before moving forward with public reporting. Published by Oxford University Press on behalf of the Infectious Diseases Society of America 2014. This work is written by (a) US Government employee(s) and is in the public domain in the US.

DALY-Based Health Risk Assessment of Construction Noise in Beijing, China

Science.gov (United States)

Xiao, Jun; Li, Xiaodong; Zhang, Zhihui

2016-01-01

Noise produced by construction activities has become the second most serious acoustic polluting element in China. To provide industry practitioners with a better understanding of the health risks of construction noise and to aid in creating environmentally friendly construction plans during early construction stages, we developed a quantitative model to assess the health impairment risks (HIA) associated with construction noise for individuals living adjacent to construction sites. This model classifies noise-induced health impairments into four categories: cardiovascular disease, cognitive impairment, sleep disturbance, and annoyance, and uses disability-adjusted life years (DALYs) as an indicator of damage. Furthermore, the value of a statistical life (VSL) is used to transform DALYs into a monetary value based on the affected demographic characteristics, thereby offering policy makers a reliable theoretical foundation for establishing reasonable standards to compensate residents suffering from construction noise. A practical earthwork project in Beijing is used as a case study to demonstrate the applicability of the proposed model. The results indicate that construction noise could bring significant health risks to the neighboring resident community, with an estimated 34.51 DALYs of health damage and 20.47 million yuan in social costs. In particular, people aged 45–54 are most vulnerable to construction noise, with the greatest health risks being caused by sleep disturbance. PMID:27792207

Development of Bioavailability Adjustment Factors: A Feasibility Study

National Research Council Canada - National Science Library

Rembish, Steve

2000-01-01

The primary purpose of this effort is to investigate the feasibility of developing and using bioavailability adjustment factors to modify intake assumptions used in risk assessments on a site-specific basis...

Risk-based inspection of nuclear power plants

International Nuclear Information System (INIS)

Masopust, R.

1995-01-01

A multidiscipline research programme was developed in the USA to establish risk-based inspections for NPP structures and equipment components. Based on this US research effort, the risk-based procedure for developing inspection guidelines for NPPs is described. The procedure includes the definition of systems, qualitative risk assessment, qualitative risk analysis and development of the inspection programme. The method, when adopted and modified, is recommended also for risk-based inspections of structures and equipment of WWER-type NPPs. A pilot application of the method to unit 1 of the Surry NPP is summarized. (Z.S.) 1 tab., 1 fig., 5 refs

Validation and Adjustment of the Leipzig-Halifax Acute Aortic Dissection Type A Scorecard.

Science.gov (United States)

Mejàre-Berggren, Hanna; Olsson, Christian

2017-11-01

The novel Leipzig-Halifax (LH) scorecard for acute aortic dissection type A (AADA) stratifies risk of in-hospital death based on age, malperfusion syndromes, critical preoperative state, and coronary disease. The study aim was to externally validate the LH scorecard performance and, if adequate, propose adjustments. All consecutive AADA patients operated on from 1996 to 2016 (n = 509) were included to generate an external validation cohort. Variables related to in-hospital death were analyzed using univariable and multivariable analysis. The LH scorecard was applied to the validation cohort, compared with the original study, and variable selection was adjusted using validation measures for discrimination and calibration. In-hospital mortality rate was 17.7% (LH cohort 18.7%). Critical preoperative state and Penn class non-Aa were independent predictors (odds ratio [OR] 2.42 and 2.45, respectively) of in-hospital death. The LH scorecard was adjusted to include Penn class non-Aa, critical preoperative state, and coronary disease. Assessing discrimination, area under receiver operator characteristic curve for the LH scorecard was 0.61 versus 0.66 for the new scorecard (p = 0.086). In-hospital mortality rates in low-, medium-, and high-risk groups were 14%, 15%, and 48%, respectively (LH scorecard) versus 11%, 23%, and 43%, respectively (new scorecard), and goodness-of-fit p value was 0.01 versus 0.86, indicating better calibration by the new scorecard. A lower Akaike information criterion value, 464 versus 448, favored the new scorecard. Through adjustment of the LH scorecard after external validation, prognostic performance improved. Further validated, the LH scorecard could be a valuable risk prediction tool. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Comparison between clinical significance of height-adjusted and weight-adjusted appendicular skeletal muscle mass.

Science.gov (United States)

Furushima, Taishi; Miyachi, Motohiko; Iemitsu, Motoyuki; Murakami, Haruka; Kawano, Hiroshi; Gando, Yuko; Kawakami, Ryoko; Sanada, Kiyoshi

2017-02-13

This study aimed to compare relationships between height- or weight-adjusted appendicular skeletal muscle mass (ASM/Ht 2 or ASM/Wt) and risk factors for cardiometabolic diseases or osteoporosis in Japanese men and women. Subjects were healthy Japanese men (n = 583) and women (n = 1218). The study population included a young group (310 men and 357 women; age, 18-40 years) and a middle-aged and elderly group (273 men and 861 women; age, ≥41 years). ASM was measured by dual-energy X-ray absorptiometry. The reference values for class 1 and 2 sarcopenia in each sex were defined as values one and two standard deviations below the sex-specific means of the young group, respectively. The reference values for class 1 and 2 sarcopenia defined by ASM/Ht 2 were 7.77 and 6.89 kg/m 2 in men and 6.06 and 5.31 kg/m 2 in women, respectively. The reference values for ASM/Wt were 35.0 and 32.0% in men and 29.6 and 26.4% in women, respectively. In both men and women, ASM/Wt was negatively correlated with higher triglycerides (TG) and positively correlated with serum high-density lipoprotein cholesterol (HDL-C), but these associations were not found in height-adjusted ASM. In women, TG, systolic blood pressure, and diastolic blood pressure in sarcopenia defined by ASM/Wt were significantly higher than those in normal subjects, but these associations were not found in sarcopenia defined by ASM/Ht 2 . Whole-body and regional bone mineral density in sarcopenia defined by ASM/Ht 2 were significantly lower than those in normal subjects, but these associations were not found in sarcopenia defined by ASM/Wt. Weight-adjusted definition was able to identify cardiometabolic risk factors such as TG and HDL-C while height-adjusted definition could identify factors for osteoporosis.

Development of a diagnosis- and procedure-based risk model for 30-day outcome after pediatric cardiac surgery.

Science.gov (United States)

Crowe, Sonya; Brown, Kate L; Pagel, Christina; Muthialu, Nagarajan; Cunningham, David; Gibbs, John; Bull, Catherine; Franklin, Rodney; Utley, Martin; Tsang, Victor T

2013-05-01

The study objective was to develop a risk model incorporating diagnostic information to adjust for case-mix severity during routine monitoring of outcomes for pediatric cardiac surgery. Data from the Central Cardiac Audit Database for all pediatric cardiac surgery procedures performed in the United Kingdom between 2000 and 2010 were included: 70% for model development and 30% for validation. Units of analysis were 30-day episodes after the first surgical procedure. We used logistic regression for 30-day mortality. Risk factors considered included procedural information based on Central Cardiac Audit Database "specific procedures," diagnostic information defined by 24 "primary" cardiac diagnoses and "univentricular" status, and other patient characteristics. Of the 27,140 30-day episodes in the development set, 25,613 were survivals, 834 were deaths, and 693 were of unknown status (mortality, 3.2%). The risk model includes procedure, cardiac diagnosis, univentricular status, age band (neonate, infant, child), continuous age, continuous weight, presence of non-Down syndrome comorbidity, bypass, and year of operation 2007 or later (because of decreasing mortality). A risk score was calculated for 95% of cases in the validation set (weight missing in 5%). The model discriminated well; the C-index for validation set was 0.77 (0.81 for post-2007 data). Removal of all but procedural information gave a reduced C-index of 0.72. The model performed well across the spectrum of predicted risk, but there was evidence of underestimation of mortality risk in neonates undergoing operation from 2007. The risk model performs well. Diagnostic information added useful discriminatory power. A future application is risk adjustment during routine monitoring of outcomes in the United Kingdom to assist quality assurance. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Risk-based remediation: Approach and application

International Nuclear Information System (INIS)

Frishmuth, R.A.; Benson, L.A.

1995-01-01

The principle objective of remedial actions is to protect human health and the environment. Risk assessments are the only defensible tools available to demonstrate to the regulatory community and public that this objective can be achieved. Understanding the actual risks posed by site-related contamination is crucial to designing cost-effective remedial strategies. All to often remedial actions are overdesigned, resulting in little to no increase in risk reduction while increasing project cost. Risk-based remedial actions have recently been embraced by federal and state regulators, industry, government, the scientific community, and the public as a mechanism to implement rapid and cost-effective remedial actions. Emphasizing risk reduction, rather than adherence to ambiguous and generic standards, ensures that only remedial actions required to protect human health and the environment at a particular site are implemented. Two sites are presented as case studies on how risk-based approaches are being used to remediate two petroleum hydrocarbon contaminated sites. The sites are located at two US Air Force Bases, Wurtsmith Air Force Base (AFB) in Oscoda, Michigan and Malmstrom AFB in Great Falls, Montana

Developing points-based risk-scoring systems in the presence of competing risks.

Science.gov (United States)

Austin, Peter C; Lee, Douglas S; D'Agostino, Ralph B; Fine, Jason P

2016-09-30

Predicting the occurrence of an adverse event over time is an important issue in clinical medicine. Clinical prediction models and associated points-based risk-scoring systems are popular statistical methods for summarizing the relationship between a multivariable set of patient risk factors and the risk of the occurrence of an adverse event. Points-based risk-scoring systems are popular amongst physicians as they permit a rapid assessment of patient risk without the use of computers or other electronic devices. The use of such points-based risk-scoring systems facilitates evidence-based clinical decision making. There is a growing interest in cause-specific mortality and in non-fatal outcomes. However, when considering these types of outcomes, one must account for competing risks whose occurrence precludes the occurrence of the event of interest. We describe how points-based risk-scoring systems can be developed in the presence of competing events. We illustrate the application of these methods by developing risk-scoring systems for predicting cardiovascular mortality in patients hospitalized with acute myocardial infarction. Code in the R statistical programming language is provided for the implementation of the described methods. © 2016 The Authors. Statistics in Medicine published by John Wiley & Sons Ltd. © 2016 The Authors. Statistics in Medicine published by John Wiley & Sons Ltd.

Maternal smoking, obesity, and risk of venous thromboembolism during pregnancy and the puerperium: a population-based nested case-control study

DEFF Research Database (Denmark)

Larsen, Torben Bjerregaard; Sørensen, Henrik Toft; Gislum, Mette

2007-01-01

BACKGROUND: Smoking and obesity are associated with adverse pregnancy outcomes. The aim of the present study was to examine the association between smoking, obesity (BMI>30), and risk for venous thromboembolism (VTE) during pregnancy and the puerperium. MATERIALS AND METHODS: In a population......) for VTE as a measure of relative risk. RESULTS: Smoking and obesity were associated with increased risk of VTE during pregnancy and the puerperium (adjusted OR 2.7 (95% CI: 1.5, 4.9) and 5.3 (95% CI: 2.1, 13.5), respectively). Obesity appeared to be associated with a higher risk of pulmonary embolism...... (adjusted OR: 14.9 (95% CI: 3.0, 74.8) than of deep venous thrombosis (adjusted OR: 4.4, 95% CI: 1.6, 11.9). CONCLUSION: Smoking and obesity are risk factors for VTE in pregnancy and the puerperium....

Sleep apnea and the subsequent risk of Parkinson’s disease: a 3-year nationwide population-based study

Directory of Open Access Journals (Sweden)

Chou PS

2017-03-01

Full Text Available Ping-Song Chou,1 Chiou-Lian Lai,1–3 Yii-Her Chou,4,5,* Wei-Pin Chang6,* 1Department of Neurology, Kaohsiung Medical University Hospital, 2Department of Neurology, Faculty of Medicine, College of Medicine, 3Department of Neurology, Kaohsiung Municipal Hsiao-Kang Hospital, 4Department of Urology, Faculty of Medicine, College of Medicine, 5Department of Urology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, 6School of Health Care Administration, Taipei Medical University, Taipei City, Taiwan *These authors contributed equally to this work Purpose: Sleep apnea (SA-induced chronic intermittent hypoxia increases oxidative stress and inflammation, which may contribute to the pathophysiology of Parkinson’s disease (PD. This study evaluated the risk of PD following SA diagnosis.Patients and methods: This was a 3-year nationwide population-based matched cohort study using claims data from the National Health Insurance Research Database (NHIRD, Taiwan. We analyzed 1,944 patients diagnosed as having SA between 1997 and 2005 and a matched cohort of 9,720 non-SA patients from the NHIRD. Patients with a history of PD were excluded. Each patient was followed up for 3 years to evaluate subsequent PD development.Results: Of the 11,664 patients, 17 (0.9% and 38 (0.4% from the SA and matched non-SA cohorts, respectively, were subsequently diagnosed as having PD during follow-up. After adjustments for potential confounders, the SA cohort had a 1.85-fold higher risk of PD than the non-SA cohort (95% confidence interval [CI] =1.02–3.35; P=0.042. After age and sex stratification, PD development was independently associated with SA only in men (adjusted hazard ratio [HR], 2.26; 95% CI =1.11–4.63; P<0.05 and in patients aged ≥60 years (adjusted HR, 1.93; 95% CI =1.01–3.71; P<0.05.Conclusion: Our study suggests that patients with SA are at an increased longitudinal risk of PD. Furthermore, age and male sex are independently

[Factors affecting in-hospital mortality in patients with sepsis: Development of a risk-adjusted model based on administrative data from German hospitals].

Science.gov (United States)

König, Volker; Kolzter, Olaf; Albuszies, Gerd; Thölen, Frank

2018-05-01

Inpatient administrative data from hospitals is already used nationally and internationally in many areas of internal and public quality assurance in healthcare. For sepsis as the principal condition, only a few published approaches are available for Germany. The aim of this investigation is to identify factors influencing hospital mortality by employing appropriate analytical methods in order to improve the internal quality management of sepsis. The analysis was based on data from 754,727 DRG cases of the CLINOTEL hospital network charged in 2015. The association then included 45 hospitals of all supply levels with the exception of university hospitals (range of beds: 100 to 1,172 per hospital). Cases of sepsis were identified via the ICD codes of their principal diagnosis. Multiple logistic regression analysis was used to determine the factors influencing in-hospital lethality for this population. The model was developed using sociodemographic and other potential variables that could be derived from the DRG data set, and taking into account current literature data. The model obtained was validated with inpatient administrative data of 2016 (51 hospitals, 850,776 DRG cases). Following the definition of the inclusion criteria, 5,608 cases of sepsis (2016: 6,384 cases) were identified in 2015. A total of 12 significant and, over both years, stable factors were identified, including age, severity of sepsis, reason for hospital admission and various comorbidities. The AUC value of the model, as a measure of predictability, is above 0.8 (H-L test p>0.05, R 2 value=0.27), which is an excellent result. The CLINOTEL model of risk adjustment for in-hospital lethality can be used to determine the mortality probability of patients with sepsis as principal diagnosis with a very high degree of accuracy, taking into account the case mix. Further studies are needed to confirm whether the model presented here will prove its value in the internal quality assurance of hospitals

Correlates of sexual risk behaviors among young Black MSM: implications for clinic-based counseling programs

Science.gov (United States)

Crosby, Richard A.; Mena, Leandro; Ricks, JaNelle

2018-01-01

This study applied an 8-item index of recent sexual risk behaviors to young Black men who have sex with men (YBMSM) and evaluated the distribution for normality. The distribution was tested for associations with possible antecedents of sexual risk. YBMSM (N=600), ages 16–29 years, were recruited from an STI clinic, located in the Southern United States. Men completed an extensive audio-computer assisted self-interview. Thirteen possible antecedents of sexual risk, as assessed by the index, were selected for analyses. The 8-item index formed a normal distribution with a mean of 4.77 (sd=1.77). In adjusted analyses, not having completed education beyond high school was associated with less risk, as was having sex with females. Conversely, meeting sex partners online was associated with greater risk, as was reporting that sex partners were drunk during sex. The obtained normal distribution of sexual risk behaviors suggests a corresponding need to “target and tailor” clinic-based counseling and prevention services for YBMSM. Avoiding sex when partners are intoxicated may be an especially valuable goal of counseling sessions. PMID:27875903

A Flexure-Based Mechanism for Precision Adjustment of National Ignition Facility Target Shrouds in Three Rotational Degrees of Freedom

International Nuclear Information System (INIS)

Boehm, K.-J.; Gibson, C. R.; Hollaway, J. R.; Espinoza-Loza, F.

2016-01-01

This study presents the design of a flexure-based mount allowing adjustment in three rotational degrees of freedom (DOFs) through high-precision set-screw actuators. The requirements of the application called for small but controlled angular adjustments for mounting a cantilevered beam. The proposed design is based on an array of parallel beams to provide sufficiently high stiffness in the translational directions while allowing angular adjustment through the actuators. A simplified physical model in combination with standard beam theory was applied to estimate the deflection profile and maximum stresses in the beams. A finite element model was built to calculate the stresses and beam profiles for scenarios in which the flexure is simultaneously actuated in more than one DOF.

Remote Sensing-based Methodologies for Snow Model Adjustments in Operational Streamflow Prediction

Science.gov (United States)

Bender, S.; Miller, W. P.; Bernard, B.; Stokes, M.; Oaida, C. M.; Painter, T. H.

2015-12-01

Water management agencies rely on hydrologic forecasts issued by operational agencies such as NOAA's Colorado Basin River Forecast Center (CBRFC). The CBRFC has partnered with the Jet Propulsion Laboratory (JPL) under funding from NASA to incorporate research-oriented, remotely-sensed snow data into CBRFC operations and to improve the accuracy of CBRFC forecasts. The partnership has yielded valuable analysis of snow surface albedo as represented in JPL's MODIS Dust Radiative Forcing in Snow (MODDRFS) data, across the CBRFC's area of responsibility. When dust layers within a snowpack emerge, reducing the snow surface albedo, the snowmelt rate may accelerate. The CBRFC operational snow model (SNOW17) is a temperature-index model that lacks explicit representation of snowpack surface albedo. CBRFC forecasters monitor MODDRFS data for emerging dust layers and may manually adjust SNOW17 melt rates. A technique was needed for efficient and objective incorporation of the MODDRFS data into SNOW17. Initial development focused in Colorado, where dust-on-snow events frequently occur. CBRFC forecasters used retrospective JPL-CBRFC analysis and developed a quantitative relationship between MODDRFS data and mean areal temperature (MAT) data. The relationship was used to generate adjusted, MODDRFS-informed input for SNOW17. Impacts of the MODDRFS-SNOW17 MAT adjustment method on snowmelt-driven streamflow prediction varied spatially and with characteristics of the dust deposition events. The largest improvements occurred in southwestern Colorado, in years with intense dust deposition events. Application of the method in other regions of Colorado and in "low dust" years resulted in minimal impact. The MODDRFS-SNOW17 MAT technique will be implemented in CBRFC operations in late 2015, prior to spring 2016 runoff. Collaborative investigation of remote sensing-based adjustment methods for the CBRFC operational hydrologic forecasting environment will continue over the next several years.

Acute maternal infection and risk of pre-eclampsia: a population-based case-control study.

Directory of Open Access Journals (Sweden)

Caroline Minassian

Full Text Available Infection in pregnancy may be involved in the aetiology of pre-eclampsia. However, a clear association between acute maternal infection and pre-eclampsia has not been established. We assessed whether acute urinary tract infection, respiratory tract infection, and antibiotic drug prescriptions in pregnancy (a likely proxy for maternal infection are associated with an increased risk of pre-eclampsia.We used a matched nested case-control design and data from the UK General Practice Research Database to examine the association between maternal infection and pre-eclampsia. Primiparous women aged at least 13 years and registered with a participating practice between January 1987 and October 2007 were eligible for inclusion. We selected all cases of pre-eclampsia and a random sample of primiparous women without pre-eclampsia (controls. Cases (n=1533 were individually matched with up to ten controls (n=14236 on practice and year of delivery. We calculated odds ratios and 95% confidence intervals for pre-eclampsia comparing women exposed and unexposed to infection using multivariable conditional logistic regression. After adjusting for maternal age, pre-gestational hypertension, diabetes, renal disease and multifetal gestation, the odds of pre-eclampsia were increased in women prescribed antibiotic drugs (adjusted odds ratio 1.28;1.14-1.44 and in women with urinary tract infection (adjusted odds ratio 1.22;1.03-1.45. We found no association with maternal respiratory tract infection (adjusted odds ratio 0.91;0.72-1.16. Further adjustment for maternal smoking and pre-pregnancy body mass index made no difference to our findings.Women who acquire a urinary infection during pregnancy, but not those who have a respiratory infection, are at an increased risk of pre-eclampsia. Maternal antibiotic prescriptions are also associated with an increased risk. Further research is required to elucidate the underlying mechanism of this association and to determine

Nuclear insurance risk assessment using risk-based methodology

International Nuclear Information System (INIS)

Wendland, W.G.

1992-01-01

This paper presents American Nuclear Insurers' (ANI's) and Mutual Atomic Energy Liability Underwriters' (MAELU's) process and experience for conducting nuclear insurance risk assessments using a risk-based methodology. The process is primarily qualitative and uses traditional insurance risk assessment methods and an approach developed under the auspices of the American Society of Mechanical Engineers (ASME) in which ANI/MAELU is an active sponsor. This process assists ANI's technical resources in identifying where to look for insurance risk in an industry in which insurance exposure tends to be dynamic and nonactuarial. The process is an evolving one that also seeks to minimize the impact on insureds while maintaining a mutually agreeable risk tolerance

13 CFR 120.1000 - Risk-Based Lender Oversight.

Science.gov (United States)

2010-01-01

... 13 Business Credit and Assistance 1 2010-01-01 2010-01-01 false Risk-Based Lender Oversight. 120.1000 Section 120.1000 Business Credit and Assistance SMALL BUSINESS ADMINISTRATION BUSINESS LOANS Risk-Based Lender Oversight Supervision § 120.1000 Risk-Based Lender Oversight. (a) Risk-Based Lender...

design and implementation of a microcontroller-based adjustable ...

African Journals Online (AJOL)

HOD

1, DEPARTMENT OF COMPUTER ENGINEERING, UNIVERSITY OF BENIN, BENIN CITY, EDO STATE, NIGERIA ... ICs, to design a user friendly charger circuit that manually adjusts the voltage .... the multivibrator integrated circuit does it.

Effect of gender on psychosocial adjustment of colorectal cancer survivors with ostomy.

Science.gov (United States)

Gautam, Sital; Poudel, Anju

2016-12-01

Stoma can pose extensive challenges for colorectal cancer survivors. Identifying the psychological and social adjustment among them and how it differs by gender will aid in identifying those particularly at risk of having poor adjustment and in planning programs to improve their adjustment. The purpose of this study was to determine the effect of gender on psychosocial adjustment of colorectal cancer survivors with ostomy. A descriptive cross sectional study was carried out in the stoma clinic of B.P. Koirala Memorial Cancer Hospital, Bharatpur, Nepal. A purposive sample of 122 patients with ostomy was taken from the above mentioned setting. Selection criteria included colorectal cancer survivors having ostomy for at least 6 months. Data on socio-demographic and clinical variables were collected. Psychosocial adjustment was measured using Ostomy Adjustment Inventory-23 (OAI-23). A total of 122 patients were included in the study. Mean time since ostomy surgery was 2.53 and 1.98 years for men and women respectively. Both men and women had significant impairment in the psychosocial adjustment, however, men had significantly lower psychosocial adjustment score (37.68±12.96 vs . 43.45±12.81, t=-2.47, P=0.015) at 95% CI as compared to women and they reported more negative emotions. Furthermore, men significantly predicted low acceptance {β=-3.078, P=0.023, ΔR 2 =0.036, F [4,117] =7.90, Postomy should be monitored for psychosocial concerns in regular basis and health care providers should tailor care based on their need. Approaches of survivorship care and psychosocial interventions in colorectal cancer survivors with ostomy should take into account gender specific concerns and requirements to aid adjustment.

Algorithm for lamotrigine dose adjustment before, during, and after pregnancy

DEFF Research Database (Denmark)

Sabers, A

2012-01-01

Sabers A. Algorithm for lamotrigine dose adjustment before, during, and after pregnancy. Acta Neurol Scand: DOI: 10.1111/j.1600-0404.2011.01627.x. © 2011 John Wiley & Sons A/S. Background -  Treatment with lamotrigine (LTG) during pregnancy is associated with a pronounced risk of seizure deterior......Sabers A. Algorithm for lamotrigine dose adjustment before, during, and after pregnancy. Acta Neurol Scand: DOI: 10.1111/j.1600-0404.2011.01627.x. © 2011 John Wiley & Sons A/S. Background -  Treatment with lamotrigine (LTG) during pregnancy is associated with a pronounced risk of seizure...

Risk-Adjusted Analysis of Relevant Outcome Drivers for Patients after More Than Two Kidney Transplants

Directory of Open Access Journals (Sweden)

Lampros Kousoulas

2015-01-01

Full Text Available Renal transplantation is the treatment of choice for patients suffering end-stage renal disease, but as the long-term renal allograft survival is limited, most transplant recipients will face graft loss and will be considered for a retransplantation. The goal of this study was to evaluate the patient and graft survival of the 61 renal transplant recipients after second or subsequent renal transplantation, transplanted in our institution between 1990 and 2010, and to identify risk factors related to inferior outcomes. Actuarial patient survival was 98.3%, 94.8%, and 88.2% after one, three, and five years, respectively. Actuarial graft survival was 86.8%, 80%, and 78.1% after one, three, and five years, respectively. Risk-adjusted analysis revealed that only age at the time of last transplantation had a significant influence on patient survival, whereas graft survival was influenced by multiple immunological and surgical factors, such as the number of HLA mismatches, the type of immunosuppression, the number of surgical complications, need of reoperation, primary graft nonfunction, and acute rejection episodes. In conclusion, third and subsequent renal transplantation constitute a valid therapeutic option, but inferior outcomes should be expected among elderly patients, hyperimmunized recipients, and recipients with multiple operations at the site of last renal transplantation.

A Computational Tool for Testing Dose-related Trend Using an Age-adjusted Bootstrap-based Poly-k Test

Directory of Open Access Journals (Sweden)

Hojin Moon

2006-08-01

Full Text Available A computational tool for testing for a dose-related trend and/or a pairwise difference in the incidence of an occult tumor via an age-adjusted bootstrap-based poly-k test and the original poly-k test is presented in this paper. The poly-k test (Bailer and Portier 1988 is a survival-adjusted Cochran-Armitage test, which achieves robustness to effects of differential mortality across dose groups. The original poly-k test is asymptotically standard normal under the null hypothesis. However, the asymptotic normality is not valid if there is a deviation from the tumor onset distribution that is assumed in this test. Our age-adjusted bootstrap-based poly-k test assesses the significance of assumed asymptotic normal tests and investigates an empirical distribution of the original poly-k test statistic using an age-adjusted bootstrap method. A tumor of interest is an occult tumor for which the time to onset is not directly observable. Since most of the animal carcinogenicity studies are designed with a single terminal sacrifice, the present tool is applicable to rodent tumorigenicity assays that have a single terminal sacrifice. The present tool takes input information simply from a user screen and reports testing results back to the screen through a user-interface. The computational tool is implemented in C/C++ and is applied to analyze a real data set as an example. Our tool enables the FDA and the pharmaceutical industry to implement a statistical analysis of tumorigenicity data from animal bioassays via our age-adjusted bootstrap-based poly-k test and the original poly-k test which has been adopted by the National Toxicology Program as its standard statistical test.

Economic analysis of coal price-electricity price adjustment in China based on the CGE model

International Nuclear Information System (INIS)

He, Y.X.; Zhang, S.L.; Yang, L.Y.; Wang, Y.J.; Wang, J.

2010-01-01

In recent years, coal price has risen rapidly, which has also brought a sharp increase in the expenditures of thermal power plants in China. Meantime, the power production price and power retail price have not been adjusted accordingly and a large number of thermal power plants have incurred losses. The power industry is a key industry in the national economy. As such, a thorough analysis and evaluation of the economic influence of the electricity price should be conducted before electricity price adjustment is carried out. This paper analyses the influence of coal price adjustment on the electric power industry, and the influence of electricity price adjustment on the macroeconomy in China based on computable general equilibrium models. The conclusions are as follows: (1) a coal price increase causes a rise in the cost of the electric power industry, but the influence gradually descends with increase in coal price; and (2) an electricity price increase has an adverse influence on the total output, Gross Domestic Product (GDP), and the Consumer Price Index (CPI). Electricity price increases have a contractionary effect on economic development and, consequently, electricity price policy making must consequently consider all factors to minimize their adverse influence.

Risk assessment of Giardia in rivers of southern China based on continuous monitoring

Institute of Scientific and Technical Information of China (English)

Wei An; Dongqing Zhang; Shumin Xiao; Jianwei Yu; Min Yang

2012-01-01

The occurrence and risks of Giardia in China have been unclear to date,which has made it difficult to properly manage source water as well as to create reasonable drinking water standards.The levels of Giardia in river networks of several cities in Zhejiang Province,China were found to be in the range of 0-5 oocysts/10 L in the rainy season in 2008.The mortality due to Giardia infection for people in this region was calculated to be from 0 to 1.95 × 10-s persons using a conditional probability equation.Based on multiple unboiled water intake routes,the disability-adjusted life years (DALYs) due to Giardia infection for people who consumed conventionally treated water was 0.625 (95% CI:0.137-2.05) per 105 persons,with the symptom of hospitalization making the highest contribution to total DALYs (0.56 per 105 persons; 95% CI:0.122-1.84).The DALYs decreased to 0.425 (95% CI:0.137-2.05) per 105 persons per year for those consuming water treated with advanced technology.These values were lower than the acceptable risk (1.97 × 10-5 DALYs per year).This study revealed the risk of Giardia infection to the people in river networks of Zhejiang Province for the first time,and provides a method to evaluate the risk of Giardia infection.The results are useful for the modification of drinking water quality standards based on cost-benefit analysis.

Adjustable Parameter-Based Distributed Fault Estimation Observer Design for Multiagent Systems With Directed Graphs.

Science.gov (United States)

Zhang, Ke; Jiang, Bin; Shi, Peng

2017-02-01

In this paper, a novel adjustable parameter (AP)-based distributed fault estimation observer (DFEO) is proposed for multiagent systems (MASs) with the directed communication topology. First, a relative output estimation error is defined based on the communication topology of MASs. Then a DFEO with AP is constructed with the purpose of improving the accuracy of fault estimation. Based on H ∞ and H 2 with pole placement, multiconstrained design is given to calculate the gain of DFEO. Finally, simulation results are presented to illustrate the feasibility and effectiveness of the proposed DFEO design with AP.

Pneumonia is an independent risk factor for pyogenic liver abscess: A population-based, nested, case-control study.

Science.gov (United States)

Ho, Sai-Wai; Yeh, Chao-Bin; Yang, Shun-Fa; Yeh, Han-Wei; Huang, Jing-Yang; Teng, Ying-Hock

2017-01-01

Bacteremic pneumonia is considered a potential cause of distal organ abscess formation. Therefore, we hypothesize that pneumonia is a risk factor for pyogenic liver abscess (PLA).The aim of this study is to explore the association between pneumonia and PLA. A nationwide, population-based, nested, case-control study was conducted using data from the Taiwan National Health Insurance Research Database. In total, 494 patients with PLA and 1,976 propensity score matched controls were enrolled. Conditional logistic regression was used to estimate adjusted odds ratios (aORs) in patients with exposure to pneumonia before PLA. After matched and adjusted for confounding factors including age, sex, urbanization, income, chronic liver disease, alcohol-related disease, biliary stone, chronic kidney disease, diabetes mellitus, chronic liver disease, and cancer, hospitalization for pneumonia remained an independent risk factor for PLA with an aORs of 2.104 [95% confidence interval (CI) = 1.309-3.379, p = 0.0021]. Moreover, the aORs were significantly higher among patients hospitalized for pneumonia within 30 days (aORs = 10.73, 95% CI = 3.381-34.054), 30-90 days (aORs = 4.698, 95% CI = 1.541-14.327) and 90-180 (aORs = 4.000, 95% CI = 1.158-13.817) days before PLA diagnosis. Pneumonia is an independent risk factor for subsequent PLA. Moreover, hospitalization for pneumonia within 180 days before PLA diagnosis was associated with an increased risk of PLA.

Adjusting a cancer mortality-prediction model for disease status-related eligibility criteria

Directory of Open Access Journals (Sweden)

Kimmel Marek

2011-05-01

Full Text Available Abstract Background Volunteering participants in disease studies tend to be healthier than the general population partially due to specific enrollment criteria. Using modeling to accurately predict outcomes of cohort studies enrolling volunteers requires adjusting for the bias introduced in this way. Here we propose a new method to account for the effect of a specific form of healthy volunteer bias resulting from imposing disease status-related eligibility criteria, on disease-specific mortality, by explicitly modeling the length of the time interval between the moment when the subject becomes ineligible for the study, and the outcome. Methods Using survival time data from 1190 newly diagnosed lung cancer patients at MD Anderson Cancer Center, we model the time from clinical lung cancer diagnosis to death using an exponential distribution to approximate the length of this interval for a study where lung cancer death serves as the outcome. Incorporating this interval into our previously developed lung cancer risk model, we adjust for the effect of disease status-related eligibility criteria in predicting the number of lung cancer deaths in the control arm of CARET. The effect of the adjustment using the MD Anderson-derived approximation is compared to that based on SEER data. Results Using the adjustment developed in conjunction with our existing lung cancer model, we are able to accurately predict the number of lung cancer deaths observed in the control arm of CARET. Conclusions The resulting adjustment was accurate in predicting the lower rates of disease observed in the early years while still maintaining reasonable prediction ability in the later years of the trial. This method could be used to adjust for, or predict the duration and relative effect of any possible biases related to disease-specific eligibility criteria in modeling studies of volunteer-based cohorts.

42 CFR 413.231 - Adjustment for wages.

Science.gov (United States)

2010-10-01

... 42 Public Health 2 2010-10-01 2010-10-01 false Adjustment for wages. 413.231 Section 413.231... Disease (ESRD) Services and Organ Procurement Costs § 413.231 Adjustment for wages. (a) CMS adjusts the labor-related portion of the base rate to account for geographic differences in the area wage levels...

Habitual sleep duration and insomnia and the risk of cardiovascular events and all-cause death: report from a community-based cohort.

Science.gov (United States)

Chien, Kuo-Liong; Chen, Pei-Chung; Hsu, Hsiu-Ching; Su, Ta-Chen; Sung, Fung-Chang; Chen, Ming-Fong; Lee, Yuan-Teh

2010-02-01

To investigate the relationship between sleep duration and insomnia severity and the risk of all-cause death and cardiovascular disease (CVD) events. Prospective cohort study. Community-based. A total of 3,430 adults aged 35 years or older. None. During a median 15.9 year (interquartile range, 13.1 to 16.9) follow-up period, 420 cases developed cardiovascular disease and 901 cases died. A U-shape association between sleep duration and all-cause death was found: the age and gender-adjusted relative risks (95% confidence interval [CI]) of all-cause death (with 7 h of daily sleep being considered for the reference group) for individuals reporting or = 9 h were 1.15 (0.91-1.45), 1.02 (0.85-1.25), 1.05 (0.88-1.27), and 1.43 (1.16-1.75); P for trend, 0.019. However, the relationship between sleep duration and risk of CVD were linear. The multivariate-adjusted relative risk (95% CI) for all-cause death (using individuals without insomnia) were 1.02 (0.86-1.20) for occasional insomnia, 1.15 (0.92-1.42) for frequent insomnia, and 1.70 (1.16-2.49) for nearly everyday insomnia (P for trend, 0.028). The multivariate adjusted relative risk (95% CI) was 2.53 (1.71-3.76) for all-cause death and 2.07 (1.11-3.85) for CVD rate in participants sleeping > or = 9 h and for those with frequent insomnia. Sleep duration and insomnia severity were associated with all-cause death and CVD events among ethnic Chinese in Taiwan. Our data indicate that an optimal sleep duration (7-8 h) predicted fewer deaths.

A model-based risk management framework

Energy Technology Data Exchange (ETDEWEB)

Gran, Bjoern Axel; Fredriksen, Rune

2002-08-15

The ongoing research activity addresses these issues through two co-operative activities. The first is the IST funded research project CORAS, where Institutt for energiteknikk takes part as responsible for the work package for Risk Analysis. The main objective of the CORAS project is to develop a framework to support risk assessment of security critical systems. The second, called the Halden Open Dependability Demonstrator (HODD), is established in cooperation between Oestfold University College, local companies and HRP. The objective of HODD is to provide an open-source test bed for testing, teaching and learning about risk analysis methods, risk analysis tools, and fault tolerance techniques. The Inverted Pendulum Control System (IPCON), which main task is to keep a pendulum balanced and controlled, is the first system that has been established. In order to make risk assessment one need to know what a system does, or is intended to do. Furthermore, the risk assessment requires correct descriptions of the system, its context and all relevant features. A basic assumption is that a precise model of this knowledge, based on formal or semi-formal descriptions, such as UML, will facilitate a systematic risk assessment. It is also necessary to have a framework to integrate the different risk assessment methods. The experiences so far support this hypothesis. This report presents CORAS and the CORAS model-based risk management framework, including a preliminary guideline for model-based risk assessment. The CORAS framework for model-based risk analysis offers a structured and systematic approach to identify and assess security issues of ICT systems. From the initial assessment of IPCON, we also believe that the framework is applicable in a safety context. Further work on IPCON, as well as the experiences from the CORAS trials, will provide insight and feedback for further improvements. (Author)

Maternal Obesity: Risks for Developmental Delays in Early Childhood.

Science.gov (United States)

Duffany, Kathleen O'Connor; McVeigh, Katharine H; Kershaw, Trace S; Lipkind, Heather S; Ickovics, Jeannette R

2016-02-01

To assess the risk for neurodevelopmental delays for children of mothers who were obese (≥200 pounds) prior to pregnancy, and to characterize delays associated with maternal obesity among children referred to and found eligible to receive Early Intervention Program services. We conducted a retrospective cohort study (N = 541,816) using a population-based New York City data warehouse with linked birth and Early Intervention data. Risks for children suspected of a delay and 'significantly delayed', with two moderate or one severe delay, were calculated. Among the group of children eligible by delay for Early Intervention, analyses assessed risk for being identified with a moderate-to-severe delay across each of five functional domains as well as risks for multiple delays. Children of mothers who were obese were more likely to be suspected of a delay (adjusted RR 1.19 [CI 1.15-1.22]) and borderline association for 'significantly delayed' (adjusted RR 1.01 [CI 1.00-1.02). Among children eligible by delay, children of mothers who were obese evidenced an increased risk for moderate-to-severe cognitive (adjusted RR 1.04 [CI 1.02-1.07]) and physical (adjusted RR 1.04 [CI 1.01-1.08]) delays and for global developmental delay (adjusted RR 1.05 [CI 1.01-1.08]). Maternal obesity is associated with increased risk of developmental delay in offspring. Among children with moderate or severe delays, maternal obesity is associated with increased risk of cognitive and physical delays as well as with increased risk for global developmental delay. While causation remains uncertain, this adds to the growing body of research reporting an association between maternal obesity and neurodevelopmental delays in offspring.

Increased long-term risk of major adverse cardiovascular events in patients with carbon monoxide poisoning: A population-based study in Taiwan.

Directory of Open Access Journals (Sweden)

Chung-Shun Wong

Full Text Available Carbon monoxide (CO poisoning may cause toxicity to the cardiovascular system. However, the association between CO poisoning and the risk of major adverse cardiovascular events (MACE remains unestablished. We investigated the incidence of MACE after CO poisoning in Taiwan and evaluated whether CO-poisoned individuals had a higher risk of MACE than did the general population.Using Taiwan's National Health Insurance Research Database (NHIRD during 2005-2013, a nationwide population-based cohort study was conducted among patients who experienced CO poisoning between 2005 and 2013. CO poisoning was defined according to the International Classification of Diseases, Ninth Revision, Clinical Modification codes. The study cohort comprised patients with CO poisoning between 2005 and 2010 (N = 13,939. Each patient was matched according to age, sex and index date with four randomly selected controls from the comparison cohort (N = 55,756. All patients were followed from the study date until MACE development, death, or the end of 2013. The hazard ratios for MACE were compared between the two cohorts by using Cox proportional hazards regressions analyses.Incident cases of MACE were identified from the NHIRD. After adjustment for potential confounders, the study cohort was independently associated with a higher MACE risk (adjusted hazard ratio, 2.00; 95% confidence interval, 1.83-2.18.This population-based cohort study indicated that patients with CO poisoning have a higher risk of MACE than do individuals without CO poisoning.

Long-term Risk of Dementia in Persons With Schizophrenia: A Danish Population-Based Cohort Study.

Science.gov (United States)

Ribe, Anette Riisgaard; Laursen, Thomas Munk; Charles, Morten; Katon, Wayne; Fenger-Grøn, Morten; Davydow, Dimitry; Chwastiak, Lydia; Cerimele, Joseph M; Vestergaard, Mogens

2015-11-01

Although schizophrenia is associated with several age-related disorders and considerable cognitive impairment, it remains unclear whether the risk of dementia is higher among persons with schizophrenia compared with those without schizophrenia. To determine the risk of dementia among persons with schizophrenia compared with those without schizophrenia in a large nationwide cohort study with up to 18 years of follow-up, taking age and established risk factors for dementia into account. This population-based cohort study of more than 2.8 million persons aged 50 years or older used individual data from 6 nationwide registers in Denmark. A total of 20 683 individuals had schizophrenia. Follow-up started on January 1, 1995, and ended on January 1, 2013. Analysis was conducted from January 1, 2015, to April 30, 2015. Incidence rate ratios (IRRs) and cumulative incidence proportions (CIPs) of dementia for persons with schizophrenia compared with persons without schizophrenia. During 18 years of follow-up, 136 012 individuals, including 944 individuals with a history of schizophrenia, developed dementia. Schizophrenia was associated with a more than 2-fold higher risk of all-cause dementia (IRR, 2.13; 95% CI, 2.00-2.27) after adjusting for age, sex, and calendar period. The estimates (reported as IRR; 95% CI) did not change substantially when adjusting for medical comorbidities, such as cardiovascular diseases and diabetes mellitus (2.01; 1.89-2.15) but decreased slightly when adjusting for substance abuse (1.71; 1.60-1.82). The association between schizophrenia and dementia risk was stable when evaluated in subgroups characterized by demographics and comorbidities, although the IRR was higher among individuals younger than 65 years (3.77; 3.29-4.33), men (2.38; 2.13-2.66), individuals living with a partner (3.16; 2.71-3.69), those without cerebrovascular disease (2.23; 2.08-2.39), and those without substance abuse (1.96; 1.82-2.11). The CIPs (95% CIs) of developing

Noninvasive Computed Tomography-based Risk Stratification of Lung Adenocarcinomas in the National Lung Screening Trial.

Science.gov (United States)

Maldonado, Fabien; Duan, Fenghai; Raghunath, Sushravya M; Rajagopalan, Srinivasan; Karwoski, Ronald A; Garg, Kavita; Greco, Erin; Nath, Hrudaya; Robb, Richard A; Bartholmai, Brian J; Peikert, Tobias

2015-09-15

Screening for lung cancer using low-dose computed tomography (CT) reduces lung cancer mortality. However, in addition to a high rate of benign nodules, lung cancer screening detects a large number of indolent cancers that generally belong to the adenocarcinoma spectrum. Individualized management of screen-detected adenocarcinomas would be facilitated by noninvasive risk stratification. To validate that Computer-Aided Nodule Assessment and Risk Yield (CANARY), a novel image analysis software, successfully risk stratifies screen-detected lung adenocarcinomas based on clinical disease outcomes. We identified retrospective 294 eligible patients diagnosed with lung adenocarcinoma spectrum lesions in the low-dose CT arm of the National Lung Screening Trial. The last low-dose CT scan before the diagnosis of lung adenocarcinoma was analyzed using CANARY blinded to clinical data. Based on their parametric CANARY signatures, all the lung adenocarcinoma nodules were risk stratified into three groups. CANARY risk groups were compared using survival analysis for progression-free survival. A total of 294 patients were included in the analysis. Kaplan-Meier analysis of all the 294 adenocarcinoma nodules stratified into the Good, Intermediate, and Poor CANARY risk groups yielded distinct progression-free survival curves (P < 0.0001). This observation was confirmed in the unadjusted and adjusted (age, sex, race, and smoking status) progression-free survival analysis of all stage I cases. CANARY allows the noninvasive risk stratification of lung adenocarcinomas into three groups with distinct post-treatment progression-free survival. Our results suggest that CANARY could ultimately facilitate individualized management of incidentally or screen-detected lung adenocarcinomas.

Development and Validation of an Agency for Healthcare Research and Quality Indicator for Mortality After Congenital Heart Surgery Harmonized With Risk Adjustment for Congenital Heart Surgery (RACHS-1) Methodology.

Science.gov (United States)

Jenkins, Kathy J; Koch Kupiec, Jennifer; Owens, Pamela L; Romano, Patrick S; Geppert, Jeffrey J; Gauvreau, Kimberlee

2016-05-20

The National Quality Forum previously approved a quality indicator for mortality after congenital heart surgery developed by the Agency for Healthcare Research and Quality (AHRQ). Several parameters of the validated Risk Adjustment for Congenital Heart Surgery (RACHS-1) method were included, but others differed. As part of the National Quality Forum endorsement maintenance process, developers were asked to harmonize the 2 methodologies. Parameters that were identical between the 2 methods were retained. AHRQ's Healthcare Cost and Utilization Project State Inpatient Databases (SID) 2008 were used to select optimal parameters where differences existed, with a goal to maximize model performance and face validity. Inclusion criteria were not changed and included all discharges for patients model includes procedure risk group, age (0-28 days, 29-90 days, 91-364 days, 1-17 years), low birth weight (500-2499 g), other congenital anomalies (Clinical Classifications Software 217, except for 758.xx), multiple procedures, and transfer-in status. Among 17 945 eligible cases in the SID 2008, the c statistic for model performance was 0.82. In the SID 2013 validation data set, the c statistic was 0.82. Risk-adjusted mortality rates by center ranged from 0.9% to 4.1% (5th-95th percentile). Congenital heart surgery programs can now obtain national benchmarking reports by applying AHRQ Quality Indicator software to hospital administrative data, based on the harmonized RACHS-1 method, with high discrimination and face validity. © 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Long-term allopurinol use decreases the risk of prostate cancer in patients with gout: a population-based study.

Science.gov (United States)

Shih, H-J; Kao, M-C; Tsai, P-S; Fan, Y-C; Huang, C-J

2017-09-01

Clinical observations indicated an increased risk of developing prostate cancer in gout patients. Chronic inflammation is postulated to be one crucial mechanism for prostate carcinogenesis. Allopurinol, a widely used antigout agent, possesses potent anti-inflammation capacity. We elucidated whether allopurinol decreases the risk of prostate cancer in gout patients. We analyzed data retrieved from Taiwan National Health Insurance Database between January 2000 and December 2012. Patients diagnosed with gout during the study period with no history of prostate cancer and who had never used allopurinol were selected. Four allopurinol use cohorts (that is, allopurinol use (>365 days), allopurinol use (181-365 days), allopurinol use (91-180 days) and allopurinol use (31-90 days)) and one cohort without using allopurinol (that is, allopurinol use (No)) were included. The study end point was the diagnosis of new-onset prostate cancer. Multivariable Cox proportional hazards regression and propensity score-adjusted Cox regression models were used to estimate the association between the risk of prostate cancer and allopurinol treatment in gout patients after adjusting for potential confounders. A total of 25 770 gout patients (aged between 40 and 100 years) were included. Multivariable Cox regression analyses revealed that the risk of developing prostate cancer in the allopurinol use (>365 days) cohort was significantly lower than the allopurinol use (No) cohort (adjusted hazard ratio (HR)=0.64, 95% confidence interval (CI)=0.45-0.9, P=0.011). After propensity score adjustment, the trend remained the same (adjusted HR=0.66, 95% CI=0.46-0.93, P=0.019). Long-term (more than 1 year) allopurinol use may associate with a decreased risk of prostate cancer in gout patients.

10 CFR 905.34 - Adjustment provisions.

Science.gov (United States)

2010-01-01

... continue to take place based on existing contract/marketing criteria principles. ... 10 Energy 4 2010-01-01 2010-01-01 false Adjustment provisions. 905.34 Section 905.34 Energy DEPARTMENT OF ENERGY ENERGY PLANNING AND MANAGEMENT PROGRAM Power Marketing Initiative § 905.34 Adjustment...

Risk Probability Estimating Based on Clustering

DEFF Research Database (Denmark)

Chen, Yong; Jensen, Christian D.; Gray, Elizabeth

2003-01-01

of prior experiences, recommendations from a trusted entity or the reputation of the other entity. In this paper we propose a dynamic mechanism for estimating the risk probability of a certain interaction in a given environment using hybrid neural networks. We argue that traditional risk assessment models...... from the insurance industry do not directly apply to ubiquitous computing environments. Instead, we propose a dynamic mechanism for risk assessment, which is based on pattern matching, classification and prediction procedures. This mechanism uses an estimator of risk probability, which is based...

Refined estimates of local recurrence risks by DCIS score adjusting for clinicopathological features: a combined analysis of ECOG-ACRIN E5194 and Ontario DCIS cohort studies.

Science.gov (United States)

Rakovitch, E; Gray, R; Baehner, F L; Sutradhar, R; Crager, M; Gu, S; Nofech-Mozes, S; Badve, S S; Hanna, W; Hughes, L L; Wood, W C; Davidson, N E; Paszat, L; Shak, S; Sparano, J A; Solin, L J

2018-06-01

Better tools are needed to estimate local recurrence (LR) risk after breast-conserving surgery (BCS) for DCIS. The DCIS score (DS) was validated as a predictor of LR in E5194 and Ontario DCIS cohort (ODC) after BCS. We combined data from E5194 and ODC adjusting for clinicopathological factors to provide refined estimates of the 10-year risk of LR after treatment by BCS alone. Data from E5194 and ODC were combined. Patients with positive margins or multifocality were excluded. Identical Cox regression models were fit for each study. Patient-specific meta-analysis was used to calculate precision-weighted estimates of 10-year LR risk by DS, age, tumor size and year of diagnosis. The combined cohort includes 773 patients. The DS and age at diagnosis, tumor size and year of diagnosis provided independent prognostic information on the 10-year LR risk (p ≤ 0.009). Hazard ratios from E5194 and ODC cohorts were similar for the DS (2.48, 1.95 per 50 units), tumor size ≤ 1 versus  > 1-2.5 cm (1.45, 1.47), age ≥ 50 versus  15%) 10-year LR risk after BCS alone compared to utilization of DS alone or clinicopathological factors alone. The combined analysis provides refined estimates of 10-year LR risk after BCS for DCIS. Adding information on tumor size and age at diagnosis to the DS adjusting for year of diagnosis provides improved LR risk estimates to guide treatment decision making.

ACA Risk Adjustment - Overview, Context, and Challenges

Data.gov (United States)

U.S. Department of Health & Human Services — Volume 4, Issue 3 of the Medicare and Medicaid Research Review includes three articles describing the Department of Health and Human Services (HHS) developed risk...

Risk management for whales

OpenAIRE

Cont, R; Wagalath, L

2016-01-01