Probability Of Admission Research Articles

Changes in patient admissions after the 2015 Earthquake: a tertiary hospital-based study in Kathmandu, Nepal

Literature on earthquake impact on hospital admissions is lacking, particularly in low-resource settings. Our aim was to study the pattern of admissions before and after the 2015 earthquake in a tertiary hospital in Nepal. We used routine hospital data from 9,596 admissions, and defined four periods: pre-earthquake (pre-EQ), acute (EQ1), post-acute (EQ2), and post-earthquake (post-EQ). We compared length of hospital stay (LOS) across the study periods using negative binomial regressions. We used logistic regressions to study changes in probability of admission for diagnostic categories, and Generalized Additive Models to model the difference in number of admissions compared to pre-EQ baseline. LOS was longer in EQ1 than during pre-EQ, in particular for injury-related admissions. In EQ1, the odds of injury admissions increased, while they decreased for the majority of other diagnoses, with the odds of pregnancy-related admissions remaining low until post-EQ. The number of admissions dropped in EQ1 and EQ2, and returned to pre-EQ trends in post-EQ, accumulating 381 admissions lost (CI: 206–556). Our findings suggest that hospital disaster plans must not only foresee injury management after earthquakes, but also ensure accessibility, in particular for pregnant women, and promote a quick return to normality to prevent additional negative health outcomes.

Effect Modification of Multimorbidity on the Association Between Regularity of General Practitioner Contacts and Potentially Avoidable Hospitalisations.

Scheduled regular contact with the general practitioner (GP) may lower the risk of potentially avoidable hospitalisations (PAHs). Despite the high prevalence of multimorbidity, little is known about its effect on the relationship between regularity of GP contact and PAHs. To investigate potential effect modification of multimorbidity on the relationship between regularity of GP contact and probability of PAHs. A retrospective, cross-sectional study. 229,964 individuals aged 45years and older from the 45 and Up Study in New South Wales, Australia, from 2009 to 2015. The main exposure was regularity of GP contact (capturing dispersion of GP contacts); the outcomes were PAHs evaluated by unplanned hospitalisations, chronic ambulatory care sensitive condition (ACSC) hospitalisations and unplanned chronic ACSC hospitalisations. Multivariable logistic regression models and population attributable fractions (PAF) were conducted to identify effect modification of multimorbidity, assessed by Rx-Risk comorbidity score. Compared with the lowest quintile of regularity, the highest quintile had significantly lower predicted probability of unplanned admission (- 79.9 per 1000 people at risk, 95% confidence interval (CI) - 85.6; - 74.2), chronic ACSC (- 6.07 per 1000 people at risk, 95%CI - 8.07; - 4.08) and unplanned chronic ACSC hospitalisation (- 4.68 per 1000 people at risk, 95%CI - 6.11; - 3.26). Effect modification of multimorbidity was observed. Specifically, the PAF among people with no multimorbidity indicated that 31.7% (95%CI 28.7-34.4%) of unplanned, 36.4% (95%CI 25.1-45.9%) of chronic ACSC and 48.9% (95%CI 32.9-61.1%) of unplanned chronic ACSC hospitalisation would be reduced by a shift to the highest quintile of regularity. However, among people with 10+ morbidities, the proportional reduction was only 5.2% (95%CI 3.8-6.5%), 9.0% (95%CI 0.5-16.8%) and 17.8% (95%CI 5.4-28.5%), respectively. Weakening of the association between regularity and PAHs with increasing levels of multimorbidity suggests a need to improve primary care support to prevent PAHs for patients with multimorbidity.

The Returns to Elite University Education: a Quasi-Experimental Analysis

Abstract I take advantage of a discontinuity in the probability of admission to a highly selective private university to estimate causal returns to investing in elite university education. I use a newly assembled data set that combines individual administrative records about high school attendance, university admission, university attendance, and tax returns. I find a discontinuity in income of 38 log points at the admission cutoff. The fuzzy regression discontinuity estimate for the elite enrollment effect is 58 log points. This should be interpreted as the average treatment effect for students applying to the elite university who are close to the cutoff and chose to enroll. When I take into account the evidence that students enrolling in the elite university tend to make different field choices, the net institutional enrollment premium is 41 log points. Cumulated over 15 years, the net-of-tuition elite premium is €246,991. I explore potential channels explaining the sizeable enrollment effects and I find that students just above the admission cutoff are 15 percentage points more likely to complete a university degree, they are 26 percentage points more likely to graduate on time and attend university with substantially higher quality peers.

Identification of School Admission Effects Using Propensity Scores Based on a Matching Market Structure

A large literature estimates various school admission and graduation effects by employing variation in student admission scores around schools’ admission cutoffs, assuming (quasi-) random school assignment close to the cutoffs. In this paper, I present evidence suggesting that the samples corresponding to typical applications of the regression discontinuity design (RDD) fail to satisfy these assumptions. I distinguish ex-post randomization (as in admission lotteries applicable to those at the margin of admission) from ex-ante randomization, reflecting uncertainty about the market structure of applicants, which can be naturally quantified by resampling from the applicant population. Using data from the Croatian centralized college admission system, I show that these ex-ante admission probabilities differ dramatically between treated and non-treated students within typical RDD bandwidths. Such unbalanced admission probability distributions suggest that bandwidths (and sample sizes) should be drastically reduced to avoid selection bias. I also show that a sizeable fraction of quasi-randomized assignments occur outside of the typical RDD bandwidths, suggesting that these are also inefficient. As an alternative, I propose a new estimator, the Propensity Score Discontinuity Design (PSDD), based on all observations with random assignments, which compares outcomes of applicants matched on ex-ante admission probabilities, conditional on admission scores.

Postoperative Admission in Critical Care Units Following Gynecologic Oncology Surgery: Outcomes Based on a Systematic Review and Authors' Recommendations.

The present study aimed to evaluate the predictors of admission to the Critical Care Units (CCUs) and factors predisposing to prolonged stay in CCUs after gynecological oncology surgery. Studies which addressed cases of women who underwent surgery for gynecological malignancies and required postoperative CCU admission were included. Seven studies with 3820 patients were included. Among them, 1680 required admission to CCU. Advanced age, higher Charlson Comorbidity Index (CCI) score, longer operative times, protracted blood loss and intestinal resection were associated with higher probability of CCU admission. Patients' age, operative times, blood loos and intestinal resection were significant predictors of prolonged stay to CCUs. Admission to CCU and length of stay following surgery for gynecologic malignancies is driven by specific patient characteristics as well as intraoperative values. Further studies are needed to validate high risk patients who will benefit from postoperative care to CCUs to ensure favorable postoperative outcomes and cost-effectiveness.

ABOUT RELATIONSHIP BETWEEN THE SIGNAL POWER, NUMBER OF M-QAM POSITIONS AND NOISE IMMUNITY IN BROADBAND WIRELESS ACCESS SYSTEMS

Is studied the effect of measurement error on the accuracy of selecting the modulation type in the transmitter of the base station. The article discusses changes in the statistical characteristics of the measured signal as it passes through the stage of the feedback loop of the system of the LMDS type. Probabilistic characteristics of pilot-signal are determined at the output of this loop. The aim of the work was to find a compromise between the type of modulation and the power of the BS transmitter to maintain the transmission faithfulness within the given limits in the forward channel of an interactive wireless broadband radio access system of the LMDS. In this system a transition is made from one type of modulation to another in order to maintain the noise immunity of the system within the admissible limits. An adaptive controlling method of modulation type makes it possible to obtain an energy gain in the forward channel of the system. It is useful to determine the type of modulation by measuring the current value of the signal-to-interference ratio at the base station (BS) receiver. For this purpose a pilot signal is transmitted on the reverse channel of the system. This signal, passing through the turbulent medium, undergoes attenuation, and therefore at the input of the BS receiver we have a random process. Moreover, the distribution law of this process can be different and is determined by the communication channel model. The problem consisted in determining the necessary probabilistic characteristics of the output process by using the system parameters and probabilistic characteristics of the input random process. For this purpose the cumulants of the input random process and the random process at the output of the linear inertial system are determined. An expression for the probability density of the random process at the output of a linear inertial system is obtained. The graphics of the error probability on the energy parameter at 16-QAM and 64-QAM type of modulation are constructed. The influence of the measurement error on the accuracy of the choice of the modulation type in the transmitter of the BS is studied. The limits of the change in the energy parameter are defined graphically, under which the modulation type changes to ensure a given error probability. It is determined, that the system is more critical to the measurement error at high admissible error probability, i.e. at high error probabilities, small errors in the measurement of the signal-to-noise ratio make it necessary to transition to a more noise-immune modulation mode.

The impact of COVID-19 in diabetic kidney disease and chronic kidney disease: A population-based study.

Background:The spectrum of pre-existing renal disease is known as a risk factor for severe COVID-19 outcomes. However, little is known about the impact of COVID-19 on patients with diabetic nephropathy in comparison to patients with chronic kidney disease.Methods:We used the Mexican Open Registry of COVID-19 patients 11 to analyze anonymized records of those who had symptoms related to COVID-19 to analyze the rates of SARS-CoV-2 infection, development of COVID-19 pneumonia, admission, intubation, Intensive Care Unit admission and mortality. Robust Poisson regression was used to relate sex and age to each of the six outcomes and find adjusted prevalences and adjusted prevalence ratios. Also, binomial regression models were performed for those outcomes that had significant results to generate probability plots to perform a fine analysis of the results obtained along age as a continuous variable.Results:The adjusted prevalence analysis revealed that that there was an 87.9% higher probability of developing COVID-19 pneumonia in patients with diabetic nephropathy, a 5% higher probability of being admitted, a 101.7% higher probability of intubation and a 20.8% higher probability of a fatal outcome due to COVID-19 pneumonia in comparison to CKD patients (p<0.01).Conclusions:Patients with diabetic nephropathy had nearly a twofold rate of COVID-19 pneumonia, a higher probability of admission, a twofold probability of intubation and a higher chance of death once admitted compared to patients with chronic kidney disease alone. Also, both diseases had higher COVID-19 pneumonia rates, intubation rates and case-fatality rates compared to the overall population.

Effect of income on length of stay in a hospital or long-term care facility among older adults with dementia in Japan.

We aimed to ascertain the degree of influence of income disparity among older people with newly developed dementia on the probability and duration of stay in a hospital or long-term care facility and the degree of influence on medical expenses for hospitalization and care costs. This was a retrospective cohort study. Study participants included 12 829 individuals aged 75 years or older not diagnosed with dementia between April 2012 and March 2013 but newly diagnosed with dementia between April 2013 and March 2014. Participants were categorized according to income. We evaluated the associations of income with the probability and duration of stay in a hospital or long-term care facility and the costs for hospitalization and care. In the adjusted analyses, high-income individuals had a lower probability of admission to a hospital or long-term care facility than middle- and high-income individuals. In all hospitals, low-income individuals had the longest duration of stay, but in long-term care facilities, income categories varied by facility type. Medical expenses for hospitalization and care costs were highest in the low-income group. Income category affects the probability and duration of stay in the hospital or a long-term care facility, as well as expenses for hospitalization and care. It is necessary to consider a policy to enable low-income older patients with dementia to continue living at home.

Association of daily copayments with use of hospital care among medicare advantage enrollees

BackgroundWhile the traditional Medicare program imposes a deductible for hospital admissions, many Medicare Advantage plans have instituted per-diem copayments for hospital care. Little evidence exists about the effects of changes in cost-sharing for hospital care among the elderly. Changing inpatient benefits from a deductible to a per diem may benefit enrollees with shorter lengths of stay, but adversely affect the out-of-pocket burden for hospitalized enrollees with longer lengths of stay.MethodsWe used a quasi-experimental difference-in-differences study to compare longitudinal changes in proportion hospitalized, inpatient admissions and days per 100 enrollees, and hospital length of stay between enrollees in MA plans that changed inpatient benefit from deductible at admission to per diem, intervention plans, and enrollees in matched control plans – similar plans that maintained inpatient deductibles. The study population included 423,634 unique beneficiaries enrolled in 23 intervention plans and 36 matched control plans in the 2007–2010 period.ResultsThe imposition of per-diem copayments were associated with adjusted declines of 1.3 admissions/100 enrollees (95% CI − 1.8 to − 0.9), 6.9 inpatient days/100 enrollees (95% CI − 10.1 to − 3.8) and 0.7 percentage points in the probability of hospital admission (95% CI − 1.0 to − 0.4), with no significant change in adjusted length of stay in intervention plans relative to control plans. For persons with 2 or more hospitalizations in the year prior to the cost-sharing change, adjusted declines were 3.5 admissions/100 (95% CI − 8.4 to 1.4), 31.1 days/100 (95% CI − 75.2 to 13.0) and 2.2 percentage points in the probability of hospitalization (95% CI − 3.8 to − 0.6) in intervention plans relative to control plans.ConclusionsInstituting per-diem copayments was associated with reductions in number of admissions and hospital stays, but not length of stay once admitted. Effects of inpatient cost-sharing changes were magnified for persons with greater baseline use of hospital care.

The Sydney triage to admission risk tool (START) to improve patient flow in an emergency department: a model of care implementation pilot study

BackgroundThe Sydney Triage to Admission Risk Tool (START) is a validated clinical analytics tool designed to estimate the probability of in-patient admission based on Emergency Department triage characteristics.MethodsThis was a single centre pilot implementation study using a matched case control sample of patients assessed at ED triage. Patients in the intervention group were identified at triage by the START tool as likely requiring in-patient admission and briefly assessed by an ED Consultant. Bed management were notified of these patients and their likely admitting team based on senior early assessment. Matched controls were identified on the same day of presentation if they were admitted to the same in-patient teams as patients in the intervention group and same START score category. Outcomes were ED length of stay and proportion of patients correctly classified as an in-patient admission by the START tool.ResultsOne hundred and thirteen patients were assessed using the START-based model of care. When compared with matched control patients, this intervention model of care was associated with a significant reduction in ED length of stay [301 min (IQR 225–397) versus 423 min (IQR 297–587) p < 0.001] and proportion of patients meeting 4 h length of stay thresholds increased from 24 to 45% (p < 0.001).ConclusionIn this small pilot implementation study, the START tool, when used in conjunction with senior early assessment was associated with a reduction in ED length of stay. Further controlled studies are now underway to further examine its utility across other ED settings.

Meteorological factors for subarachnoid hemorrhage in the greater Düsseldorf area revisited: a machine learning approach to predict the probability of admission of patients with subarachnoid hemorrhage.

Reported data regarding the relation between the incidence of spontaneous subarachnoid hemorrhage (SAH) and weather conditions are conflicting and do so far not allow prognostic models. Admissions for spontaneous SAH (ICD I60.*) 2009-2018 were retrieved form our hospital data base. Historical meteorological data for the nearest meteorological station, Düsseldorf Airport, was retrieved from the archive of the Deutsche Wetterdienst (DWD). Airport is in the center of our catchment area with a diameter of approximately 100 km. Pearson correlation matrix between mean daily meteorological variables and the daily admissions of one or more patients with subarachnoid hemorrhage was calculated and further analysis was done using deep learning algorithms. For the 10-year period from January 1, 2009 until December 31, 2018, a total of 1569 patients with SAH were admitted. No SAH was admitted on 2400 days (65.7%), 1 SAH on 979 days (26.7%), 2 cases on 233 days (6.4%), 3 SAH on 37 days (1.0%), 4 in 2 days (0.05%), and 5 cases on 1 day (0.03%). Pearson correlation matrix suggested a weak positive correlation of admissions for SAH with precipitation on the previous day and weak inverse relations with the actual mean daily temperature and the temperature change from the previous days, and weak inverse correlations with barometric pressure on the index day and the day before. Clustering with admission of multiple SAH on a given day followed a Poisson distribution and was therefore coincidental. The deep learning algorithms achieved an area under curve (AUC) score of approximately 52%. The small difference from 50% appears to reflect the size of the meteorological impact. Although in our data set a weak correlation of the probability to admit one or more cases of SAH with meteorological conditions was present during the analyzed time period, no helpful prognostic model could be deduced with current state machine learning methods. The meteorological influence on the admission of SAH appeared to be in the range of only a few percent compared with random or unknown factors.

The Effects of Utilization of Individualized Pain Plans in Treatment of Vaso-Occlusive Crises in the Emergency Department

Background Sickle cell disease (SCD) is an inherited blood disorder that affects millions of people worldwide, with approximately 100,000 Americans affected (Center for Disease Control, 2017). In the U.S., SCD results in over 200,000 emergency department (ED) visits annually, with pain as the most common complaint (Lanzkron S, et al 2010). At The Ohio State University (OSU) Wexner Medical Center, there is a comprehensive care center for patients with SCD. At their initial patient visit, the patient and their hematologist determine a customized pain plan to be enacted when they present to the ED in acute vaso-occlusive crisis (VOC). In January 2015, these plans were implemented to allow for more rapid treatment of pain crisis in the ED at OSU. Methods A multidisciplinary group was formed in order to accelerate the treatment of SCD patients who presented with VOC. The group's goal was to reduce the time to first opioid by utilizing individualized pain plans for each patient. This would reduce the amount of time deciding the best course of treatment. With reduction in time to first opioid, outcomes including overall length of ED stay, disposition, and length of inpatient admission were identified. Data regarding these endpoints were collected from 01/01/14 to 12/31/15. Generalized linear models were fit to compare the clinical outcomes pre and post implementation of the new protocol. Comorbidities were associated with outcomes using the same modeling technique, where univariable models were built and multi-test adjustment was performed through false-discovery rate (FDR). Results During the 2-year study period, 214 patients with SCD accumulated 2429 ED visits in total. The model estimated a 48% decrease in time to first opioid after implementation of the individualized pain plan protocol (p&lt;0.0001). There was also a decrease in the length of ED stay by 22% (p&lt;0.0001). No significant difference between the type of disposition (discharged to home, inpatient admission, eloping from ED, or leaving without being seen) was found. No difference was found between the average number of visits to the ED and the length of inpatient admission pre and post protocol. The data did reveal a 13% increase in length of ED stay in patients with comorbid kidney disease (FDR p=0.02) and a 12% increase in length of stay in the ED for patients with history of venous thromboembolism (VTE) (FDR p=0.04). Patients with history of VTE were also found to have a 39% longer hospital admission than those without (FDR p=0.05). The odds of getting discharged from the ED were 55% lower in patients with essential hypertension (FDR p=0.02) and they were 2 times more likely than patients without hypertension to be admitted to the hospital (FDR p=0.05). Conclusion Utilization of individualized pain plans for patients with sickle cell disease presenting with VOC results in a significant reduction in the amount of time to first opioid administration. Implementation of the protocol also led to a reduction in length of stay in the emergency department, however the probability of admission did not change. In examining the effect of comorbidities on clinical outcomes, patients with history of kidney disease or VTE had increased length of ED stay and those with history of VTE also had longer hospital admissions. Patients with comorbid essential hypertension were also twice as likely to be admitted to the hospital though length of inpatient admission did not change. It is possible that patients with kidney disease have worse disease as evidenced by end-organ damage due to repeated vascular insult, ischemia, and inflammation. Similarly, those with history of VTE may have higher viscosity, endothelial adhesion, and dysfunction leading to clots. Patients with comorbid essential hypertension can also be thought to have recurrent vascular damage leading to systemic hypertension. From this information, it can be concluded that utilizing individualized pain plans in SCD patients with VOC will lead to decreased time to analgesia and perhaps decrease use of healthcare resources. Disclosures Desai: Novartis: Research Funding; Pfizer: Membership on an entity's Board of Directors or advisory committees, Research Funding; University of Pittsburgh: Research Funding; Ironwood: Other: Adjudication Board; Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees, Research Funding; Potomac: Speakers Bureau.

Levofloxacin Prophylaxis Is Effective and Cost-Effective in Pediatric Patients with Acute Myeloid Leukemia

Background and Objectives: Bacterial sepsis is a common complication in pediatric patients with acute myeloid leukemia (AML) undergoing intensive myelosuppressive chemotherapy. Up to 60% of children experience at least one documented infectious complication during therapy, with bacterial causes being most common; infection related mortality may reach 11% (Sung et al, Pediatric Blood &amp; Cancer, 2008). Randomized controlled trials in children undergoing intensive chemotherapy have demonstrated a reduction in bacteremia risk with prophylactic levofloxacin use. This study evaluates epidemiologic data regarding factors associated with levofloxacin use, the impact of levofloxacin on infectious outcomes and the cost-effectiveness of this strategy. Methods: We queried the Pediatric Health Information System (PHIS) database, which collects billing and coding data from 52 pediatric hospitals, for inpatient encounters of children with AML admitted for chemotherapy with a length of stay ≥14 days from 2013-2018. We collected demographics, information on infectious outcomes and utilization of hospital resources. Variables were compared between children who received levofloxacin prophylaxis during their hospitalization and those who did not using chi-square or Fisher's exact test for categorical variables and t-test of means for continuous variables. We next developed a decision model comparing levofloxacin prophylaxis through count nadir until recovery to no prophylaxis during a single chemotherapy cycle for AML using published data from randomized controlled trials. We assumed bacteremia was present only in the setting of fevers. We used published literature to estimate the probability of ICU admission or death with or without bacteremia. It was assumed that antibacterial prophylaxis only altered the probabilities of febrile neutropenia and bacteremia. Strategies were compared to analyze incremental costs per bacteremia episode avoided, ICU admission avoided and death avoided. Medication costs were obtained from the Federal Supply Schedule. Costs related to infectious complications and ICU admissions were obtained for patients with AML from PHIS during the 2018 calendar year. Multiple sensitivity analyses tested the robustness of results. Results: Overall, 26.3% of children received levofloxacin prophylaxis. The decision to use prophylaxis varied significantly by geographic division, AML disease status, year of admission and chemotherapy regimen (Table 1). Patients who received prophylaxis had decreased risk of bacterial infection, C. diff infection, ICU admission and overall antibiotic exposure, not including levofloxacin, during that encounter (Table 2). There was no significant difference between groups regarding length of stay or hospitalization costs. In PHIS, each bacteremia episode added an average of $119,478 to hospitalization costs. Using baseline probabilities from our literature review, levofloxacin prophylaxis cost $7,252 per bacteremia episode avoided compared with no prophylaxis. This resulted in cost savings of over $100,000 with prophylaxis as the favored strategy. When probabilities for each parameter in the model were altered by 1-way sensitivity analyses, results were sensitive to variation in bacteremia risk with prophylaxis, febrile neutropenia risk, levofloxacin cost and the cost of levofloxacin-related adverse events. However, none of the variations in parameter values generated a result which exceeded a cost-effectiveness threshold of $50,000 per bacteremia episode avoided. In a probabilistic sensitivity analysis, when all parameters were varied simultaneously over the distribution of their potential probabilities, the probability that levofloxacin use was cost-effective at a willingness-to-pay threshold of $50,000 was 95.1%. When considering other outcomes, levofloxacin prophylaxis cost $73,088 per ICU admission avoided compared to actual added costs of $94,181, or $198,525 per death avoided. Conclusions: Based on available evidence, antibacterial prophylaxis with levofloxacin is effective in reducing bacterial sepsis in pediatric AML patients undergoing intensive chemotherapy. Levofloxacin prophylaxis may also be cost saving when the costs of infectious complications and other adverse health outcomes are considered.

Birth weight, neonatal care, and infant mortality: Evidence from macrosomic babies

This study demonstrates that rule-of-thumb health treatment decision-making exists when assigning medical care to macrosomic newborns with an extremely high birth weight and estimates the short-run health return to neonatal care for infants at the high end of the birth weight distribution. Using a regression discontinuity design, we find that infants born with a birth weight above 5000 grams have a 2 percentage-point higher probability of admission to a neonatal intensive care unit and a 1 percentage-point higher probability of antibiotics receipt, compared to infants with a birth weight below 5000 grams. We also find that being born above the 5000-gram cutoff has a mortality-reducing effect: infants with a birth weight larger than 5000 grams face a 0.15 percentage-point lower risk of mortality in the first week and a 0.20 percentage-point lower risk of mortality in the first month, compared to their counterparts with a birth weight below 5000 grams. We do not find any evidence of changes in health treatments and mortality at macrosomic cutoffs lower than 5000 grams, which is consistent with the idea that such treatment decisions are guided by the higher expected morbidity and mortality risk associated with infants weighing more than 5000 grams.

177 Disparities in Admission or Transfer for Inpatient Treatment after Emergency Mental Health Visits

While it is widely recognized that disparities exist in access to mental health (MH) care, the emergency department (ED) should serve as the safety net where all patients can access necessary care. We examine whether there are disparities based on patient race/ethnicity and insurance status in disposition to inpatient settings (admission or transfer) for adolescents and young adults with MH ED visits. We perform multivariate regression analysis of all MH ED visits from 2010 to 2014 reported to the Healthcare Cost and Utilization Project’s State emergency department and State Inpatient Discharge Databases for Arizona, Florida, New York, New Jersey, North Carolina, Maryland, Nevada, Kentucky, Rhode Island, and Iowa for 10-29 year olds. MH ED visits were defined as visits with a primary MH or substance abuse diagnosis or a secondary or tertiary diagnosis of suicidal ideation or attempt. We examine the probability that a MH ED visit results in an admission or transfer for further treatment and report predicted probabilities by primary payer and race/ethnicity. Regressions also control for age, sex, year, hospital location, and median income of the patient’s home address. We also perform diagnosis-specific regressions for encounters related to suicide, serious mental illness, substance use, or alcohol use. We report comparisons of predicted probabilities using Bonferroni-corrected critical values. 2.6 million MH ED visits were analyzed. For MH ED visits, the probability of admission or transfer for MH ED visits varied by the patient’s insurance and race/ethnicity (see Table). When all MH ED visits were analyzed, significantly more visits by privately insured (33.1%) than self-pay patients (25.8%) resulted in an inpatient disposition (p<0.01). Disposition after MH ED visits also varied by patient race/ethnicity. A significantly higher proportion of MH ED visits by white patients (34.0%) than black (30.8%, p<0.01), Native American (30.7%, p<0.01) or Hispanic (30.4%, p<0.01) patients resulted in admission or transfer. Differences in disposition were seen for all MH disorders analyzed, including for suicide-related visits. When compared with suicide-related visits by whites, a significantly smaller proportion of suicide-related visits by blacks, Hispanics and Native Americans resulted in admission or transfer (p<0.01 for all comparisons). Suicide-related visits by uninsured patients were significantly less likely than those by patients with private insurance, Medicaid or Medicare to result in admission or transfer (p<0.01 for all comparisons). We demonstrate sizeable disparities in disposition to inpatient settings after MH ED visits based on patient race/ethnicity and insurance status. Psychiatric inpatient beds are limited and socioeconomic disparities in access to this resource are concerning, particularly in ED patients who may have limited access to outpatient psychiatric care. Future research should focus on identifying and mitigating the underlying causes of these disparities.TablePredicted probabilities of ED disposition of admission or transfer.All Mental Health % (95% CI)Suicide-Related % (95% CI)Serious Mental Illness % (95% CI)Alcohol Use % (95% CI)Substance Use % (95% CI)PayerPrivate Insurance33.1 (33.0-33.2)66.4 (66.2-66.7)58.3 (58.0-58.6)7.2 (7.0-7.4)22.8 (22.5-23.0)Medicare36.5 (36.3-36.8)70.9 (70.2-71.6)58.7 (58.2-59.3)11.7 (10.9-12.6)25.9 (24.8-26.9)Medicaid35.7 (35.6-35.8)67.9 (67.7-68.1)58.1 (57.9-58.3)14.6 (14.3-14.9)25.5 (25.2-25.7)Self-Pay25.8 (25.7-25.9)55.2 (54.9-55.5)45.1 (44.7-45.4)5.4 (5.3-5.5)15.3 (15.1-15.6)Race/EthnicityWhite34.0 (33.9-34.0)65.8 (65.6-66.0)57.0 (56.7-57.2)9.5 (9.4-9.7)22.8 (22.6-23.0)Black30.8 (30.7-30.9)62.4 (62.0-62.7)54.6 (54.4-54.9)6.1 (6.0-6.3)15.2 (14.8-15.6)Hispanic30.4 (30.2-30.5)63.2 (62.8-63.6)54.7 (54.4-55.1)7.1 (6.9-7.3)18.8 (18.4-19.3)Asian33.5 (33.1-33.9)67.2 (66.1-68.2)61.6 (60.6-62.6)5.3 (4.7-6.0)19.1 (17.6-20.6)Native American30.7 (30.2-31.3)60.6 (59.3-62.0)57.5 (55.5-59.5)6.1 (5.6-6.5)21.2 (19.4-22.9) Open table in a new tab

The impact of a named GP scheme on continuity of care and emergency hospital admission: a cohort study among older patients in England, 2012–2016

ObjectiveTo investigate whether the introduction of a named general practitioner (GP, family physician) improved patients’ healthcare for patients aged 75 and over in England.SettingRandom sample of 27 500 patients aged...

Academic English Proficiency Assessment Using a Computerized Adaptive Test

This paper describes the steps to convert a paper-and-pencil English proficiency test for academic purposes, consisting of multiple choice items administered following the Admissible Probability Measurement Procedure [24], adopted by the graduate program at the Institute of Mathematics and Computer Sciences at the University of São Paulo (ICMC-USP), Brazil, to a computerized adaptive test (CAT) based on an Item Response Theory Model (IRT). Despite the fact that the program accepts various internationally recognized tests that attest non-native speakers English proficiency, such as the Test of English as a Foreign Language (TOEFL), the International English Language Testing System (IELTS) and the Cambridge English: Proficiency (CPE), for instance, its requirement is incoherent in public universities in Brazil due to the cost, which ranges from US$ 200.00 to US$ 300.00 per exam. The TAI-PI software (Computerized Adaptive Test for English Proficiency), which was developed in Java language and SQLite, started to be used to assess the English pro?ciency of students on the program from October, 2013. The statistical methodology used was defined considering the history and aims of the test and adopted Samejima's Graded Response Model [21], the Kullback-Leibler information criterion for item selection, the a posteriori estimation method for latent trait [2] and the Shadow Test approach [29] to impose restrictions (content and test length) on the test composition of each individual. A description of the test design, the statistical methods used, and the results of a real application of TAI-PI for graduate students are presented in this paper, as well as the validation studies of the new methodology for pass or fail classification, showing the good quality of the new evaluation system and examination of improvement using the IRT and CAT methods.

Effects of Changes in ICU Bed Supply on ICU Utilization.

The availability of intensive care unit (ICU) beds may influence the demand for critical care. Although small studies support a model of supply-induced demand in the ICU, there is a paucity of system-wide data. The objective of this study was to determine the relationship between ICU bed supply and ICU admission in United States hospitals. Retrospective cohort study using all-payer inpatient records from Florida, Massachusetts, New Jersey, New York, and Washington from 2010 to 2012, linked to hospital data from Medicare's Healthcare Cost Reporting Information System. Three patient groups with a low likelihood of benefiting from ICU admission-low severity patients with acute myocardial infarction and pulmonary embolism; and high severity patients with metastatic cancer at the end of life. We compared the risk-adjusted probability of ICU admission at hospitals that increased their ICU bed supply over time to matched hospitals that did not, using a difference-in-differences approach. For patients with acute myocardial infarction, ICU supply increases were associated with an increase in the probability of ICU admission that diminished over time. For patients with pulmonary embolism, there was a trend toward an association between change in ICU supply and ICU admission that did not meet statistical significance. For patients with metastatic cancer, admission to hospitals with an increasing ICU supply was not associated with changes in the probability of ICU admission. Increases in ICU bed supply were associated with inconsistent changes in the probability of ICU admission that varied across patient subgroups.

Stability under events for a class of hybrid dynamical systems with continuous and discrete time variables

This studies the stability under events for a class of hybrid dynamical systems (HDSs). The HDS is modelled via continuous and discrete time (CDT) variables. It is allowed that an HDS has time-varying, unstable, non-linear, different dwell time, and infinite number of subsystems. The stability under events reflects the effects of switching and impulse type events in HDS. By defining the length of CDT variable and extending the notion of hybrid-event-time in the literature, the concepts on global uniform asymptotic stability (GUAS) and event-GUAS are reasonably defined. By employing multiple Lyapunov-like functions, criteria on GUAS and event-GUAS are established. Moreover, by extending average dwell time (ADT) to hybrid ADT, the relations between GUAS and event-GUAS are derived. And the criteria on global uniform exponential stability under events (event-GUES) are obtained. A method via maximal admissible probabilities of unstable subsystems is proposed to test the conditions of event-GUES. As two special cases, the traditional stability criteria of only continuous or discrete variables are also derived. Finally, three examples are provided to verify the main results.

Polymorphism of autoimmune encephalitis

This review analyses the current understanding and diagnostic approaches to the management of patients with autoimmune encephalitis. Cellular and synaptic targets, involved in the pathological process in autoimmune encephalitis, are described. The presence of clinical and immunological differences in the pathology is emphasized: on the one hand, non-structural damage to the nervous system is combined with the subacute development of cognitive impairment, epileptic and psychopathological syndromes, which, on the other hand, are associated with polymorphic immunological heterogeneity. The algorithm for clinical and laboratory diagnosis is described, based on our own clinical observations of three patients. The first patient was diagnosed with a cross-autoimmune syndrome with a combination of Hodgkin’s lymphoma and anti-NMDA encephalitis, probably triggered by the reactivation of the Epstein–Barr virus with a fatal outcome. The second patient was diagnosed with autoimmune anti-LGI1 limbic encephalitis, and the third patient was seronegative to the available immunological antigens. The authors note the need to rethink the concept of ‘encephalitis of unknown aetiology’ and its transformation into ‘autoimmune encephalitis’ with the immunological diagnosis of three antigens (NMDA, LGI1, CASPR2). Considering the rarity of the disease, the high probability of initial admission to an infectious diseases or psychiatric hospital, it is worthwhile to explore this problem more widely at various research forums and to create a comprehensive, interdisciplinary approach to the diagnosis of this disease in the Russian Federation.