Chance Variation Research Articles

A - 102 Neuropsychological Insights into Kearns-Sayre Syndrome: a Case Study

Abstract Objective Kearns-Sayre Syndrome (KSS) is a genetic mitochondrial and neuromuscular condition with multisystemic effects, including the eyes, heart, muscles, and cognition. Very little is known regarding the cognitive profile of patients with KSS, and existing studies have presented mixed findings. Results in one study revealed impairments in visuospatial abilities and attention, while another study found impairments in global cognition and word-finding. Interestingly, both studies revealed impairments in executive functions. Method This abstract presents the case of a 46-year-old right-handed, African American female diagnosed with KSS in 2021. Symptoms of KSS first appeared in 2010 with progressive vision loss and bilateral ptosis. Genetic testing revealed MT-T1 mutation consistent with KSS. Electroretinography findings revealed mild cone atrophy and mild-to-moderate concentric visual field defects. Attentional difficulties were noted in 2016 and resulted in a diagnosis of ADHD. Memory problems were first noticed in 2016 and have persisted since then. Magnetic resonance imaging results from May 2023 revealed no structural abnormalities in the brain. Results A comprehensive neuropsychological evaluation completed in March 2024 revealed mostly intact neurocognitive functioning. Notably, performance on memory and visuospatial measures were within normal limits. However, poor performance was revealed on one measure of executive functioning. Conclusions It remains unclear whether the poor performance seen on a measure of executive functioning reflects a true cognitive deficit or just chance variation. Even so, with little information regarding the cognitive profile of KSS, baseline neuropsychological testing should be considered to monitor related cognitive changes over time.

Comparing methods for assessing the reliability of health care quality measures.

Quality measurement plays an increasing role in U.S. health care. Measures inform quality improvement efforts, public reporting of variations in quality of care across providers and hospitals, and high-stakes financial decisions. To be meaningful in these contexts, measures should be reliable and not heavily impacted by chance variations in sampling or measurement. Several different methods are used in practice by measure developers and endorsers to evaluate reliability; however, there is uncertainty and debate over differences between these methods and their interpretations. We review methods currently used in practice, pointing out differences that can lead to disparate reliability estimates. We compare estimates from 14 different methods in the case of two sets of mental health quality measures within a large health system. We find that estimates can differ substantially and that these discrepancies widen when sample size is reduced.

A one-chart scheme for joint monitoring of the two parameters of zero-inflated Poisson processes

The high-quality processes usually have more count of zeros than are expected under chance variation and are commonly modeled by zero-inflated Poisson (ZIP) distribution. A ZIP model has two parameters— ϕ ( ϕ ∈ [ 0 , 1 ] ) and λ ( λ >0). Often separate control charts are used for monitoring the two parameters. But a one-chart scheme for joint monitoring of the two parameters offers significant operational advantages. A few one-chart schemes for joint monitoring of the two parameters are reported in literature. However, the monitoring statistic of none of these schemes is defined directly on the observed quality characteristics. This leads to difficulty in understanding of these schemes by the practitioners. Any control charting scheme developed directly on the observed quality characteristic is intuitively appealing to the practitioners and can be easy to interpretations by the practitioners. In this article, a one-chart scheme (called Gamma chart) is developed considering average number of nonconformities in the samples as the monitoring statistic. The performance of the Gamma chart is studied via simulation. The results reveal that it efficiently detect the out-of-control process conditions resulting from moderate shifts in ϕ and/or λ . Finally, a case study from an Indian automobile industry is presented.

Camera Eyes and Convergence in Creative Evolution

This paper presents an updated argument for Bergson’s theory of evolutionary convergence. Convergence refers to the repeated appearance of like characters, such as the camera-like eye, across distant lineages like snails and spiders, or humans and octopuses. It is an infamously difficult phenomenon to explain by dint of natural selection for chance variations alone. Convergent evolution exacerbates the improbability that chance changes at an insensible scale could be accumulated over generations in order to come together in the composition of a complex eye in one lineage, since it requires that chance variations succeeding each other in a chance order repeatedly arrive together at the same complex result, the eye, across lineages as distant as cephalopods from vertebrates. Bergson’s idea is that convergence is not an accident or anomaly of an otherwise random variational process, but that it rather reveals something important about how evolution works. What it reveals is a deep unity – or homology – underlying the contingent plurality of life forms, and a kind of pattern, or orthogenetic trend, to their repeated convergence on the same organs and traits. This paper explains that idea, links it with the history of orthogenetic theories of evolution, and suggests that it may remain viable according to the current science.

Multiple mating does not benefit females of a polyandrous pollinating fig wasp

In some species, females vary in the numbers of times they mate. While polyandry will always be beneficial to a male that mate with a previously mated female, the effect on female fitness is unclear. From females' perspective, variation in matedness can reflect adaptive differences in females’ requirements for mating or non-adaptive chance factors. Pollinating fig wasps have been considered to be mostly monandrous although polyandry has been confirmed in a number of species. Here we first show that the pollinating fig wasp, Platyscapa awekei, is polyandrous. Second, we show that intraspecific variation in female matedness may be explained best by chance encounters between males and receptive females. The mean number of offspring does not increase with polyandry. Nor is there evidence of sperm limitation. These observations rule out direct benefits to females. Despite evidence for multiply-mated females having mated with less compatible males, multiple mating is not combined with selective preference for more compatible males' sperm, ruling out indirect benefits. Therefore variation in female matedness seems to have no fitness benefit to females and from the females' perspective may be best explained by chance variation in encounter rates between males and receptive females.

The God of Chance and Purpose: Divine Involvement in a Secular Evolutionary World

The God of Chance and Purpose: Divine Involvement in a Secular Evolutionary World

Plants are the drivers of geographic variation of floral odours in brood site pollination mutualisms: A case study of Ficus hirta

Plant odours are central for pollinator attraction. This is particularly true in obligate brood site pollination mutualisms. However, we know little about the evolution of olfactory signalling in these mutualisms. Here, we investigate geographic variation of floral odour in the obligate host-specific brood site pollination mutualism between Ficus hirta and its specialised pollinators. Floral scent samples from nine locations in China were collected using head-space adsorption and were analysed by gas chromatography-mass spectrometry. We evidence progressive geographic divergence of floral odours. The pattern of variation fits plant genetic structure for neutral genes but differs from pollinating insect structuring into species and populations. In our study system, the geographic variation of receptive floral odour presents a pattern that is not distinguishable from neutral drift. The variation is not canalised by the insects. We propose that this pattern characterises obligate brood site pollination mutualisms in which pollinators are host specific and dispersal of plant and insect is limited. Insects with their short generation times and large population sizes rapidly track any chance variation in host receptive inflorescence odours. Plants are the drivers and insects the followers. The source of the geographic variation in floral odours can be genetic or phenotypic in response to local conditions. Strict sense plant-insect co-evolution is not involved. In contrast, previous results on another Ficus-pollinating wasp association suggest that stabilising selection could be at work in more dispersive systems.

HMOX1 STR polymorphism and malaria: an analysis of a large clinical dataset

BackgroundInducible expression of heme oxygenase-1 (encoded by the gene HMOX1) may determine protection from heme released during malaria infections. A variable length, short tandem GT(n) repeat (STR) in HMOX1 that may influence gene expression has been associated with outcomes of human malaria in some studies. In this study, an analysis of the association between variation at the STR in HMOX1 on severe malaria and severe malaria subtypes is presented in a large, prospectively collected dataset (MalariaGEN).MethodsThe HMOX1 STR was imputed using a recently developed reference haplotype panel designed for STRs. The STR was classified by total length and split into three alleles based on an observed trimodal distribution of repeat lengths. Logistic regression was used to assess the association between this repeat on cases of severe malaria and severe malaria subtypes (cerebral malaria and severe malarial anaemia). Individual analyses were performed for each MalariaGEN collection site and combined for meta-analysis. One site (Kenya), had detailed clinical metadata, allowing the assessment of the effect of the STR on clinical variables (e.g. parasite count, platelet count) and regression analyses were performed to investigate whether the STR interacted with any clinical variables.ResultsData from 17,960 participants across 11 collection sites were analysed. In logistic regression, there was no strong evidence of association between STR length and severe malaria (Odds Ratio, OR: 0.96, 95% confidence intervals 0.91–1.02 per ten GT(n) repeats), although there did appear to be an association at some sites (e.g., Kenya, OR 0.90, 95% CI 0.82–0.99). There was no evidence of an interaction with any clinical variables.ConclusionsMeta-analysis suggested that increasing HMOX1 STR length is unlikely to be reliably associated with severe malaria. It cannot be ruled out that repeat length may alter risk in specific populations, although whether this is due to chance variation, or true variation due to underlying biology (e.g., gene vs environment interaction) remains unanswered.

Predicting ACL Injury Using Machine Learning on Data From an Extensive Screening Test Battery of 880 Female Elite Athletes

Background: Injury risk prediction is an emerging field in which more research is needed to recognize the best practices for accurate injury risk assessment. Important issues related to predictive machine learning need to be considered, for example, to avoid overinterpreting the observed prediction performance. Purpose: To carefully investigate the predictive potential of multiple predictive machine learning methods on a large set of risk factor data for anterior cruciate ligament (ACL) injury; the proposed approach takes into account the effect of chance and random variations in prediction performance. Study Design: Case-control study; Level of evidence, 3. Methods: The authors used 3-dimensional motion analysis and physical data collected from 791 female elite handball and soccer players. Four common classifiers were used to predict ACL injuries (n = 60). Area under the receiver operating characteristic curve (AUC-ROC) averaged across 100 cross-validation runs (mean AUC-ROC) was used as a performance metric. Results were confirmed with repeated permutation tests (paired Wilcoxon signed-rank-test; P < .05). Additionally, the effect of the most common class imbalance handling techniques was evaluated. Results: For the best classifier (linear support vector machine), the mean AUC-ROC was 0.63. Regardless of the classifier, the results were significantly better than chance, confirming the predictive ability of the data and methods used. AUC-ROC values varied substantially across repetitions and methods (0.51-0.69). Class imbalance handling did not improve the results. Conclusion: The authors’ approach and data showed statistically significant predictive ability, indicating that there exists information in this prospective data set that may be valuable for understanding injury causation. However, the predictive ability remained low from the perspective of clinical assessment, suggesting that included variables cannot be used for ACL prediction in practice.

A martingale formulation for stochastic compartmental susceptible-infected-recovered (SIR) models to analyze finite size effects in COVID-19 case studies

&lt;p style='text-indent:20px;'&gt;Deterministic compartmental models for infectious diseases give the mean behaviour of stochastic agent-based models. These models work well for counterfactual studies in which a fully mixed large-scale population is relevant. However, with finite size populations, chance variations may lead to significant departures from the mean. In real-life applications, &lt;i&gt;finite size effects&lt;/i&gt; arise from the variance of individual realizations of an epidemic course about its fluid limit. In this article, we consider the classical stochastic Susceptible-Infected-Recovered (SIR) model, and derive a martingale formulation consisting of a deterministic and a stochastic component. The deterministic part coincides with the classical deterministic SIR model and we provide an upper bound for the stochastic part. Through analysis of the stochastic component depending on varying population size, we provide a theoretical explanation of &lt;i&gt;finite size effects&lt;/i&gt;. Our theory is supported by quantitative and direct numerical simulations of theoretical infinitesimal variance. Case studies of coronavirus disease 2019 (COVID-19) transmission in smaller populations illustrate that the theory provides an envelope of possible outcomes that includes the field data.&lt;/p&gt;

Measuring capabilities of zero-inflated processes

The high-quality processes usually have more count of zeros than are expected under chance variation of its underlying Poisson or other count distribution. Therefore, these processes are usually referred to as zero-inflated processes. The zeroinflated processes are commonly modelled by zero-inflated Poisson (ZIP) or zero-inflated negative binomial (ZINB) distribution. In a manufacturing set up, the evaluation of process capability index of a zero-inflated process can be useful in many ways, e.g. i) predicting how well the process will hold the specifications, ii) selecting between competing vendors, and iii) assisting product developers/designers in modifying the process, etc. However, researchers have given very little attentions on this aspect of zero-inflated processes. Only one such attempt is reported in literature. But, it does not always represent the true capabilities of zero-inflated processes, and sometimes it may give very misleading impression about the capability of the concerned process. In this article, the concept of Borges and Ho (2001) is applied to zero-inflated processes and a new approach for computation of process capability index of zero-inflated processes is developed. The proposed method reveals the true capabilities of zero-inflated processes consistently. Application of the proposed approach and its effectiveness are illustrated using two datasets published by past researchers.

A Novel SARS-CoV-2 Viral Sequence Bioinformatic Pipeline Has Found Genetic Evidence That the Viral 3' Untranslated Region (UTR) Is Evolving and Generating Increased Viral Diversity.

An unprecedented amount of SARS-CoV-2 sequencing has been performed, however, novel bioinformatic tools to cope with and process these large datasets is needed. Here, we have devised a bioinformatic pipeline that inputs SARS-CoV-2 genome sequencing in FASTA/FASTQ format and outputs a single Variant Calling Format file that can be processed to obtain variant annotations and perform downstream population genetic testing. As proof of concept, we have analyzed over 229,000 SARS-CoV-2 viral sequences up until November 30, 2020. We have identified over 39,000 variants worldwide with increased polymorphisms, spanning the ORF3a gene as well as the 3′ untranslated (UTR) regions, specifically in the conserved stem loop region of SARS-CoV-2 which is accumulating greater observed viral diversity relative to chance variation. Our analysis pipeline has also discovered the existence of SARS-CoV-2 hypermutation with low frequency (less than in 2% of genomes) likely arising through host immune responses and not due to sequencing errors. Among annotated non-sense variants with a population frequency over 1%, recurrent inactivation of the ORF8 gene was found. This was found to be present in the newly identified B.1.1.7 SARS-CoV-2 lineage that originated in the United Kingdom. Almost all VOC-containing genomes possess one stop codon in ORF8 gene (Q27∗), however, 13% of these genomes also contains another stop codon (K68∗), suggesting that ORF8 loss does not interfere with SARS-CoV-2 spread and may play a role in its increased virulence. We have developed this computational pipeline to assist researchers in the rapid analysis and characterization of SARS-CoV-2 variation.

Time trends and prescribing patterns of opioid drugs in UK primary care patients with non-cancer pain: A retrospective cohort study.

BackgroundThe US opioid epidemic has led to similar concerns about prescribed opioids in the UK. In new users, initiation of or escalation to more potent and high dose opioids may contribute to long-term use. Additionally, physician prescribing behaviour has been described as a key driver of rising opioid prescriptions and long-term opioid use. No studies to our knowledge have investigated the extent to which regions, practices, and prescribers vary in opioid prescribing whilst accounting for case mix. This study sought to (i) describe prescribing trends between 2006 and 2017, (ii) evaluate the transition of opioid dose and potency in the first 2 years from initial prescription, (iii) quantify and identify risk factors for long-term opioid use, and (iv) quantify the variation of long-term use attributed to region, practice, and prescriber, accounting for case mix and chance variation.Methods and findingsA retrospective cohort study using UK primary care electronic health records from the Clinical Practice Research Datalink was performed. Adult patients without cancer with a new prescription of an opioid were included; 1,968,742 new users of opioids were identified. Mean age was 51 ± 19 years, and 57% were female. Codeine was the most commonly prescribed opioid, with use increasing 5-fold from 2006 to 2017, reaching 2,456 prescriptions/10,000 people/year. Morphine, buprenorphine, and oxycodone prescribing rates continued to rise steadily throughout the study period. Of those who started on high dose (120–199 morphine milligram equivalents [MME]/day) or very high dose opioids (≥200 MME/day), 10.3% and 18.7% remained in the same MME/day category or higher at 2 years, respectively. Following opioid initiation, 14.6% became long-term opioid users in the first year. In the fully adjusted model, the following were associated with the highest adjusted odds ratios (aORs) for long-term use: older age (≥75 years, aOR 4.59, 95% CI 4.48–4.70, p < 0.001; 65–74 years, aOR 3.77, 95% CI 3.68–3.85, p < 0.001, compared to <35 years), social deprivation (Townsend score quintile 5/most deprived, aOR 1.56, 95% CI 1.52–1.59, p < 0.001, compared to quintile 1/least deprived), fibromyalgia (aOR 1.81, 95% CI 1.49–2.19, p < 0.001), substance abuse (aOR 1.72, 95% CI 1.65–1.79, p < 0.001), suicide/self-harm (aOR 1.56, 95% CI 1.52–1.61, p < 0.001), rheumatological conditions (aOR 1.53, 95% CI 1.48–1.58, p < 0.001), gabapentinoid use (aOR 2.52, 95% CI 2.43–2.61, p < 0.001), and MME/day at initiation (aOR 1.08, 95% CI 1.07–1.08, p < 0.001). After adjustment for case mix, 3 of the 10 UK regions (North West [16%], Yorkshire and the Humber [15%], and South West [15%]), 103 practices (25.6%), and 540 prescribers (3.5%) had a higher proportion of patients with long-term use compared to the population average. This study was limited to patients prescribed opioids in primary care and does not include opioids available over the counter or prescribed in hospitals or drug treatment centres.ConclusionsOf patients commencing opioids on very high MME/day (≥200), a high proportion stayed in the same category for a subsequent 2 years. Age, deprivation, prescribing factors, comorbidities such as fibromyalgia, rheumatological conditions, recent major surgery, and history of substance abuse, alcohol abuse, and self-harm/suicide were associated with long-term opioid use. Despite adjustment for case mix, variation across regions and especially practices and prescribers in high-risk prescribing was observed. Our findings support greater calls for action for reduction in practice and prescriber variation by promoting safe practice in opioid prescribing.

Determination of the virulence of single nucleopolyhedrovirus occlusion bodies using a novel laser capture microdissection method.

Determination of the virulence of occlusion bodies (OBs), which are the horizontal transmission structures of nucleopolyhedroviruses (NPVs), is an important area of baculovirology. A method for inoculating an insect with an isolated OB was developed using Helicoverpa armigera nucleopolyhedrovirus (HearNPV) infection of second instar Helicoverpa armigera larvae as a model NPV-host pathosystem. In this novel method, laser capture microdissection (LCM) was used to directly catapult single OBs onto the surface of insect diet in bioassay containers. Since exposure via the natural oral horizontal transmission route of each larva to a single OB was established and not subject to chance variation, the method facilitated determination of the insect mortality rate (4.8%) associated with exposure to single HearNPV OBs. Droplet feeding bioassays confirmed that the novel method did not reduce OB virulence. The LCM method sets a foundation for virulence and genetic diversity studies based on single NPV OBs.

Getting a Grip on Variability.

Because science is a modeling enterprise, a key question for educators is: What kind of repertoire can initiate students into the practice of generating, revising, and critiquing models of the natural world? Based on our 20years of work with teachers and students, we nominate variability as a set of connected key ideas that bridge mathematics and science and are fundamental for equipping youngsters for the posing and pursuit of questions about science. Accordingly, we describe a sequence for helping young students begin to reason productively about variability. Students first participate in random processes, such as repeated measure of a person's outstretched arms, that generate variable outcomes. Importantly, these processes have readily discernable sources of variability, so that relations between alterations in processes and changes in the collection of outcomes can be easily established and interpreted by young students. Following these initial steps, students invent and critique ways of visualizing and measuring distributions of the outcomes of these processes. Visualization and measure of variability are then employed as conceptual supports for modeling chance variation in components of the processes. Ultimately, students reimagine samples and inference in ways that support reasoning about variability in natural systems.

Sources of evolutionary contingency: chance variation and genetic drift

Contingency-theorists have gestured to a series of phenomena such as random mutations or rare Armageddon-like events as that which accounts for evolutionary contingency. These phenomena constitute a class, which may be aptly called the ‘sources of contingency’. In this paper, I offer a probabilistic conception of what it is to be a source of contingency and then examine two major candidates: chance variation and genetic drift, both of which have historically been taken to be ‘chancy’ in a number of different senses. However, contra the gesturing of contingency-theorists, chance variation and genetic drift are not always strong sources of contingency, as they can be non-chancy (and hence, directional) in at least one sense that opposes evolutionary contingency. The probabilistic conception offered herein allows for sources of contingency to appropriately vary in strength. To this end, I import Shannon’s information entropy as a statistical measure for systematically assessing the strength of a source of contingency, which is part and parcel of identifying sources of contingency. In brief, the higher the entropy, the greater the strength. This is also empirically significant because molecular, mutational, and replicative studies often contain sufficient frequency or probability data to allow for entropies to be calculated. In this way, contingency-theorists can evaluate the strength of a source of contingency in real-world cases. Moreover, the probabilistic conception also makes conceptual room for the converse of sources of contingency: ‘sources of directionality’, which ought to be recognised, as they can interact with genuine sources of contingency in undermining evolutionary contingency.

O18 National variation and factors associated with long-term opioid use for non-cancer pain in the first year of use

Abstract Background Physician prescribing behaviour has been described as a key driver of rising opioid prescriptions and long-term opioid use. However, the effect of prescribers requires interpretation within context. No studies have investigated the extent to which regions, practices, prescribers, vary in opioid prescribing by considering this hierarchy together, whilst accounting for case-mix. Objectives: (i)quantify and identify risk factors for the transition from new-users to long-term opioid users (ii) quantify variation of long-term use attributed to region, practice, prescriber, accounting for patient mix and chance variation. Methods We conducted a retrospective observational study between 2006-2017 using Clinical Practice Research Datalink. New users of opioids, ≥18 years, without cancer were identified. Long-term opioid use was defined as ≥ 3 opioid prescriptions within a 90-day period from index date, or ≥ 1 opioid prescription lasting at least 90-days in the first year. A multi-level random-effects logistic regression model was used to examine the association of patient characteristics with the odds of becoming a long-term opioid-user. To examine variation in opioid use among prescribers, GP-practices and region after adjusting for case-mix, we used a nested random-effect structure. A ‘high-risk’ region, prescriber or practice was defined as those where the entire adjusted 95% CI lay above population average. Results 1,968,742 new opioid users were included; 14.6% transitioned to long-term use. In the fully-adjusted model, factors associated with higher-odds of long-term use included high morphine-milligram equivalents (MME)/day at first prescription, older-age, deprivation, fibromyalgia, rheumatological conditions and prior surgery (Table 1). After adjustment for case-mix, the North-West, Yorkshire and South-West were found to be high-risk regions for long-term use. 103 practices (25.6%) and 540 prescribers (3.5%) were associated with a significantly higher risk of long-term use. The odds of becoming a long-term user for patients belonging to these prescribers reached up to &amp;gt; 3.5 times than the population average. Conclusion Prescribing factors, age, deprivation and conditions including fibromyalgia and rheumatological conditions were associated with higher odds of long-term opioid use. In the first UK study evaluating long-term opioid prescribing with patient-level characteristics adjustment, variation in regions, especially practices and prescribers were observed. Our findings support greater calls for action to reduce practice/prescriber variation by promoting safe practice in opioid-prescribing. Disclosures M. Jani: None. B. Birlie-Yimer: None. T. Sheppard: None. M. Lunt: None. W.G. Dixon: None.

28 QUALITY OF CARE INITIATIVE IMPROVES OUTCOMES FOR PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Abstract Introduction There is significant variation in processes and outcomes of care for patients with inflammatory bowel disease (IBD), suggesting opportunities to improve quality of care. Recent efforts to define quality measures for IBD have identified emergency room (ER) visits, hospitalizations, corticosteroid use, and opioid use as indicators of care quality. We hypothesized that IBD care could be improved through a structured quality improvement (QI) program. Methods We utilized the Breakthrough Series Collaborative approach developed by the Institute for Healthcare Improvement to improve care for adults with IBD. We identified primary and secondary drivers of urgent care need for patients including those at high risk for ER use, and a multi-stakeholder panel developed 19 practice change ideas that could influence those drivers. Between January 2018 and May 2019, clinical sites participating in a QI collaborative across the United States tested and implemented various change ideas, shared ongoing results during coached monthly webinars, and participated in 3 in-person meetings to learn QI methods and share best practices. Patient-reported outcomes (PROs) were collected at clinical visits, including recent ER use and hospitalizations, use of steroids and narcotics, and measures of care utilization. Providers rated whether patients were at high risk for urgent care needs. Site performance on key measures were monitored using statistical control charts, with assessment for common cause (due to chance) variation and special cause (non-random) variation. Results We collected data prospectively from 20,382 discrete visits at twenty-six participating clinical practices (14 academic/university, 12 private/community). Disease type included Crohn’s disease (58%), ulcerative colitis (39%), and other (3%); 54% were female. During the 15-month project period, improvement with special cause variation was noted across multiple measures. Collaborative-wide decreases were seen in ER utilization (18% to 14%, relative reduction of 22%; Figure), hospitalization (14% to 11%, relative reduction of 21%), steroid use (14% to 10%, relative reduction of 29%), and narcotic utilization (8% to 4%, relative reduction of 50%). Successful change ideas tested by sites included proactive maintenance of a “high risk” patient list, reserved outpatient visits for urgent needs, “morning-after” contact with patients who went to the ER, patient education about how and when to get help, and proactively scheduling earlier follow-up for high risk patients. Conclusions Outcomes of IBD care were improved using a structured QI program that facilitates small changes in practice structure, sharing of best practices across sites, and ongoing feedback. Spread of successful change ideas may facilitate broad improvement in IBD care and significant cost savings when applied to a large population. Changes in Key Measures Over Time Statistical Process Control Chart Showing Monthly Proportion of Patients Reporting Recent ER Utilization

Pre and post IFRS and value relevance of accounting information of money deposit banks in Nigeria

This study sets out to demonstrate the difference between pre and post IFRS EPS and BVPS in the MDBs in Nigeria. Experimental design of pre-post test research was employed using dependent paired samples t-test to compare the mean differences in value relevance of EPS and BVPS. The results reveal significant values of 0.001 < 0.05 and 0.013 < 0.05 for EPS and BVPS individually. There was also found an average increase of 0.52 and 4.58 for EPS and BVPS which is not by chance variations but attributable to the adoption of IFRS. The implication suggests IFRS adoption worthwhile for increasing the value relevance of the accounting information, quality, reliability, comparability and understandability of financial statements. The study recommends increased compliance and appreciation of shareholders' confidence plus enhanced interest in investment of resources for anticipated increase in EPS and BVPS in MDBs in Nigeria.

Pre and post IFRS and value relevance of accounting information of money deposit banks in Nigeria

This study sets out to demonstrate the difference between pre and post IFRS EPS and BVPS in the MDBs in Nigeria. Experimental design of pre-post test research was employed using dependent paired samples t-test to compare the mean differences in value relevance of EPS and BVPS. The results reveal significant values of 0.001 < 0.05 and 0.013 < 0.05 for EPS and BVPS individually. There was also found an average increase of 0.52 and 4.58 for EPS and BVPS which is not by chance variations but attributable to the adoption of IFRS. The implication suggests IFRS adoption worthwhile for increasing the value relevance of the accounting information, quality, reliability, comparability and understandability of financial statements. The study recommends increased compliance and appreciation of shareholders' confidence plus enhanced interest in investment of resources for anticipated increase in EPS and BVPS in MDBs in Nigeria.