Cluster-robust Standard Errors Research Articles

The Impact of the Free Senior High School Education Policy and Double-Track System on Quality Education Outcomes: A Quasi-Experimental Policy Evaluation Study in Ghana

In the 2017/2018 academic year, the government of Ghana, through the Ministry of Education, began an educational reform policy codenamed the “Free Senior High School” (FSHS) policy to fully absorb the cost, increase enrolment, and improve the quality of education for all public senior high schools in Ghana. To accommodate more students and reduce overcrowding in schools, the government, as part of the FSHS policy, introduced the double-track system, which divides the total student population and staff into two tracks; as one of the tracks attends school, the other is on vacation and vice versa. No study has assessed this policy on education outcomes. This study assessed the impact of the FSHS policy and the double-track system on quality education outcomes and explored the challenges associated with the implementation of the policies. The study further identified strategies needed to address these challenges. The study employed a quasi-experimental study design using a pre-post data collection instrument designed to assess quality education metrics. We also used a comparative cross-sectional study design and qualitative design methodologies to evaluate the FSHS policy and the double-track system. We quantified the impact of the policies using quantile and ordinary least square regression models with cluster robust standard errors. Our evaluation of the policy showed a significant decline in quality of education outcomes and academic performance. Students who attended the double-track schools performed poorly in all the core subjects compared with non-double-track schools. The challenges associated with the implementation of the policy were financial constraints, infrastructure deficit, inadequate and delayed release of food items, lack of teaching and learning materials, inadequate contact hours, and poor implementation of the policy and the double-track system. Government must comprehensively review the FSHS policy and consider cost sharing with parents and caregivers to sustain the policy.

Antimicrobial stewardship: Attitudes and practices of healthcare providers in selected health facilities in Uganda.

Though antimicrobial stewardship (AMS) programmes are the cornerstone of Uganda's national action plan (NAP) on antimicrobial resistance, there is limited evidence on AMS attitude and practices among healthcare providers in health facilities in Uganda. We determined healthcare providers' AMS attitudes, practices, and associated factors in selected health facilities in Uganda. We conducted a cross-sectional study among nurses, clinical officers, pharmacy technicians, medical officers, pharmacists, and medical specialists in 32 selected health facilities in Uganda. Data were collected once from each healthcare provider in the period from October 2019 to February 2020. Data were collected using an interview-administered questionnaire. AMS attitude and practice were analysed using descriptive statistics, where scores of AMS attitude and practices for healthcare providers were classified into high, fair, and low using a modified Blooms categorisation. Associations of AMS attitude and practice scores were determined using ordinal logistic regression. This study reported estimates of AMS attitude and practices, and odds ratios with 95% confidence intervals were reported. We adjusted for clustering at the health facility level using clustered robust standard errors. A total of 582 healthcare providers in 32 healthcare facilities were recruited into the study. More than half of the respondents (58%,340/582) had a high AMS attitude. Being a female (aOR: 0.66, 95% CI: 0.47-0.92, P < 0.016), having a bachelor's degree (aOR: 1.81, 95% CI: 1.24-2.63, P < 0.002) or master's (aOR: 2.06, 95% CI: 1.13-3.75, P < 0.018) were significant predictors of high AMS attitude. Most (46%, 261/582) healthcare providers had fair AMS practices. Healthcare providers in the western region's health facilities were less likely to have a high AMS practice (aOR: 0.52, 95% CI 0.34-0.79, P < 0.002). In this study, most healthcare providers in health facilities had a high AMS attitude and fair AMS practice.

High Burden of Adverse Drug Reactions to Isoniazid Preventive Therapy in People Living With HIV at 3 Tertiary Hospitals in Uganda: Associated Factors.

HIV is one of the most important risk factors of tuberculosis (TB)-related morbidity and mortality. Isoniazid preventive therapy (IPT) is recommended to prevent latent TB reactivation in patients with HIV. However, due to multiple therapies and comorbidities, these patients are predisposed to adverse drug reactions (ADRs) that lead to increased morbidity and mortality. The aim of this study was to determine the prevalence and associated factors of suspected IPT-linked ADRs in HIV-positive patients using IPT. A cross-sectional study was conducted between February and March 2020 at 3 regional referral hospitals (RRHs) in central Uganda. We sampled 660 HIV-positive patients aged 10 years or older who received IPT between July and December 2019 inclusive. Patients were interviewed using a pretested structured questionnaire, and their treatment records were reviewed. A modified Poisson regression model with clustered robust standard errors was used to identify factors associated with suspected IPT-linked ADRs. The prevalence of the suspected ADRs was 51% (334 of the 660; 95% confidence interval [CI]: 18% to 83%). Patients self-reported 7-fold the number of suspected ADRs documented in the clinical files by the health care workers. Musculoskeletal symptoms were the most frequently experienced reaction (14%), followed by dizziness (13%) and peripheral neuropathy (11%). Serious suspected ADRs were experienced by 12% of the study participants; the most common were hepatotoxicity (26%), dizziness (23%), and neuropathy (17%). Female sex (aPR [adjusted prevalence ratio]: 0.92, 95% CI: = 0.88 to 0.95), study site (aPR: 1.09, 95% CI: = 1.09 to 1.18), level of education (aPR: 0.94, 95% CI: = 0.94 to 0.99), history of TB (aPR: 0.93, 95% CI: = 0.87 to 0.99), good IPT adherence (aPR: 1.16, 95% CI: = 1.05 to 1.29), and use of protease inhibitor (PI)-based antiretroviral therapy (aPR: 1.01, 95% CI: = 1.00 to 1.02) were significantly associated with suspected IPT-linked ADRs. The prevalence of suspected IPT-linked ADRs is high, and hepatotoxicity is the most commonly reported serious suspected ADR. Patients self-reported more suspected ADRs than those documented in clinical files by health care workers. Patient engagement could improve ADR detection and potentially strengthen the pharmacovigilance system. Patients with a high risk of ADR ought to be monitored regularly to enable early detection and management.

Bridging the gap between multilevel modeling and economic methods

Many datasets used in the social sciences have a hierarchical structure, where lower units of aggregation are ‘nested’ in higher units. In many disciplines, such data are analyzed using multilevel modeling (MLM, also known as hierarchical linear modeling). However, MLM as a framework is relatively unknown in economics. Instead, economists use a range of separate econometric methods, including cluster-robust standard errors, fixed effects models, models with cross-level interactions, and estimated dependent variable models. Relying on an extensive literature review, this paper describes this methodological divide and provides a detailed comparison between MLM and ‘economic methods’ in their abilities to deal with three methodological challenges inherent in multilevel data ‒ clustering, omitted variables, and coefficients' heterogeneity across groups. We unfold the comparative advantages of these two methodological approaches and provide practical recommendations about which of them should be used, why, and in what settings.

Nightlife activity and crime: The impact of COVID-19 related nightlife restrictions on violent crime

ObjectivesThe present study examines how varying levels of restrictions on the nightlife economy have impacted violent crime during the COVID-19 pandemic and the extent to which the crime preventive side-effects of restrictions are associated with the density of alcohol outlets. MethodsThe Data stems from geocoded locations of violent crimes combined with data on the density of on-premises alcohol outlets and the level of COVID-19 restrictions in Copenhagen, Denmark. We use a negative binomial count model with cluster robust standard error to assess the effect of the interaction between alcohol outlet density and COVID-related restriction levels on the nightlife economy on the frequency of violent crime. ResultsThe article reveals how both the level of restrictions on the nightlife economy and the density of alcohol outlets significantly impacted the frequency of violent crime. The regression analysis shows that the effect of restrictions on the nightlife economy depends on the concentration of on-premises alcohol outlets in the area. In areas with a high concentration of outlets, we observe a much higher reduction in crime as consequence of the COVID-19 related restrictions. ConclusionsThe results shows that a more restricted nightlife economy, including earlier closing times, could have a crime preventive effect, especially in areas with a high density of alcohol outlets.

Is Obesity Associated With Better Liver Transplant Outcomes? A Retrospective Study of Hospital Length of Stay and Mortality Following Liver Transplantation.

The rise in obesity in the United States, along with improvements in antiviral therapies, has led to an increase in the number of obese patients receiving liver transplants. Currently, obesity is a relative contraindication for liver transplant, although exact body mass index (BMI) limits continue to be debated. Studies conflict regarding outcomes in obese patients, while some argue that BMI should not be used as an exclusion criterion at all. Therefore, this retrospective study-utilizing a large national database-seeks to elucidate the association between recipient BMI and hospital length of stay and mortality following liver transplant. A retrospective study was conducted using the United Network for Organ Sharing Standard Transplant Analysis and Research database. Fine-Gray competing risk regressions were used to explore the association between BMI and rate of discharge, which varies inversely with length of stay. In our model, subdistribution hazard ratio (SHR) represented the relative change in discharge rate compared to normal BMI, with in-hospital death was considered as a competing event for live discharge. Cox proportional hazard models were built to assess the association of BMI category on all-cause mortality after liver transplantation. Cluster-robust standard errors were used in all analyses to construct confidence intervals. Within the final sample (n = 47,038), overweight (≥25 and <30 kg/m2) patients comprised the largest BMI group (34.7%). The competing risk regression model showed an association for increased length of stay among underweight (SHR = 0.82, 95% confidence interval [CI], 0.77-0.89; P < .001) and class 3 obesity patients (SHR = 0.88, 95% CI, 0.83-0.94; P < .001), while overweight (SHR = 1.05, 95% CI, 1.03-1.08; P < .001) and class 1 obesity (SHR = 1.04, 95% CI, 1.01-1.07; P = .01) were associated with decreased length of stay. When the sample excluded patients with low pretransplant functional status, however, length of stay was not significantly shorter for overweight and obesity class 1 patients. Cox proportional hazard models demonstrated increased survival among overweight, class 1 and class 2 obesity patients and decreased survival among underweight patients. Our results provide evidence that overweight and obesity class 1 are associated with decreased length of stay and mortality following liver transplant, while underweight and obesity class 3 are associated with prolonged length of stay. Pretransplant functional status may contribute to outcomes for overweight and class 1 obese patients, which necessitates continued investigation of the isolated impact of BMI in those who have had a liver transplant.

Secular trends in low birth weight and child undernutrition in West Africa: evidence from complex nationwide surveys, 1985-2019.

We present prevalence estimates and secular trends of stunting, wasting, underweight, and anaemia among children under 5 years of age and low birth weight (LBW) over the period 1985-2019 in West Africa (WA). Analysis of Demographic and Health Survey (DHS) and World Bank data. DerSimonian-Laird random effect model with the Knapp-Hartung adjustment to the standard error was used to derive overall prevalence estimates. We used fixed effect ordinary least square regression models with cluster robust standard error to conduct time trends analyses. West Africa. Children aged 0 to 59 months. Three distinct periods (1986-1990, 1993-1996 and 1997-2000) of sharp increases in prevalence of all outcomes was observed. After the year 2000, prevalence of all outcomes except LBW started to decline with some fluctuations. LBW prevalence showed a steady increase after 2000. We observed a decline in prevalence of stunting (β = -0·20 %; 95 % CI -0·43 %, 0·03 %), log-wasting (β = -0·02 %; 95 % CI -0·02 %, -0·01 %), log-underweight (β = -0·02 %; 95 % CI -0·03 %, -0·01 %) anaemia (β = -0·44; 95 % CI -0·55 %, -0·34 %), and an increase in LBW (β = 0·06 %; 95 % CI -0·10 %, 0·22 %) in WA over the period. Pooled prevalence of stunting, wasting, underweight, anaemia and LBW in WA for the period 1985-2019 was 26·1 %, 16·4 %, 22·7 %, 76·2 % and 11·3 %, respectively. Child undernutrition prevalence varied greatly between countries and the year cohorts. We observed marginal reductions in prevalence of all outcomes except anaemia where the reductions were quite striking and LBW where an increase was noted. There is the need for more rigorous and sustained targeted interventions in WA.

Abstract PO-207: Impact of Medicaid expansion on stage at diagnosis for US adults with pancreatic cancer: A population-based study

Abstract Introduction: We evaluated whether expansion of state Medicaid programs is associated with earlier-stage at diagnosis for pancreatic cancer among those under the age of 65, before and after Medicaid expansion considering key demographic, clinical, and geographic covariates. Methods: We obtained Surveillance, Epidemiology, and End-Results (SEER-18) data on individuals under 65 years of age diagnosed with pancreatic cancer from 2007-2016, including Urban Influence Code (UIC) and Social Deprivation Index (SDI) data. We defined early stage as either local or regional disease (versus advanced disease). To estimate the effect of Medicaid expansion on stage at diagnosis, we used a Difference-in-Differences (DD) model, at the individual level, comparing those from early-adopting states in 2014 to non-early-adopting states. We utilized cluster-robust standard errors and explored the role of covariates including demographic factors (race, sex, insurance coverage at diagnosis), clinical indicators (disease located in the head of the pancreas), and county characteristics (UIC and SDI). Results: The probability of early-stage disease at diagnosis increased by 3.9 percentage points (ppt) for those from Medicaid expansion states post-expansion (n=36,609). After adjustment for key covariates, the ppt was attenuated to 2.7. Of note, we observed evidence of interactions with sex and race. Indeed, the beneficial effect of living in an expansion state on stage at diagnosis was less pronounced for men (increase in the probability of early stage at diagnosis by 2.1ppt) than women (3.6ppt) and non-existent for blacks (-3.1ppt) compared to whites (4.9ppt) and other races (4.8ppt). Redefining early stage to only local stage attenuated the beneficial effect for all groups and increased the negative effect for blacks. Conclusion: Medicaid expansion is associated with earlier stage at diagnosis for pancreatic cancer; however, this beneficial effect is not uniform across sex and race. This underscores the need to investigate the impact of policy changes and implementation strategies on disparities in pancreatic cancer survival. Citation Format: Erin M. Mobley, Christina Guerrier, Ian Tfirn, Michael S. Gutter, Kimberly Vigal, Keouna Pather, Brett Baskovich, Ziad Awad, Alexander S Parker. Impact of Medicaid expansion on stage at diagnosis for US adults with pancreatic cancer: A population-based study [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-207.

Mechanical properties of porcine spinal dura mater and pericranium

BackgroundThe objective of this study was to characterize and compare the mechanical properties of porcine pericranium and spinal dura mater, to evaluate the mechanical suitability of pericranium as a dural graft. MethodEighty-eight spinal dura (cervical, thoracic, and lumbar regions, in ventral longitudinal, dorsal longitudinal and circumferential orientations) and eighteen pericranium samples (ventral-dorsal, and lateral orientations) from four pigs, were harvested and subjected to uniaxial loading while hydrated. The stiffness, strain at toe-linear regions transition, strain at linear-yield regions transition and other structural and mechanical properties were measured. Stress-strain curves were fitted to a one-term Ogden model and Ogden parameters were calculated. Linear regression models with cluster-robust standard errors were used to assess the effect of region and orientation on material and structural properties. ResultsBoth spinal dura and pericranium exhibited distinct anisotropy and were stiffer in the longitudinal direction. The tissues exhibited structural and mechanical similarities especially in terms of stiffness and strains in the linear region. Stiffness ranged from 1.28 to 5.32 N/mm for spinal dura and 2.42–3.90 N/mm for pericranium. In the circumferential and longitudinal directions, the stiffness of spinal dura specimens was statistically similar to that of pericranium in the same orientation. The strain at the upper bound of the linear region of longitudinal pericranium (28.0%) was statistically similar to that of any spinal dura specimens (24.4–32.9%). ConclusionsAutologous pericranium has advantageous physical properties for spinal duraplasty. The present study demonstrated that longitudinally oriented pericranium is mechanically compatible with spinal duraplasty procedures. Autologous pericranium grafts will likely support the mechanical loads transmitted from the spinal dura, but further biomechanical analyses are required to study the effect of the lower yield strain of circumferential pericranium compared to spinal dura. Finally, the Ogden parameters calculated for pericranium, and the spinal dura at each spinal level, will be useful for computational models incorporating these soft tissues.

A Critical Review of Statistical Methods for Twin Studies Relating Exposure to Early Life Health Conditions.

When investigating disease etiology, twin data provide a unique opportunity to control for confounding and disentangling the role of the human genome and exposome. However, using appropriate statistical methods is fundamental for exploiting such potential. We aimed to critically review the statistical approaches used in twin studies relating exposure to early life health conditions. We searched PubMed, Scopus, Web of Science, and Embase (2011–2021). We identified 32 studies and nine classes of methods. Five were conditional approaches (within-pair analyses): additive-common-erratic (ACE) models (11 studies), generalized linear mixed models (GLMMs, five studies), generalized linear models (GLMs) with fixed pair effects (four studies), within-pair difference analyses (three studies), and paired-sample tests (two studies). Four were marginal approaches (unpaired analyses): generalized estimating equations (GEE) models (five studies), GLMs with cluster-robust standard errors (six studies), GLMs (one study), and independent-sample tests (one study). ACE models are suitable for assessing heritability but require adaptations for binary outcomes and repeated measurements. Conditional models can adjust by design for shared confounders, and GLMMs are suitable for repeated measurements. Marginal models may lead to invalid inference. By highlighting the strengths and limitations of commonly applied statistical methods, this review may be helpful for researchers using twin designs.

Disparities in postpartum depression screening participation between immigrant and Danish-born women.

BackgroundQualitative studies suggest that immigrant women experience barriers for postpartum depression (PPD) screening. This study examines the prevalence of participation in PPD screening in the universal home-visiting programme in Denmark, in relation to migrant status and its association with acculturation factors, such as length of residence and age at migration.MethodsThe sample consists of 77 694 births from 72 292 mothers (2015–18) that participated in the programme and were registered in the National Child Health Database. Lack of PPD screening using the Edinburgh Postpartum Depression Scale (EPDS) was examined in relation to migrant group and acculturation factors. We used Poisson regression with cluster robust standard errors to estimate crude and adjusted relative risk.ResultsIn total, 27.8% of Danish-born women and 54.7% of immigrant women lacked screening. Compared with Danish-born women, immigrant women in all groups were more likely to lack PPD screening (aRR ranging from 1.81 to 1.90). Women with low acculturation were more likely to lack screening. Women who migrated as adults [aRR = 1.27 (95% CI 1.16, 1.38)] and women who had resided in Demark for <5 years [aRR = 1.37 (95% CI 1.28, 1.46)] were more likely to lack screening.ConclusionsImmigrant women in Denmark, particularly recent immigrants, are at increased risk of not being screened for PPD using the EPDS. This can lead to under-recognition of PPD among immigrant women. More work is needed to understand how health visitors recognize the mental health needs of immigrant women who are not screened, and whether this gap results in reduced use of mental health services.

Do the Attributes of Audit Committee Explain Non-Performing Loans? Evidence from an Emerging Economy

This study examined whether various attributes of the audit committee of listed banks in Bangladesh explain the level of non-performing loans (NPLs). This study used a panel data set comprising all 30 listed banks with 250 bank-year observations for the period 2013–2017. It employed the random-effects GLS regression model with cluster robust standard error and AR (1) disturbance to examine the effect of several audit committee attributes on NPLs. We found that holding audit committee meetings frequently and a higher number of independent members in the audit committee facilitate to reduce NPLs. We, however, find no explicit evidence that the other attributes of the audit committee examined (audit committee size, financial experience and financial literacy of the audit committee members, professional qualifications of the audit committee Chairman) contribute in reducing NPLs. The findings will be useful for policymakers of the banking sector in Bangladesh and the relevant regulatory bodies in enabling them to understand the role of the various attributes of the audit committee in the incidence of NPLs. Keywords: attributes, audit committee, non-performing loans (NPLs), listed banks, Bangladesh

SUSTAINABILITY BONDS. AN INTERNATIONAL EVENT STUDY

Sustainability bonds enable capital-raising and investment for those projects that have both a positive impact on the environment and a positive social outcome. This study examines the stock market reaction to the announcement of sustainability bonds issuance. The present research is designed as follows: first, an event study that examines the market reaction and second, a highlight of drivers influencing this market reaction via a linear regression with cluster-robust standard errors. Overall, small and negative sample-wide reactions to sustainability bond issue announcements were found. Additionally, the study finds significant negative abnormal returns before the publication in June 2018 of The Sustainability Bond Guidelines by the International Capital Market Association. Specifically, the size of the bond issue, whether the bond is callable or not, the announcement of the issue as a single event in a day, the company’s Return on Assets, the firm’s social disclosure score, and the issuance of the bond prior or after June 2018 are statistically significant factors that influence the stock returns of issuers.

Prescription Drug Monitoring and Child Maltreatment in the United States, 2004-2018

To test whether a policy approach aimed at decreasing prescription drug misuse, specifically, state monitoring of controlled substance prescriptions-prescription drug monitoring programs (PDMPs)-were associated with changes in Child Protective Services-reported maltreatment prevalence. Using a difference-in-differences design and maltreatment data (2004-2018) from 50 states and the District of Columbia, we compared the prevalence of total maltreatment incidents and total victims, in states with and without PDMPs, before and after implementation. Exploratory analyses further examined models disaggregated by maltreatment type (neglect, physical abuse, sexual abuse, psychological abuse) and among different racial/ethnic groups. Quasi-Poisson models included state-level covariates, state- and year-fixed effects, and cluster-robust standard errors. Difference-in-differences models identified greater relative reductions in PDMP states relative to controls (total prevalence ratio, 0.87; 95% CI, 0.80, 0.940; victimization prevalence ratio, 0.92; 95% CI, 0.85-0.98) over the observation period. Decreases seemed to be driven by changes in neglect (prevalence ratio, 0.87; 95% CI, 0.80-0.93) and physical abuse (prevalence ratio, 0.78; 95% CI, 0.71-0.87) incidents, and may have been especially salient for American Indian/Alaskan Native children (prevalence ratio, 0.78; 95% CI, 0.65-0.94). We found evidence supporting an association between prescription drug monitoring and reduced maltreatment prevalence at the state level. Policies aimed at restricting the prescribing and dispensing of controlled substances may have indirect implications for child welfare.

ECE Program Supports and Teacher-Perceived Support from Families: Are They Connected?

According to the Conservation of Resources theory of stress, early care and education (ECE) teachers who receive greater tangible and interpersonal supports from their workplaces will be more positive and effective in their roles. This may translate to them perceiving or eliciting greater support from families, which is a key component to family engagement, a growing area of study in the ECE landscape. This study explores whether four program-level supports (benefits, professional development supports, teacher social supports, program-level family involvement activities) are associated with teacher-perceived support from families. The hypothesis was that all four will be positively associated. This study uses survey data from 102 preschool teachers and 13 preschool program directors in urban areas of two US states. We use ordinary least squares regression with cluster-robust standard errors and a stepwise build-up modeling procedure to determine associations between independent and dependent variables. While teacher social supports had the expected positive association with teacher-perceived support from families, family involvement activities were negatively associated. Our findings suggest that programs looking to improve family engagement may consider interpersonal/cultural supports for teachers and the larger school community. All else equal, simply offering more family involvement activities may not improve engagement culture.

Using cluster-robust standard errors when analyzing group-randomized trials with few clusters.

Accounting for dependent observations in cluster-randomized trials (CRTs) using nested data is necessary in order to avoid misestimated standard errors resulting in questionable inferential statistics. Cluster-robust standard errors (CRSEs) are often used to address this issue. However, CRSEs are still well-known to underestimate standard errors for group-level variables when the number of clusters is low (e.g., < 50) and with CRTs, a small number of clusters, due to logistical or financial considerations, is the norm rather than the exception. Using a simulation with various conditions, we investigate the use of a small sample correction (i.e., CR2 estimator) proposed by Bell and McCaffrey (2002) together with empirically derived degrees of freedom estimates (dofBM). Findings indicate that even with as few as 10 clusters, the CR2 estimator used with dofBM yields generally unbiased results with acceptable type I error and coverage rates. Results show that coverage and type I error rates can be largely influenced by the choice of dof, not just the standard error adjustments. An applied example is provided together with R syntax to conduct the analysis. To facilitate the use of different CRSEs, a free graphical, menu-driven SPSS add-on to compute the various cluster-robust variance estimates can be downloaded from https://github.com/flh3/CR2/tree/master/SPSS .

Business Model Involvement, Adaptive Capacity, and the Triple Bottom Line at the Base of the Pyramid

Almost two decades ago, Prahalad and Hammond [Harv Bus Rev, 80(9):48–59, 2002] introduced the base/bottom of the pyramid (BOP) approach to profitably serving the poor with business models adapted from developed markets while alleviating poverty. In response to disappointing results and ethical criticism, the BOP approach evolved from a just-for-profit approach with a passive role of the poor to an inclusive development approach that integrates the principles of the triple bottom line. A recent review of the BOP literature [Dembek et al., J Bus Ethics 165(3):365–382, 2020], however, reveals a lack of empirical evidence to support the sustainable BOP approach. In this paper, we specify the assumptions underlying the sustainable BOP approach and test them using structural equation modeling with clustered robust standard errors on a unique dataset of 212 firms. Our findings show that BOP business model involvement and adaptive capacity are significant drivers of the triple bottom line at the BOP; however, business model adaptive capacity does not guarantee an ecologically sustainable performance at the BOP. We find that there is a need for further extension of the ethical foundations of the sustainable BOP approach.

Transfusion Associated Circulatory Overload in Ambulatory Transfusions

Introduction: Transfusion Associated Circulatory Overload (TACO) is a leading cause of transfusion related adverse events. Existing estimates of TACO incidence are derived from observations in a predominantly inpatient setting, where, incidence estimates range from 1 to 8% of transfusions (Bachowski G, et al. A Compendium of Transfusion Practice Guidelines Third Edition 2017: American Association Blood Banks). This is the first report of incidence and risk factors for TACO in ambulatory transfusions.Methods: A retrospective cohort analysis of ambulatory patients transfused in a tertiary haematology centre was undertaken in a 12 month period between January to December 2014. Electronic medical records, electronic transfusion database, and patient notes were utilized to obtain data. Variables included age, gender, haematological diagnosis, documented congestive heart failure (CHF) or chronic kidney disease (CKD), details of transfusion encounter, and post transfusion medical review. For the purpose of this study, TACO was defined as documented evidence of hypervolaemia on clinical review and/or if otherwise unplanned diuretic therapy was prescribed for symptoms/signs of fluid overload.Logistic regression models were used to measure associations between TACO events and patient covariates, using cluster-robust Huber-White standard errors to account for the repeated observations on patients. Variables were selected for entry into the statistical models based on a review of existing evidence. Statistical analyses were programed using Stata v13.0 (StataCorp Ltd, College Station, Tx) and was approved by institutional ethics committee.Results: A total of 812 transfusion encounters in 94 ambulatory patients (male=50, female=44), with a mean age of 76 ±11.3 years was observed. The most common underlying haematological diagnoses included myelodysplasia, myelofiborisis, acute leukemia, (table 1). At baseline, 11.2% (14/94) and 13.6% (17/94) of subjects had documented history of CHF and CKD (table 1).There was a total of 1723 packed red cell units (PRBC) transfused across the 812 ambulatory transfusion encounters. The median number of units transfused was 2 per encounter (range 1-4) and median cumulative number of transfusions received per patient was 7 (range 1-28) over the study period. TACO was observed in 7.03% of all transfusion encounters (a total of 57 events in 32 subjects).No cases resulted in inpatient investigation, management or death.The variables of age, gender, CHF, CKD, PRBC units per encounter, and cumulative units received were assessed in regression models. In a univariate model, age was observed to be significantly associated with TACO, odds ratio=1.048 (p=0.011 95%, CI 1.011-1.086).The remaining variables were not statistically significant predictors of TACO in either univariate or multivariate model and significance for age was not retained in a multivariate model (p=0.06) as shown in table 2.Conclusions: This data confirms TACO is an important consideration in the ambulatory transfusions and occurred in 7.03% of transfusion encounters. This is similar to the range seen in hospitalized patients though it was reassuring that no severe cases were observed. Patient age appeared to be an important risk factor in the univariate model with the odds for TACO increasing with each year. In contrast to hospitalized patients, CHF and CKD did not increase the odds for TACO in multivariate regression models. To our knowledge, this is first study to report on incidence and risk factors for TACO in ambulatory transfusions providing a new perspective on this important aspect of haemovigilance. These results also enable better patient information prior to consenting for transfusions. Our study is limited by the retrospective and single center design, but provides vital baseline data for future prospective studies. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Patient need and provider referrals to diabetes self-management education.

This study measured the likelihood of adult patients with diabetes being referred to diabetes self-management education (DSME) when "in need" according to clinical guidelines and identified which types of clinical need predict a greater likelihood of provider referral to DSME. This repeated cross-sectional analysis utilized patient electronic health records (EHRs) and a statewide health information exchange database to examine a 7-year panel (2010-2016) of adult patients with diabetes. Our analytic sample included 8782 adult patients with diabetes with a total of 356,631 encounters. Fixed-effects linear probability models with clustered robust standard errors estimated the association between patients' need for DSME and likelihood of being referred to the service. Models controlled for patients' health status, prior utilization, encounter setting, comorbidity risk scores, the state's expansion of Medicaid, and the count of accredited DSME program sites in the community. Most patient encounters indicated at least 1 type of need for DSME, but less than 7% of those encounters with a documented need resulted in a provider referral. In regression analysis, clinical indicators of need increased the likelihood that patients would be referred to DSME. Patients exhibiting multiple types of need were most likely to be referred to DSME. Although findings indicate that patient need for DSME does improve the likelihood of being referred, provider referral rates were significantly lower than anticipated. Future research should explore barriers to clinical guideline adherence and whether clinical decision support in EHR systems can facilitate provider referrals.

Associations between Natural Resource Extraction and Incidence of Acute and Chronic Health Conditions: Evidence from Tanzania.

Natural resource extraction projects are often accompanied by complex environmental and social-ecological changes. In this paper, we evaluated the association between commodity extraction and the incidence of diseases. We retrieved council (district)-level outpatient data from all public and private health facilities from the District Health Information System (DHIS2). We combined this information with population data from the 2012 national population census and a geocoded list of resource extraction projects from the Geological Survey of Tanzania (GST). We used Poisson regression with random effects and cluster-robust standard errors to estimate the district-level associations between the presence of three types of commodity extraction (metals, gemstone, and construction materials) and the total number of patients in each disease category in each year. Metal extraction was associated with reduced incidence of several diseases, including chronic diseases (IRR = 0.61, CI: 0.47–0.80), mental health disorders (IRR = 0.66, CI: 0.47–0.92), and undernutrition (IRR = 0.69, CI: 0.55–0.88). Extraction of construction materials was associated with an increased incidence of chronic diseases (IRR = 1.47, CI: 1.15–1.87). This study found that the presence of natural resources commodity extraction is significantly associated with changes in disease-specific patient volumes reported in Tanzania’s DHIS2. These associations differed substantially between commodities, with the most protective effects shown from metal extraction.