Focus Theme Research Articles

The Registry of the International Society for Heart and Lung Transplantation: Thirty-third Adult Lung and Heart–Lung Transplant Report—2016; Focus Theme: Primary Diagnostic Indications for Transplant

The Registry of the International Society for Heart and Lung Transplantation: Thirty-third Adult Lung and Heart–Lung Transplant Report—2016; Focus Theme: Primary Diagnostic Indications for Transplant

The Registry of the International Society for Heart and Lung Transplantation: Nineteenth Pediatric Heart Transplantation Report—2016; Focus Theme: Primary Diagnostic Indications for Transplant

The Registry of the International Society for Heart and Lung Transplantation: Nineteenth Pediatric Heart Transplantation Report—2016; Focus Theme: Primary Diagnostic Indications for Transplant

Water security in South Africa: perceptions on public expectations and municipal obligations, governance and water re-use

South Africa is a water-scarce country with increasing pressure on its water resources. Urgent interventions are needed to protect water security within this rapidly developing country. This paper reports on an interdisciplinary Water Security Colloquium, convened by the South African Young Academy of Science in 2014. A selected group of water professionals from academia, civil society and local government was brought together to discuss water security under three focus themes: ‘public expectations and municipal obligations’, ‘water security and governance: challenges and advances’, and ‘water re-use: health and infrastructural considerations’. Participant perceptions were generated using a focus group methodology, combined with participatory data collection methods. Under each theme, inputs were categorised as ‘challenges’, ‘gaps in knowledge’, and ‘solutions/recommendations’ and these inputs were thereafter ranked in order of importance via a ‘voting’ process. Major challenges perceived included a lack of both skills and political will in government, a need to restore citizen trust in government intention and capability to deliver water-related services, and a failure to up-scale existing water re-use technology. Participants identified understanding of the process and implications of the Green and Blue Drop Programmes, knowledge transfer to the public, and the role of educators as major knowledge gaps. The top suggestions proposed included creating public awareness around and buy-in to initiatives to improve water security, accessible and user-friendly conversion of research results to implementation, and ensuring an active role for educators in creating awareness around water security. In view of the concerns identified, participants suggested as potential solutions: improving government and public understanding around water issues, incentivising water re-use and conservation, introducing rising block tariffs and improving human capacity development in the water sector. Developing the ecological infrastructure that protects both quantity and quality of water and building strong partnerships among all stakeholders were also recognised as key. Keywords : capacity development, education, governance, water security, water re-use, water conservation, local government

Adult Children of Parents with Mental Illness: Losing Oneself. Who am I?

There is a limited body of research that focuses on experiences of families of people with mental illness. While the body of knowledge concerning children of parents with mental illness is increasing, there remains limited discourse surrounding the experiences of adults who have lived with childhood parental mental illness. This paper examined one major theme of a study focusing on parenting narratives of adults who had experienced childhood parental mental illness. The narrative study from a metropolitan area of Australia reflects adult children's experiences of being overwhelmed with parental mental illness. They felt unsure of their own emotions and felt they had lost a sense of who they were as individual people. Adult children felt confused about their sense of reality, particularly for those whose parent had a diagnosis of schizophrenia or psychosis. Their experiences of loss were closely associated with changing self identity. Furthermore, many of the narratives demonstrated experiences of grief for adult children. Greater understanding of adult children's perceptions of being parented by a person with mental illness, alongside their experiences of loss, has the potential to help health and social care professionals to facilitate greater resilience for families who are living with parental mental illness.

Lessons for social franchises from sustainability in business and public health studies: a systematic review

34 www.thelancet.com/lancetgh Published Online April 8, 2016 University of California, San Francisco Global Health Sciences, San Francisco, CA, USA (A Penn MS, D Montagu DrPH), University of Utah Health Sciences, Salt Lake City, UT, USA (J Negrette MBA), Asia Pacific Observatory on Health Systems and Policies, WHO Western Pacific Regional Office, Manila, Philippines (D Huntington DrPH) Correspondence to Amy Penn, University of California, San Francisco Global Health Sciences, 550 16th Street, 3rd Floor, San Francisco, CA 94158, USA amy.penn@acsf.edu Lessons for social franchises from sustainability in business and public health studies: a systematic review Amy Penn, Juan Carlos Negrette, Dale Huntington, Dominic Montagu Abstract Background Social franchising programmes are fi nanced mostly by international donor agencies; however, because such funding lacks certainty in the long term, social franchises need to think about how to continue provision of services for their targeted populations. Corporate management analysts argue that for-profi t companies face a similar challenge of uncertain funds, causing us to examine whether social franchises can learn from the business literature. In this systematic review of studies of sustainability in organisations from the business and public health sector, we aim to fi nd common themes and lessons that are applicable to social franchising.Background Social franchising programmes are fi nanced mostly by international donor agencies; however, because such funding lacks certainty in the long term, social franchises need to think about how to continue provision of services for their targeted populations. Corporate management analysts argue that for-profi t companies face a similar challenge of uncertain funds, causing us to examine whether social franchises can learn from the business literature. In this systematic review of studies of sustainability in organisations from the business and public health sector, we aim to fi nd common themes and lessons that are applicable to social franchising. Methods We included english-language articles from the Business Source Complete Database of the University of California, San Francisco, USA, and from PubMed, without any time restrictions, that hypothesised a cause or a clearly defi ned driver of sustainability. From the included studies, we compiled a list of the defi nitions of sustainability that we subsequently categorised into focus themes. Findings Our search yielded 1255, articles from which 26 met inclusion criteria. We found 13 sustainability defi nitions and categorised these into four groups: (1) fi nancial/operational independence; (2) mission and social value creation; (3) ensuring resources for future generations; and (4) adaptability. We also identifi ed sustainability themes across articles. 21 articles addressed adaptability, nine of which emphasised learning as important for sustainability. The concept of the environment appeared in 15 articles. Other themes were organisational structure (ten articles), mission/social value creation (nine articles), organisational culture (eight articles), and monitoring and metrics (nine articles). Surprisingly, the least identifi ed theme was fi nancial viability (four articles). Interpretation The lesson from the studies of business and social service provision is that institutional sustainability relies, to a great extent, on an organisation’s adaptability, internal systems for learning, and ongoing awareness of its larger environment. The analytic studies included in our search echo the fi ndings of the corporate management literature, confi rming the importance of leadership, organisational mission, and value creation to society when predicting sustainability. These process-focused predictors of institutional sustainability have not, until now, been reviewed in social franchising programmes, but may merit more research and attention in the future.

Self-assessment of Rheumatoid Arthritis Disease Activity Using a Smartphone Application. Development and 3-month Feasibility Study.

This article is part of the Focus Theme of Methods of Information in Medicine on "Methodologies, Models and Algorithms for Patients Rehabilitation". Rheumatoid arthritis (RA) is a progressive inflammatory disease that causes damage to multiple joints, decline in functional status, and premature mortality. Thus, effective and frequent objective assessments are necessary. Then, we developed a self-assessment system for RA patients based on a smartphone application. The purpose of this study was to investigate the feasibility of a self-assessment system for RA patients using a smartphone application. We measured daily disease activity in nine RA patients who used the smartphone application for a period of three months. A disease activity score (DAS28) predictive model was used and feedback comments relating to disease activity were shown to patients via the smartphone application each day. To assess participants' RA disease activity, the DAS28 based on the C-reactive protein level was measured by a rheumatologist during monthly clinical visits. The disease activity measured by the application correlated well with the patients' actual disease activity during the 3-month period, as assessed by clinical examination. Furthermore, most participants gave favourable responses to a questionnaire administered at the end of the 3-month period containing questions relating to the ease of use and usefulness of the system. The results of this feasibility study indicated that the DAS28 predictive model can longitudinally predict DAS28 and may be an acceptable and useful tool for assessment of RA disease activity for both patients and healthcare providers.

Quantitative Evaluation of Performance during Robot-assisted Treatment

This article is part of the Focus Theme of Methods of Information in Medicine on "Methodologies, Models and Algorithms for Patients Rehabilitation". The great potential of robots in extracting quantitative and meaningful data is not always exploited in clinical practice. The aim of the present work is to describe a simple parameter to assess the performance of subjects during upper limb robotic training exploiting data automatically recorded by the robot, with no additional effort for patients and clinicians. Fourteen children affected by cerebral palsy (CP) performed a training with Armeo®Spring. Each session was evaluated with P, a simple parameter that depends on the overall performance recorded, and median and interquartile values were computed to perform a group analysis. Median (interquartile) values of P significantly increased from 0.27 (0.21) at T0 to 0.55 (0.27) at T1 . This improvement was functionally validated by a significant increase of the Melbourne Assessment of Unilateral Upper Limb Function. The parameter described here was able to show variations in performance over time and enabled a quantitative evaluation of motion abilities in a way that is reliable with respect to a well-known clinical scale.

Interaction Detection with Depth Sensing and Body Tracking Cameras in Physical Rehabilitation.

This article is part of the Focus Theme of Methods of Information in Medicine on "Methodologies, Models and Algorithms for Patients Rehabilitation". This paper presents a camera based method for identifying the patient and detecting interactions between the patient and the therapist during therapy. Detecting interactions helps to discriminate between active and passive motion of the patient as well as to estimate the accuracy of the skeletal data. Continuous face recognition is used to detect, recognize and track the patient with other people in the scene (e.g. the therapist, or a clinician). We use a method based on local binary patterns (LBP). After identifying users in the scene we identify interactions between the patient and other people. We use a depth map/point cloud for estimating the distance between two people. Our method uses the association of depth regions to user identities and computes the minimal distance between the regions. Our results show state-of-the-art performance of real-time face recognition using low-resolution images that is sufficient to use in adaptive systems. Our proposed approach for detecting interactions shows 91.9% overall recognition accuracy what is sufficient for applications in the context of serious games. We also discuss limitations of the proposed method as well as general limitations of using depth cameras for serious games. We introduced a new method for frame-by-frame automated identification of the patient and labeling reliable sequences of the patient's data recorded during rehabilitation (games). Our method improves automated rehabilitation systems by detecting the identity of the patient as well as of the therapist and by detecting the distance between both over time.

Virtual Reality to Assess and Treat Lower Extremity Disorders in Post-stroke Patients

This article is part of the Focus Theme of Methods of Information in Medicine on "Methodologies, Models and Algorithms for Patients Rehabilitation". To identify support of a virtual reality system in the kinematic assessment and physiotherapy approach to gait disorders in individuals with stroke. We adapt Virtual Reality Rehabilitation System (VRRS), software widely used in the functional recovery of the upper limb, for its use on the lower limb of hemiplegic patients. Clinical scales have been used to relate them with the kinematic assessment provided by the system. A description of the use of reinforced feedback provided by the system on the recovery of deficits in several real cases in the field of physiotherapy is performed. Specific examples of functional tasks have been detailed, to be considered in creating intelligent health technologies to improve post-stroke gait. Both participants improved scores on the clinical scales, the kinematic parameters in leg stance on plegic lower extremity and walking speed > Minimally Clinically Important Difference (MCID). The use of the VRRS software attached to a motion tracking capture system showed their practical utility and safety in enriching physiotherapeutic assessment and treatment in post-stroke gait disorders.

Evaluation of Cognitive Functions through the Systemic Lisbon Battery: Normative Data

This article is part of the Focus Theme of Methods of Information in Medicine on "Methodologies, Models and Algorithms for Patients Rehabilitation". ICT is an emerging alternative to paper-and-pencil tests for the assessment of cognitive functions, allowing for the monitoring of participants' behavior while they perform simulations of instrumental activities of daily life (IADLs) in a virtual reality (VR) scenario. This requires normative values for each VR task, so that deviations to normality can be identified as indicators of cognitive impairment. To identify normative data for several IADL tasks that are available on the Systemic Lisbon Battery (SLB). Fifty-nine participants performed a series of VR tasks that require the use of the memory and executive function dimensions of cognitive functionality. Normative data for the different subsets and total score of the SLB, based on proportion of correct hits per execution time, were identified. Age and experience with video games affect (respectively, negatively and positively) performance on the SLB and should be taken into account in assessment; on the other hand, gender and education do not. Overall results suggest that the SLB may be useful to assess cognitive functioning during the execution of activities of daily living, but larger studies and with clinical samples are needed.

ACL Reconstruction Decision Support. Personalized Simulation of the Lachman Test and Custom Activities.

This article is part of the Focus Theme of Methods of Information in Medicine on "Methodologies, Models and Algorithms for Patients Rehabilitation". The objective of the proposed approach is to develop a clinical decision support system (DSS) that will help clinicians optimally plan the ACL reconstruction procedure in a patient specific manner. A full body model is developed in this study with 23 degrees of freedom and 93 muscles. The knee ligaments are modeled as non-linear spring-damper systems and a tibiofemoral contact model was utilized. The parameters of the ligaments were calibrated based on an optimization criterion. Forward dynamics were utilized during simulation for predicting the model's response to a given set of external forces, posture configuration and physiological parameters. The proposed model is quantified using MRI scans and measurements of the well-known Lachman test, on several patients with a torn ACL. The clinical potential of the proposed framework is demonstrated in the context of flexion-extension, gait and jump actions. The clinician is able to modify and fine tune several parameters such as the number of bundles, insertion position on the tibia or femur and the resting length that correspond to the choices of the surgical procedure and study their effect on the biomechanical behavior of the knee. Computational knee models can be used to predict the effect of surgical decisions and to give insight on how different parameters can affect the stability of the knee. Special focus has to be given in proper calibration and experimental validation.

Eye Gaze Correlates of Motor Impairment in VR Observation of Motor Actions.

This article is part of the Focus Theme of Methods of Information in Medicine on "Methodologies, Models and Algorithms for Patients Rehabilitation". Identify eye gaze correlates of motor impairment in a virtual reality motor observation task in a study with healthy participants and stroke patients. Participants consisted of a group of healthy subjects (N = 20) and a group of stroke survivors (N = 10). Both groups were required to observe a simple reach-and-grab and place-and-release task in a virtual environment. Additionally, healthy subjects were required to observe the task in a normal condition and a constrained movement condition. Eye movements were recorded during the observation task for later analysis. For healthy participants, results showed differences in gaze metrics when comparing the normal and arm-constrained conditions. Differences in gaze metrics were also found when comparing dominant and non-dominant arm for saccades and smooth pursuit events. For stroke patients, results showed longer smooth pursuit segments in action observation when observing the paretic arm, thus providing evidence that the affected circuitry may be activated for eye gaze control during observation of the simulated motor action. This study suggests that neural motor circuits are involved, at multiple levels, in observation of motor actions displayed in a virtual reality environment. Thus, eye tracking combined with action observation tasks in a virtual reality display can be used to monitor motor deficits derived from stroke, and consequently can also be used for rehabilitation of stroke patients.

The Long History of Lutheranism in Scandinavia. From State Religion to the People’s Church

Abstract As the main religion of Finland, but also of entire Scandinavia, Lutheranism has a centuries-long history. Until 1809 Finland formed the eastern part of the Swedish Kingdom, from 1809 to 1917 it was a Grand Duchy within the Russian Empire, and in 1917 Finland gained independence. In the 1520s the Lutheran Reformation reached the Swedish realm and gradually Lutheranism was made the state religion in Sweden. In the 19th century the Emperor in Russia recognized the official Lutheran confession and the status of the Lutheran Church as a state church in Finland. In the 20th century Lutheran church leaders preferred to use the concept people’s church. The Lutheran Church is still the majority church. In the beginning of 2015, some 74 percent of all Finns were members of the Evangelical Lutheran Church of Finland. In this issue of Perichoresis, Finnish historians interested in the role of church and Christian faith in society look at the religious history of Finland and Scandinavia. The articles are mainly organized in chronological order, starting from the early modern period and covering several centuries until the late 20th century and the building of the welfare state in Finland. This introductory article gives a brief overview of state-church relations in Finland and presents the overall theme of this issue focusing on Finnish Lutheranism. Our studies suggest that 16th and early 17th century Finland may not have been quite so devoutly Lutheran as is commonly claimed, and that late 20th century Finland may have been more Lutheran than is commonly realized.

The Registry of the International Society for Heart and Lung Transplantation: Eighteenth Official Pediatric Heart Transplantation Report—2015; Focus Theme: Early Graft Failure

The Registry of the International Society for Heart and Lung Transplantation: Eighteenth Official Pediatric Heart Transplantation Report—2015; Focus Theme: Early Graft Failure

The character and significance of Nordic purchasing and supply management research: A systematic review of the literature

This paper evaluates the character and significance of Nordic contributions to purchasing and supply management (PSM) research. The paper is based on a systematic analysis of the literature, focusing on the contributions of authors with a Nordic affiliation to PSM. We seek to identify the themes in focus of Nordic PSM research, the research methods and theories that are typically employed; ultimately we discuss if a Nordic PSM school of thought or approach can be discerned and evaluate if or in which areas Nordic PSM research has made significant impact. We conclude the paper by outlining and discussing important future avenues of research for Nordic research in PSM.

Государственное финансирование биомедицинских исследований в США, Великобритании и Германии

The description of the international practice of governmental funding of biomedical research is a significant aspect of development of the methodology for prioritization of funding of science (both basic and applied research) in the Russian Federation. The information about mechanisms of allocation of the governmental budget in biomedical research and about focus themes within biomedical research founded in open information sources is very limited.

Reliability and validity of the anesthesiologist supervision instrument when certified registered nurse anesthetists provide scores.

At many facilities in the United States, supervision of Certified Registered Nurse Anesthetists (CRNAs) is a major daily responsibility of anesthesiologists. We use the term "supervision" to include clinical oversight functions directed toward assuring the quality of clinical care whenever the anesthesiologist is not the sole anesthesia care provider. In our department, the supervision provided by each anesthesiologist working in operating rooms is evaluated each day by the CRNA(s) and anesthesiology resident(s) with whom they worked the previous day. The evaluations utilize the 9 questions developed by de Oliveira Filho for residents to assess anesthesiologist supervision. Each question is answered on a 4-point Likert scale (1 = never, 2 = rarely, 3 = frequently, and 4 = always). We evaluated the reliability and validity of the instrument when used in daily practice by CRNAs. The data set included all 7273 daily supervision scores and 1088 comments of 77 anesthesiologists provided by 49 CRNAs, as well as the 6246 scores and 681 comments provided by 62 residents, for dates of service between July 1, 2013, and June 30, 2014. Reliability of the instrument was assessed using its internal consistency. Content analysis was used to associate supervision scores (i.e., mean of the 9 answers) and presence of the verbs "see" or "saw" combined with negation in comments (e.g., "I did not see the anesthesiologist during the case(s) together"). Results are reported as the mean ± SE from among the 6 two-month periods. Supervision scores <2 were provided for 7.2% ± 0.4% of assessments and scores <3 were provided for 36.6% ± 1.1% of assessments, by 18.2 ± 0.9 and 34.0 ± 0.6 CRNAs, respectively (i.e., low scores were not attributable to just a few CRNAs or anesthesiologists). These frequencies were greater than for trainees (anesthesiology residents) (both P < 0.0001). No single question among the 9 questions in the supervision instrument explained CRNA supervision scores <2 (or <3) because of substantial (expected) interquestion correlation. Cronbach's alpha equaled 0.895 ± 0.003 among the 6 two-month periods. Among the CRNA evaluations that included a written comment, the Cronbach's alpha was 0.907 ± 0.003. Thus, like for anesthesiology residents, when used by CRNAs, the questions measured a one-dimensional attribute. The presence of a comment containing the action verb "see" or "saw," with the focus theme ("I did not see …"), increased the odds of a CRNA providing a supervision score <2 (odds ratio = 74.2, P = 0.0003) and supervision score <3 (odds ratio = 48.2, P < 0.0001). Limiting consideration to scores with comments, there too was an association between these words and a score <2 (odds ratio = 19.4, P = 0.0003) and a score <3 (odds ratio = 31.5, P < 0.0001). In Iowa, substantial anesthesiologist presence is not required for CRNA billing. More comments containing "see" or "saw" were made by CRNAs rather than residents (n = 75 [97.4%] versus n = 2 [2.6%], respectively, P < 0.0001), indicating face validity of the analysis. If some of the 9 questions were not perceived by the CRNAs as relevant to their interprofessional interactions, Cronbach's alpha would be low, not the 0.907 ± 0.003, above. Similarly, one or more of the individual questions would also not routinely be scored at its upper boundary of 4.0 ("always"). This was not so, being as the score was 4.0 for 24.9% ± 0.3% of the CRNA evaluations, and that score of 4.0 was more common than even the next most common combination of scores (P < 0.0001). The de Oliveira Filho supervision instrument was designed for use by residents. Our results show that the instrument also is reliable and valid when used by CRNAs. This is important given our previous finding that the CRNA:MD ratio had no correlation with the level of supervision provided.

Predicting Depression among Patients with Diabetes Using Longitudinal Data

This article is part of the Focus Theme of Methods of Information in Medicine on "Big Data and Analytics in Healthcare". Depression is a common and often undiagnosed condition for patients with diabetes. It is also a condition that significantly impacts healthcare outcomes, use, and cost as well as elevating suicide risk. Therefore, a model to predict depression among diabetes patients is a promising and valuable tool for providers to proactively assess depressive symptoms and identify those with depression. This study seeks to develop a generalized multilevel regression model, using a longitudinal data set from a recent large-scale clinical trial, to predict depression severity and presence of major depression among patients with diabetes. Severity of depression was measured by the Patient Health Questionnaire PHQ-9 score. Predictors were selected from 29 candidate factors to develop a 2-level Poisson regression model that can make population-average predictions for all patients and subject-specific predictions for individual patients with historical records. Newly obtained patient records can be incorporated with historical records to update the prediction model. Root-mean-square errors (RMSE) were used to evaluate predictive accuracy of PHQ-9 scores. The study also evaluated the classification ability of using the predicted PHQ-9 scores to classify patients as having major depression. Two time-invariant and 10 time-varying predictors were selected for the model. Incorporating historical records and using them to update the model may improve both predictive accuracy of PHQ-9 scores and classification ability of the predicted scores. Subject-specific predictions (for individual patients with historical records) achieved RMSE about 4 and areas under the receiver operating characteristic (ROC) curve about 0.9 and are better than population-average predictions. The study developed a generalized multilevel regression model to predict depression and demonstrated that using generalized multilevel regression based on longitudinal patient records can achieve high predictive ability.

Auditory and Nociceptive Stimuli Responses in the Electroencephalogram. A Non-linear Measures and Time-frequency Representation Based Analysis.

This article is part of the Focus Theme of Methods of Information in Medicine on "Biosignal Interpretation: Advanced Methods for Neural Signals and Images". An efficient way to investigate the neural basis of nociceptive responses is the analysis of the event-related brain potentials (ERPs). The main objective of this work was to study how adaptation and fatigue affect the ERPs to stimuli of different modalities, by characterizing the responses to infrequent and frequent stimulation in different recording periods. In this work, series of averaged EEG epochs recorded after thermal, electrical and auditory stimulation were analyzed with time-frequency representation and non-linear measures as spectral entropy and auto-mutual information function. The study was performed by considering the traditional EEG frequency bands. The defined measures presented a statistical significance p-value < 0.01 and accuracy higher than 60% by differentiating windows of response to infrequent (I) and frequent (F) stimuli between the start and end of the EEG recording. These measures permitted to observe some aspects of the subject's adaptation and the nociceptive response.

Predicting 30-day Hospital Readmission with Publicly Available Administrative Database. A Conditional Logistic Regression Modeling Approach.

This article is part of the Focus Theme of Methods of Information in Medicine on "Big Data and Analytics in Healthcare". Hospital readmissions raise healthcare costs and cause significant distress to providers and patients. It is, therefore, of great interest to healthcare organizations to predict what patients are at risk to be readmitted to their hospitals. However, current logistic regression based risk prediction models have limited prediction power when applied to hospital administrative data. Meanwhile, although decision trees and random forests have been applied, they tend to be too complex to understand among the hospital practitioners. Explore the use of conditional logistic regression to increase the prediction accuracy. We analyzed an HCUP statewide inpatient discharge record dataset, which includes patient demographics, clinical and care utilization data from California. We extracted records of heart failure Medicare beneficiaries who had inpatient experience during an 11-month period. We corrected the data imbalance issue with under-sampling. In our study, we first applied standard logistic regression and decision tree to obtain influential variables and derive practically meaning decision rules. We then stratified the original data set accordingly and applied logistic regression on each data stratum. We further explored the effect of interacting variables in the logistic regression modeling. We conducted cross validation to assess the overall prediction performance of conditional logistic regression (CLR) and compared it with standard classification models. The developed CLR models outperformed several standard classification models (e.g., straightforward logistic regression, stepwise logistic regression, random forest, support vector machine). For example, the best CLR model improved the classification accuracy by nearly 20% over the straightforward logistic regression model. Furthermore, the developed CLR models tend to achieve better sensitivity of more than 10% over the standard classification models, which can be translated to correct labeling of additional 400 - 500 readmissions for heart failure patients in the state of California over a year. Lastly, several key predictor identified from the HCUP data include the disposition location from discharge, the number of chronic conditions, and the number of acute procedures. It would be beneficial to apply simple decision rules obtained from the decision tree in an ad-hoc manner to guide the cohort stratification. It could be potentially beneficial to explore the effect of pairwise interactions between influential predictors when building the logistic regression models for different data strata. Judicious use of the ad-hoc CLR models developed offers insights into future development of prediction models for hospital readmissions, which can lead to better intuition in identifying high-risk patients and developing effective post-discharge care strategies. Lastly, this paper is expected to raise the awareness of collecting data on additional markers and developing necessary database infrastructure for larger-scale exploratory studies on readmission risk prediction.