RESUMEN
OBJECTIVE: To test a multidisciplinary approach to reduce heart failure (HF) readmissions that tailors the intensity of care transition intervention to the risk of the patient using a suite of electronic medical record (EMR)-enabled programmes. METHODS: A prospective controlled before and after study of adult inpatients admitted with HF and two concurrent control conditions (acute myocardial infarction (AMI) and pneumonia (PNA)) was performed between 1 December 2008 and 1 December 2010 at a large urban public teaching hospital. An EMR-based software platform stratified all patients admitted with HF on a daily basis by their 30-day readmission risk using a published electronic predictive model. Patients at highest risk received an intensive set of evidence-based interventions designed to reduce readmission using existing resources. The main outcome measure was readmission for any cause and to any hospital within 30 days of discharge. RESULTS: There were 834 HF admissions in the pre-intervention period and 913 in the post-intervention period. The unadjusted readmission rate declined from 26.2% in the pre-intervention period to 21.2% in the post-intervention period (p=0.01), a decline that persisted in adjusted analyses (adjusted OR (AOR)=0.73; 95% CI 0.58 to 0.93, p=0.01). In contrast, there was no significant change in the unadjusted and adjusted readmission rates for PNA and AMI over the same period. There were 45 fewer readmissions with 913 patients enrolled and 228 patients receiving intervention, resulting in a number needed to treat (NNT) ratio of 20. CONCLUSIONS: An EMR-enabled strategy that targeted scarce care transition resources to high-risk HF patients significantly reduced the risk-adjusted odds of readmission.
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Asignación de Recursos para la Atención de Salud , Insuficiencia Cardíaca , Readmisión del Paciente/economía , Anciano , Registros Electrónicos de Salud , Femenino , Hospitales Urbanos , Humanos , Masculino , Persona de Mediana Edad , Estudios de Casos Organizacionales , Readmisión del Paciente/estadística & datos numéricos , Estudios Prospectivos , Gestión de Riesgos/métodos , TexasRESUMEN
BACKGROUND: A real-time electronic predictive model that identifies hospitalized heart failure (HF) patients at high risk for readmission or death may be valuable to clinicians and hospitals who care for these patients. METHODS: An automated predictive model for 30-day readmission and death was derived and validated from clinical and nonclinical risk factors present on admission in 1372 HF hospitalizations to a major urban hospital between January 2007 and August 2008. Data were extracted from an electronic medical record. The performance of the electronic model was compared with mortality and readmission models developed by the Center for Medicaid and Medicare Services (CMS models) and a HF mortality model derived from the Acute Decompensated Heart Failure Registry (ADHERE model). RESULTS: The 30-day mortality and readmission rates were 3.1% and 24.1% respectively. The electronic model demonstrated good discrimination for 30 day mortality (C statistic 0.86) and readmission (C statistic 0.72) and performed as well, or better than, the ADHERE model and CMS models for both outcomes (C statistic ranges: 0.72-0.73 and 0.56-0.66 for mortality and readmissions respectively; P < 0.05 in all comparisons). Markers of social instability and lower socioeconomic status improved readmission prediction in the electronic model (C statistic 0.72 vs. 0.61, P < 0.05). CONCLUSIONS: Clinical and social factors available within hours of hospital presentation and extractable from an EMR predicted mortality and readmission at 30 days. Incorporating complex social factors increased the model's accuracy, suggesting that such factors could enhance risk adjustment models designed to compare hospital readmission rates.
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Registros Electrónicos de Salud/estadística & datos numéricos , Insuficiencia Cardíaca/epidemiología , Evaluación de Resultado en la Atención de Salud/estadística & datos numéricos , Readmisión del Paciente/estadística & datos numéricos , Medición de Riesgo/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Insuficiencia Cardíaca/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Pronóstico , Factores de Riesgo , Factores Socioeconómicos , Tasa de Supervivencia , Estados Unidos/epidemiología , Población Urbana/estadística & datos numéricosRESUMEN
In this study, we estimated the impact on local household livelihoods of the Natural Forest Protection Program (NFPP), which is the largest logging-ban program in the world, which aims to protect watersheds and conserve natural forests. In doing so, we used a series of microeconometric policy-evaluation techniques to assess the impacts of the NFPP on two interrelated facets of household livelihoods: income and off-farm labor supply. We found that the NFPP has had a negative impact on incomes from timber harvesting but has actually had a positive impact on total household incomes from all sources. Furthermore, we found that off-farm labor supply outside the village has increased more rapidly in NFPP than in non-NFPP areas. Based on these results, policy implications for household livelihoods were drawn and are presented herein.
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Agricultura/economía , Conservación de los Recursos Naturales/economía , Ecosistema , Composición Familiar , Agricultura Forestal/economía , Política Pública , China , Conservación de los Recursos Naturales/métodos , Empleo , Humanos , Modelos Econométricos , Factores Socioeconómicos , Movimientos del Agua , Recursos HumanosRESUMEN
INTRODUCTION: The purpose of this study was to evaluate the battery lives of cordless light-emitting diodes (LEDs) and their effect on orthodontic bracket bond strength. METHODS: One hundred eighty-six metal orthodontic brackets were bonded to extracted molars. Two LED light-curing units (L. E. Demetron [SDS/Kerr, Orange, Calif] and Ortholux [3M Unitek, Monrovia, Calif]) were evaluated. Each light was used to bond 93 specimens. One bracket was bonded every 5 minutes until the battery ran out. The lights were activated for 20 seconds, then automatically turned off for 40 seconds every minute (33% duty cycle) without recharging. Bonded specimens were stored in water at 37 degrees C for 24 hours and then subjected to shear force with a universal testing machine until bracket failure. RESULTS: Repeated measures ANOVA detected significantly weaker mean shear bond strength and fewer consecutive cures with the Ortholux compared with the L. E. Demetron light-curing unit. However, when the first 5 time points were excluded, there were no differences between the 2 lights, demonstrating that the lights performed similarly after the first 20 minutes of operation Just before battery failure, both lights still provided the same power density as at the beginning. CONCLUSIONS: Both light-curing units provided adequate power density for up to 2 hours without recharging at a 33% duty cycle. There was no significant decrease in power in cordless LED light-curing units as the battery life approached its end point.
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Recubrimiento Dental Adhesivo , Equipo Dental , Suministros de Energía Eléctrica , Soportes Ortodóncicos , Cementos de Resina/efectos de la radiación , Análisis de Varianza , Bisfenol A Glicidil Metacrilato/efectos de la radiación , Análisis del Estrés Dental , Humanos , Luz , Diente Molar , Transición de Fase , Semiconductores , Resistencia al CorteRESUMEN
Light emitting diode (LED) light-curing units have recently been used to polymerize resin-based orthodontic adhesives, and preliminary studies indicate their use has been successful. The purpose of this study was to evaluate the relationship between the shear bond strength of orthodontic brackets bonded to enamel and the duration of photopolymerization with LEDs and conventional quartz-tungsten-halogen light-curing units. Three LED light-curing units (GC e-light, GC America, Alsip, Ill; Elipar FreeLight, 3M ESPE Dental Products, St Paul, Minn; and UltraLume LED 2, Ultradent Products, South Jordan, Utah) and 1 halogen-based light-curing unit (Ortholux XT, 3M Unitek, Monrovia, Calif) were evaluated. Two hundred forty metal orthodontic brackets were bonded to extracted molars. Specimens were divided into 12 groups of 20 teeth each. Each group was cured with a different light-curing unit for 40, 20, or 10 seconds. The specimens were stored in water at 37 degrees C for 24 hours and then subjected to a shear force with a universal testing machine until bracket failure. Two-way ANOVA detected significantly weaker mean shear bond strength with the GC e-light at 10 and 40 seconds (P<.001) and higher mean shear bond strength for the UltraLume LED 2 at 40 seconds (P<.001). All experimental groups had laboratory mean shear bond strengths greater than 8 MPa, even with a 10-second cure.