A Hierarchical Multivariate Two-Part Model for Profiling Providers\u27 Effects on Healthcare Charges

Procedures for analyzing and comparing healthcare providers\u27 effects on health services delivery and outcomes have been referred to as provider profiling. In a typical profiling procedure, patient-level responses are measured for clusters of patients treated by providers that in turn, can be regarded as statistically exchangeable. Thus, a hierarchical model naturally represents the structure of the data. When provider effects on multiple responses are profiled, a multivariate model rather than a series of univariate models, can capture associations among responses at both the provider and patient levels. When responses are in the form of charges for healthcare services and sampled patients include non-users of services, charge variables are a mix of zeros and highly-skewed positive values that present a modeling challenge. For analysis of regressor effects on charges for a single service, a frequently used approach is a two-part model (Duan, Manning, Morris, and Newhouse 1983) that combines logistic or probit regression on any use of the service and linear regression on the log of positive charges given use of the service. Here, we extend the two-part model to the case of charges for multiple services, using a log-linear model and a general multivariate log-normal model, and employ the resultant multivariate two-part model as the within-provider component of a hierarchical model. The log-linear likelihood is reparameterized as proposed by Fitzmaurice and Laird (1993), so that regressor effects on any use of each service are marginal with respect to any use of other services. The general multivariate log-normal likelihood is constructed in such a way that variances of log of positive charges for each service are provider-specific but correlations between log of positive charges for different services are uniform across providers. A data augmentation step is included in the Gibbs sampler used to fit the hierarchical model, in order to accommodate the fact that values of log of positive charges are undefined for unused service. We apply this hierarchical, multivariate, two-part model to analyze the effects of primary care physicians on their patients\u27 annual charges for two services, primary care and specialty care. Along the way, we also demonstrate an approach for incorporating prior information about the effects of patient morbidity on response variables, to improve the accuracy of provider profiles that are based on patient samples of limited size

Studying Effects of Primary Care Physicians and Patients on the Trade-Off Between Charges for Primary Care and Specialty Care Using a Hierarchical Multivariate Two-Part Model

Objective. To examine effects of primary care physicians (PCPs) and patients on the association between charges for primary care and specialty care in a point-of-service (POS) health plan. Data Source. Claims from 1996 for 3,308 adult male POS plan members, each of whom was assigned to one of the 50 family practitioner-PCPs with the largest POS plan member-loads. Study Design. A hierarchical multivariate two-part model was fitted using a Gibbs sampler to estimate PCPs\u27 effects on patients\u27 annual charges for two types of services, primary care and specialty care, the associations among PCPs\u27 effects, and within-patient associations between charges for the two services. Adjusted Clinical Groups (ACGs) were used to adjust for case-mix. Principal Findings. PCPs with higher case-mix adjusted rates of specialist use were less likely to see their patients at least once during the year (estimated correlation: –.40; 95% CI: –.71, –.008) and provided fewer services to patients that they saw (estimated correlation: –.53; 95% CI: –.77, –.21). Ten of 11 PCPs whose case-mix adjusted effects on primary care charges were significantly less than or greater than zero (p \u3c .05) had estimated, case-mix adjusted effects on specialty care charges that were of opposite sign (but not significantly different than zero). After adjustment for ACG and PCP effects, the within-patient, estimated odds ratio for any use of primary care given any use of specialty care was .57 (95% CI: .45, .73). Conclusions. PCPs and patients contributed independently to a trade-off between utilization of primary care and specialty care. The trade-off appeared to partially offset significant differences in the amount of care provided by PCPs. These findings were possible because we employed a hierarchical multivariate model rather than separate univariate models

Electromagnetic induction mapping at varied soil moisture reveals field-scale soil textural patterns and gravel lenses

Knowledge of the spatial distribution of soil textural properties is important for determining soil moisture storage and soil hydraulic transport properties. Capturing field heterogeneity without exhaustive sampling and costly sample analysis is difficult. Our objective was to employ electromagnetic induction (EMI) mapping in low apparent electrical conductivity (ECa) soils at varying soil water contents to capture time invariant properties such as soil texture. Georeferenced ECa measurements were taken using a ground conductivity meter on six different days where volumetric water content (θv) varied from 0.11 to 0.23. The 50 m × 50 m field included a subsurface gravelly patch in an otherwise homogeneous silt-loam alluvial soil. Ordinary block kriging predicted ECa at unsampled areas to produce 1-m resolution maps. Temporal stability analysis was used to divide the field into three distinct ECa regions. Subsequent ground-truthing confirmed the lowest conductivity region correlated with coarse textured soil parent materials associated with a former high-energy alluvial depositional area. Combining maps using temporal stability analysis gives the clearest image of the textural difference. These maps could be informative for modeling, experimental design, sensor placement and targeted zone management strategies in soil science, ecology, hydrology, and agricultural applications

Assessing visual disturbance conditions on the Custer National Forest

Assessment of soil disturbance on the Custer National Forest was conducted during two summers to determine if the U.S. Forest Service Forest Soil Disturbance Monitoring Protocol (FSDMP) was able to distinguish post-harvest soil conditions in a chronological sequence of sites harvested using different ground-based logging systems. Results from the first year of sampling suggested that the FSDMP point sampling method may not be sensitive enough to measure post-harvest disturbance in stands with low levels of disturbance. Therefore, a revised random transect method was used during the second sampling season to determine the actual extent of soil disturbance in these cutting units. Using combined data collected from both summers I detected statistically significant differences (p \u3c 0.05) in fine fraction bulk density measurements between FSDMP disturbance classes across all sites. Disturbance class 3 (most severe) had the highest reported bulk density, which suggest that the FSDMP visual class estimates are defined adequately allowing for correlations to be made between visual disturbance and actual soil physical characteristics. Forest site productivity can be defined by its ability to retain carbon and convert it to above- and belowground biomass. However, forest management activities that alter basic site characteristics have the potential to alter productivity. Soil compaction is one critical management impact that is important to understand; compaction has been shown to impede the root growth potential of plants, reduce water infiltration rates increasing erosion potential, and alter plant available water and nutrients, depending on soil texture. A new method to assess ground cover, erosion, and other soil disturbances was recently published by the U.S. Forest Service, as the Forest Soil Disturbance Protocol (FSDMP). The FSDMP allows soil scientists to visually assign a disturbance class estimate (0 – none, 1, 2, 3 – severe) from field measures of consistently defined soil disturbance indicators (erosion, fire, rutting, compaction, and platy/massive/puddled structure) in small circular (15 cm) plots to compare soil quality properties pre- and post- harvest condition. Using this protocol we were able to determine that ground-based timber harvesting activities occurring on the Custer National Forest are not reaching the 15% maximum threshold for detrimental soil disturbance outlined by the Region 1 Soil Quality Standards

Meningococcal disease in children in Merseyside, England:a 31 year descriptive study

Meningococcal disease (MCD) is the leading infectious cause of death in early childhood in the United Kingdom, making it a public health priority. MCD most commonly presents as meningococcal meningitis (MM), septicaemia (MS), or as a combination of the two syndromes (MM/MS). We describe the changing epidemiology and clinical presentation of MCD, and explore associations with socioeconomic status and other risk factors. A hospital-based study of children admitted to a tertiary children's centre, Alder Hey Children's Foundation Trust, with MCD, was undertaken between 1977 to 2007 (n = 1157). Demographics, clinical presentations, microbiological confirmation and measures of deprivation were described. The majority of cases occurred in the 1-4 year age group and there was a dramatic fall in serogroup C cases observed with the introduction of the meningococcal C conjugate (MCC) vaccine. The proportion of MS cases increased over the study period, from 11% in the first quarter to 35% in the final quarter. Presentation with MS (compared to MM) and serogroup C disease (compared to serogroup B) were demonstrated to be independent risk factors for mortality, with odds ratios of 3.5 (95% CI 1.18 to 10.08) and 2.18 (95% CI 1.26 to 3.80) respectively. Cases admitted to Alder Hey were from a relatively more deprived population (mean Townsend score 1.25, 95% CI 1.09 to 1.41) than the Merseyside reference population. Our findings represent one of the largest single-centre studies of MCD. The presentation of MS is confirmed to be a risk factor of mortality from MCD. Our study supports the association between social deprivation and MCD

Experimental evidence for drought induced alternative stable states of soil moisture

Ecosystems may exhibit alternative stable states (ASS) in response to environmental change. Modelling and observational data broadly support the theory of ASS, however evidence from manipulation experiments supporting this theory is limited. Here, we provide long-term manipulation and observation data supporting the existence of drought induced alternative stable soil moisture states (irreversible soil wetting) in upland Atlantic heath, dominated by Calluna vulgaris (L.) Hull. Manipulated repeated moderate summer drought, and intense natural summer drought both lowered resilience resulting in shifts in soil moisture dynamics. The repeated moderate summer drought decreased winter soil moisture retention by ~10%. However, intense summer drought, superimposed on the experiment, that began in 2003 and peaked in 2005 caused an unexpected erosion of resilience and a shift to an ASS; both for the experimental drought manipulation and control plots, impairing the soil from rewetting in winter. Measurements outside plots, with vegetation removal, showed no evidence of moisture shifts. Further independent evidence supports our findings from historical soil moisture monitoring at a long-term upland hydrological observatory. The results herald the need for a new paradigm regarding our understanding of soil structure, hydraulics and climate interaction

‘Our newsroom in the cloud’: Slack, virtual newsrooms and journalistic practice

Virtual newsrooms have enormous potential: enabling journalists around the world to pool their knowledge, skills and perspectives within joint projects, such as the Panama Papers. These virtual newsrooms are supported by Online Collaborative Software (OCS), the most popular of which is Slack. But although many of the world’s top news organisations now use Slack, there is no empirical research examining its impact on workplace processes or culture. This article presents the results of a year-long ethnographic study of a global digital news outlet, whose remote journalists collaborate, almost exclusively, via Slack. We found that the platform deepened relationships and enabled new creative practices across geographic regions. However, it also contributed to the erasure of the line between private and professional spheres for workers, and introduced new opportunities for management to shape newsroom culture. We argue that the concept of ‘space’ as developed by Harvey can helpfully frame the analysis of these new, important digital platforms

The Distribution of Redshifts in New Samples of Quasi-stellar Objects

Two new samples of QSOs have been constructed from recent surveys to test the hypothesis that the redshift distribution of bright QSOs is periodic in $\log(1+z)$. The first of these comprises 57 different redshifts among all known close pairs or multiple QSOs, with image separations $\leq$ 10\arcsec, and the second consists of 39 QSOs selected through their X-ray emission and their proximity to bright comparatively nearby active galaxies. The redshift distributions of the samples are found to exhibit distinct peaks with a periodic separation of $\sim 0.089$ in $\log(1+z)$ identical to that claimed in earlier samples but now extended out to higher redshift peaks $z = 2.63, 3.45$ and 4.47, predicted by the formula but never seen before. The periodicity is also seen in a third sample, the 78 QSOs of the 3C and 3CR catalogues. It is present in these three datasets at an overall significance level $10^{-5}$ - $10^{-6}$, and appears not to be explicable by spectroscopic or similar selection effects. Possible interpretations are briefly discussed.Comment: submitted for publication in the Astronomical Journal, 15 figure

Towards a formalism for mapping the spacetimes of massive compact objects: Bumpy black holes and their orbits

Observations have established that extremely compact, massive objects are common in the universe. It is generally accepted that these objects are black holes. As observations improve, it becomes possible to test this hypothesis in ever greater detail. In particular, it is or will be possible to measure the properties of orbits deep in the strong field of a black hole candidate (using x-ray timing or with gravitational-waves) and to test whether they have the characteristics of black hole orbits in general relativity. Such measurements can be used to map the spacetime of a massive compact object, testing whether the object's multipoles satisfy the strict constraints of the black hole hypothesis. Such a test requires that we compare against objects with the ``wrong'' multipole structure. In this paper, we present tools for constructing bumpy black holes: objects that are almost black holes, but that have some multipoles with the wrong value. The spacetimes which we present are good deep into the strong field of the object -- we do not use a large r expansion, except to make contact with weak field intuition. Also, our spacetimes reduce to the black hole spacetimes of general relativity when the ``bumpiness'' is set to zero. We propose bumpy black holes as the foundation for a null experiment: if black hole candidates are the black holes of general relativity, their bumpiness should be zero. By comparing orbits in a bumpy spacetime with those of an astrophysical source, observations should be able to test this hypothesis, stringently testing whether they are the black holes of general relativity. (Abridged)Comment: 16 pages + 2 appendices + 3 figures. Submitted to PR

Deep 1.1 mm-wavelength imaging of the GOODS-S field by AzTEC/ASTE - I. Source catalogue and number counts

[Abridged] We present the first results from a 1.1 mm confusion-limited map of the GOODS-S field taken with AzTEC on the ASTE telescope. We imaged a 270 sq. arcmin field to a 1\sigma depth of 0.48 - 0.73 mJy/beam, making this one of the deepest blank-field surveys at mm-wavelengths ever achieved. Although our GOODS-S map is extremely confused, we demonstrate that our source identification and number counts analyses are robust, and the techniques discussed in this paper are relevant for other deeply confused surveys. We find a total of 41 dusty starburst galaxies with S/N >= 3.5 within this uniformly covered region, where only two are expected to be false detections. We derive the 1.1mm number counts from this field using both a "P(d)" analysis and a semi-Bayesian technique, and find that both methods give consistent results. Our data are well-fit by a Schechter function model with (S', N(3mJy), \alpha) = (1.30+0.19 mJy, 160+27 (mJy/deg^2)^(-1), -2.0). Given the depth of this survey, we put the first tight constraints on the 1.1 mm number counts at S(1.1mm) = 0.5 mJy, and we find evidence that the faint-end of the number counts at S(850\mu m) < 2.0 mJy from various SCUBA surveys towards lensing clusters are biased high. In contrast to the 870 \mu m survey of this field with the LABOCA camera, we find no apparent under-density of sources compared to previous surveys at 1.1 mm. Additionally, we find a significant number of SMGs not identified in the LABOCA catalogue. We find that in contrast to observations at wavelengths < 500 \mu m, MIPS 24 \mu m sources do not resolve the total energy density in the cosmic infrared background at 1.1 mm, demonstrating that a population of z > 3 dust-obscured galaxies that are unaccounted for at these shorter wavelengths potentially contribute to a large fraction (~2/3) of the infrared background at 1.1 mm.Comment: 21 pages, 9 figures. Accepted to MNRAS