Healthcare insurance fraud detection using data mining.

BACKGROUND: Healthcare programs and insurance initiatives play a crucial role in ensuring that people have access to medical care. There are many benefits of healthcare insurance programs but fraud in healthcare continues to be a significant challenge in the insurance industry. Healthcare insurance fraud detection faces challenges from evolving and sophisticated fraud schemes that adapt to detection methods. Analyzing extensive healthcare data is hindered by complexity, data quality issues, and the need for real-time detection, while privacy concerns and false positives pose additional hurdles. The lack of standardization in coding and limited resources further complicate efforts to address fraudulent activities effectively. METHODOLGY: In this study, a fraud detection methodology is presented that utilizes association rule mining augmented with unsupervised learning techniques to detect healthcare insurance fraud. Dataset from the Centres for Medicare and Medicaid Services (CMS) 2008-2010 DE-SynPUF is used for analysis. The proposed methodology works in two stages. First, association rule mining is used to extract frequent rules from the transactions based on patient, service and service provider features. Second, the extracted rules are passed to unsupervised classifiers, such as IF, CBLOF, ECOD, and OCSVM, to identify fraudulent activity. RESULTS: Descriptive analysis shows patterns and trends in the data revealing interesting relationship among diagnosis codes, procedure codes and the physicians. The baseline anomaly detection algorithms generated results in 902.24 seconds. Another experiment retrieved frequent rules using association rule mining with apriori algorithm combined with unsupervised techniques in 868.18 seconds. The silhouette scoring method calculated the efficacy of four different anomaly detection techniques showing CBLOF with highest score of 0.114 followed by isolation forest with the score of 0.103. The ECOD and OCSVM techniques have lower scores of 0.063 and 0.060, respectively. CONCLUSION: The proposed methodology enhances healthcare insurance fraud detection by using association rule mining for pattern discovery and unsupervised classifiers for effective anomaly detection.

Evaluating the Safety and Outcomes of Oesophagogastroduodenoscopy in Elderly Patients Presenting With Acute Upper Gastrointestinal Bleeding.

AIMS: In the absence of evidence-based guidelines regarding the safety and appropriateness of emergency endoscopy in elderly, co-morbid and frail patients, we aimed to find clinical outcomes in elderly patients who have undergone gastroscopy following an acute upper gastrointestinal bleeding (UGIB). METHODS: We carried out a retrospective observational study of patients aged 70 years and older who had undergone emergency oesophagogastroduodenoscopy (OGD) at the Royal Sussex County Hospital, Brighton, United Kingdom, between May 2020 and January 2022. Data collected for analysis included Glasgow-Blatchford score, age, gender, endoscopic findings, endoscopic treatments, immediate complications, 90-day complications, 30-day and 90-day survival, length of hospital stay and re-bleeding. RESULTS: A total of 248 study participants were categorised into two groups: age 70-79 years (n=102) and ≥80 years (n=146). Melaena (n=226, 91%, p=0.0001) was the commonest indication for emergency OGD in both groups, with the majority of patients presenting with a Glasgow-Blatchford score of ≥1 (n=200, 80.6%, p=0.2). Endoscopy findings were normal in 26.4% (n=27) of those 70-79 years and 32% (n=47) of those ≥80 years (p=0.01). Duodenal ulcer, oesophagitis and gastric ulcer were the commonest abnormal findings (n=50, 20%; n=29, 11.7%; and n=28, 11.3%, respectively). Of the participants, 93.8% (n=212) had no immediate complications. Bleeding and hypotension occurred in 2.7% (n=6) and 2% (n=5) of patients, respectively. At 90 days post-procedure, 83.3% (n=85) of those 70-79 years and 67.8% (n=99) of those ≥80 years had survived (p=0.180). CONCLUSIONS: We conclude that OGD is largely a safe procedure in older adults with acute UGIB; however, the high proportion of OGDs with normal findings reinforces the importance of careful selection of patients.

Vitamin D Supplementation in Adults with Vitamin D Deficiency and Its Effect on Metabolic Syndrome - A Randomized Controlled Study.

BACKGROUND: Inverse relationship between metabolic syndrome (MetS) and 25-hydroxyvitamin D (25(OH) D) levels is controversial. Hypovitaminosis-D has long been suspected as a risk factor for glucose intolerance. AIM: A randomized double blind placebo controlled study to evaluate effects of vitamin D supplementation on insulin resistance in subjects with hypovitaminosis-D and MetS. MATERIALS AND METHODS: Subjects were randomized to receive either oral 25(OH) D3 supplement (60000 (IU) per week for 8 weeks followed by 60,000 IU monthly for 4 months) or a placebo for six months. The parameters measured were blood pressure, vitamin D, fasting blood sugar (FBS), insulin, homeostasis model assessment (HOMA), quantitative insulin sensitivity check index (QUICKI), body mass index (BMI), and waist circumference (WC). RESULTS: There were no significant changes in parameters of vitamin-D group compared to placebo group except serum vitamin-D was significantly increased in vitamin-D group (p < 0.0001). In vitamin-D group, mean WC at baseline was 95.9 ± 6.66, which significantly changed to 94.6 ± 7.47 (p = 0.001). Mean BMI at baseline was 29.1 ± 4.06 which significantly changed to 28.5 ± 4.16 (p = 0.001). The mean vitamin-D concentration at baseline was 15.4 ± 9.03 which significantly (p < .0001) increased to 26.1 ± 11.8. In placebo group mean insulin levels was 10.7 ± 4.81IU / L which increased significantly (p = 0.03) to 15.4 ± 14.0. Mean QUICKI at baseline was 0.34 ± 0.03 which decreased significantly (p = 0.02) to 0.32 ± 0.03. CONCLUSION: In this study the relationship between vitamin D supplementation and MetS or IR was not established. Whether achieving vitamin D sufficiency in large population-based trials with a longer duration would produce more favorable results needs to be assessed.

Comparison of human mesenchymal stem cells derived from adipose and cord tissue.

BACKGROUND AIMS: Stem cell therapies can provide an alternative approach for repair and regeneration of tissues and organs. Mesenchymal stem cells (MSCs) are promising candidates for cell-based therapies. Although bone marrow-derived MSCs have multi-lineage differentiation potential, bone marrow is not an optimal source because of the isolation process and low yield. The goal of this study was to investigate comparatively for the first time the in vitro regenerative potential of human MSCs from two other sources: umbilical cord tissue and adipose tissue. METHODS: Cells from each tissue were isolated with 100% efficiency and characterized by fluorescence activated cell sorting (FACS) analysis for CD3, CD14, CD19, CD34, CD44, CD45, CD73, CD90 and CD105. Growth characteristics were investigated by population doublings, saturation density and plating efficiency. MSCs derived from both types of tissues were assessed for differentiation potential qualitatively and quantitatively. RESULTS: FACS analysis showed no differences in expression of CD3, CD14, CD19, CD34, CD44, CD45, CD73, CD90 and CD105 between cord tissue MSCs (CT-MSCs) and adipose tissue MSCs (AT-MSCs). CT-MSCs showed more proliferative potential than AT-MSCs. When cultured in low numbers to determine colony-forming units (CFUs), CT-MSCs showed less CFUs than AT-MSCs. Cells from both sources efficiently differentiated into adipose, bone, cartilage and neuronal structures as determined with histochemistry, immunofluorescence and real-time reverse transcriptase polymerase chain reaction. CONCLUSIONS: MSCs can easily be obtained from umbilical cord and adipose tissues, and it appears that both tissues are suitable sources of stem cells for potential use in regenerative medicine.

Bone marrow derived mesenchymal stem cells from aged mice have reduced wound healing, angiogenesis, proliferation and anti-apoptosis capabilities.

Decline in the function of stem cells with age, such as other cells of the body, results in an imbalance between loss and renewal. Increasing age of the donor thus diminishes the effectiveness of MSCs (mesenchymal stem cells) transplantation in age-related diseases. The clinical use of stem cell therapies needs autologous stem cell transplantation; it is essential therefore to study the repair ability and survivability of cells before transplantation. Bone marrow derived MSCs possess multi-lineage differentiation potential, but aging adversely affects their therapeutic efficacy. MSCs from young (2-3 months) and aged (23-24 months) GFP (green fluorescent protein)-expressing C57BL/6 mice were isolated and their regenerative potential was assessed in vitro. Real-time RT-PCR (reverse transcriptase-PCR) showed significantly higher expression of Sirt1 in MSCs isolated from young than older animals. Down-regulation of VEGF (vascular endothelial growth factor), SDF-1 (stromal-cell-derived factor 1), AKT (also known as protein kinase B) and up-regulation of p53, p21, Bax and p16 occurred in aged cells. Tube formation, wound healing and proliferative abilities of the young MSCs were better than the aged MSCs. The results suggest that age-related increased expression of apoptotic and senescent genes, with concomitant decrease in Sirt1 gene expression, inhibits to some extent stem cell functioning.