Big Data, Predictive Analytics, and Quality Improvement in Kidney Transplantation: A Proof of Concept.

We sought proof of concept of a Big Data Solution incorporating longitudinal structured and unstructured patient-level data from electronic health records (EHR) to predict graft loss (GL) and mortality. For a quality improvement initiative, GL and mortality prediction models were constructed using baseline and follow-up data (0-90 days posttransplant; structured and unstructured for 1-year models; data up to 1 year for 3-year models) on adult solitary kidney transplant recipients transplanted during 2007-2015 as follows: Model 1: United Network for Organ Sharing (UNOS) data; Model 2: UNOS & Transplant Database (Tx Database) data; Model 3: UNOS, Tx Database & EHR comorbidity data; and Model 4: UNOS, Tx Database, EHR data, Posttransplant trajectory data, and unstructured data. A 10% 3-year GL rate was observed among 891 patients (2007-2015). Layering of data sources improved model performance; Model 1: area under the curve (AUC), 0.66; (95% confidence interval [CI]: 0.60, 0.72); Model 2: AUC, 0.68; (95% CI: 0.61-0.74); Model 3: AUC, 0.72; (95% CI: 0.66-077); Model 4: AUC, 0.84, (95 % CI: 0.79-0.89). One-year GL (AUC, 0.87; Model 4) and 3-year mortality (AUC, 0.84; Model 4) models performed similarly. A Big Data approach significantly adds efficacy to GL and mortality prediction models and is EHR deployable to optimize outcomes.

Dimensions underlying legislator support for tobacco control policies.

OBJECTIVE: To propose and test a new classification system for characterising legislator support for various tobacco control policies. DESIGN: Cross sectional study. SUBJECTS: Federal and provincial legislators in Canada serving as of October 1996 who participated in the Canadian Legislator Study (n = 553; response rate 54%). MAIN OUTCOME MEASURES: A three factor model (Voters, Tobacco industry, Other interest groups) that assigns nine tobacco control policies according to legislators' hypothesised perceptions of which group is more directly affected by these policies. RESULTS: Based on confirmatory factor analysis, the proposed model had an acceptable fit and showed construct validity. Multivariate analysis indicated that three of the predictors (believing that the government has a role in health promotion, being a non-smoker, and knowledge that there are more tobacco than alcohol caused deaths) were associated with all three factor scales. Several variables were associated with two of the three scales. Some were unique to each scale. CONCLUSIONS: Based on our analyses, legislator support for tobacco control policies can be grouped according to our a priori factor model. The information gained from this work can help advocates understand how legislators think about different types of tobacco control policies. This could lead to the development of more effective advocacy strategies.

Hypo-osmotic stress induces calcium-dependent actin reorganization in articular chondrocytes.

OBJECTIVE: The aim of this study was to investigate the effects of hypo-osmotically induced calcium (Ca(2+)) transients on the organization of the actin cytoskeleton in articular chondrocytes. The secondary hypothesis tested was that actin restructuring following hypo-osmotic stress is mediated by gelsolin. METHODS: Isolated porcine chondrocytes were exposed to hypo-osmotic stress, and [Ca(2+)](i)was monitored using laser scanning microscopy. Calcium transients were monitored using fluorescent ratiometric imaging. The intracellular distribution of actin was examined using fluorescent immunohistochemistry and transient transfection with the pEGFP-actin plasmid. The intracellular distribution of gelsolin was investigated using fluorescent immunohistochemistry. RESULTS: Osmotic stress induced transient increases in [Ca(2+)](i)caused reorganization of intracellular actin through a mechanism that required Ca(2+)in the extracellular media. Fluorescence microscopy revealed that gelsolin was colocalized with F-actin immediately following hypo-osmotic stress but dissociated over time. CONCLUSION: These results indicate that hypo-osmotic stress induces a gelsolin-mediated reorganization of actin through a transient increase in [Ca(2+)](i).

What happens when capitated behavioral health comes to town? The transition from the Fort Bragg demonstration to a capitated managed behavioral health contract.

Capitated managed care contracts for behavioral health services are becoming more prevalent across the country in both public and private sectors. This study followed the transition from a demonstration project for child mental health services to a capitated managed behavioral health care contract with a for-profit managed care company. The focus of the study was on the impact--at both the service system and the individual consumer level--pertaining to the start-up and maintenance of a capitated managed behavioral health program. A case study using multiple methods and multiple sources of information incorporated a program fidelity framework that examined micro to macro levels of program implementation. The findings of this study include the following: access to services decreased, the lengths of stay and average daily census in the more intensive levels of treatment declined, difficult-to-treat children were shifted to the public sector, and ratings of service system performance and coordination fell.

Factors influencing implementation of the legislated smoking ban on school property in Ontario.

BACKGROUND: Implementation of legislation in Ontario, Canada, that banned smoking on school property gave rise to perceptions of problems in some schools. A telephone survey was conducted to assess these problems. This analysis identifies risk or protective factors in the school environment associated with administrators' reports of problems. METHODS: Survey data were obtained from key informants in 213 high schools. Multiple logistic regression was used to identify school-related characteristics associated with: (1) major problems in implementing the ban and (2) recommendations that schools return to designated smoking areas. RESULTS: A protective factor against both outcomes was having a school no-smoking policy prior to the ban. Also protective against major problems was a perceived decrease in student smoking during the school day. The identification of safety risks to students who leave school property to smoke was a strong risk factor for both outcomes. Beliefs that the ban was not effective and opposition to it from teachers/staff were associated with desires for its repeal. CONCLUSIONS: In implementing legislated school smoking bans, attention should be given to informing teachers and gaining their support. Strategies for dealing with potential safety risks to students who leave school property to smoke should also be devised.

The Ontario ban on smoking on school property: issues and challenges in enforcement.

We document implementation and enforcement activities undertaken by high schools and health units with regard to the 1994 ban on smoking on school property in Ontario. Telephone interviews were conducted in the early summer of 1996 with 213 high school administrators and 38 tobacco enforcement personnel in health units. While some schools are unclear about enforcement responsibility, most are making efforts to enforce the ban, including warning and suspending students. Some school administrators (30%) suggest the reinstitution of designated smoking areas on school property. One quarter of health units had not made enforcement visits in schools in the 1995-96 school year and a minority accounted for most of the warnings and tickets issued to students. While most tobacco enforcement officers perceive that schools support the ban, they report some problems in obtaining cooperation in enforcement. However, only 11% suggest returning to designated smoking areas on school property.

The Ontario ban on smoking on school property: perceived impact on smoking.

We evaluated the impact of the November 1994 ban on smoking on school property in Ontario. Telephone interviews were conducted at the end of the 1995-96 school year with 213 high school administrators. Almost all high schools (96%) prohibit smoking on school property. Although some smoking still occurs on school property, the location of smoking by students has changed, giving rise to perceptions of both benefits and risks, as well as varying complaints from parents, students, neighbours, and nearby businesses. Most of the problems arising from the ban are viewed as minor. Local conditions, particularly the geographic environment of the school, appear to be important determinants of complaints and problems. While sizeable minorities of school administrators felt the ban had favourable effects, the majority perceived little effect on either smoking behaviour or attitudes towards smoking.

Short report. How provincial and territorial legislators view tobacco and tobacco control: findings from a Canadian study.

We report on legislators' attitudes and experiences regarding tobacco and tobacco control using findings from a 1996/97 telephone survey of provincial and territorial legislators in Canada. Across all jurisdictions, legislators showed support for a number of tobacco control policies and for a major government role in implementing programs and policies to discourage youth from smoking. Further, substantial numbers of legislators indicated they did not have enough tobacco-related contact with medical and non-profit health organizations. These findings can guide the activities of health agencies, researchers and advocates in support of effective strategies to reduce the public health impact of tobacco use in Canada.

Evaluation of the human becoming theory in practice in an acute care psychiatric setting.

Using a descriptive evaluation research method, this study evaluated Parse's theory of human becoming in practice in the psychiatric setting. A pre- mid- post-implementation design served to generate qualitative data from nurses, patients, unit nurse managers, hospital nurse supervisors, and nurse documentation that illuminated changes in the quality of nursing care on three diverse pilot units. Major themes of change supported by all data sources were shifting views of human beings, altered ways of listening, altered foci of nurse-person discussions, and personal transformations. Identified themes surfaced strikingly different qualities of change for each pilot unit. Recommendations related to the successful implementation of Parse theory-based practice are presented.

Self-care myth reconsidered.

Self-care ideology and theory can do much to shape the development of health policy and the organization and delivery of health care. From a critical social perspective, self-care theory can be seen as an attempt to sustain the illusion of individual choice in contemporary health care delivery. Understanding the dominance of individual responsibility for health that permeates the essence of self-care theory provides a way of understanding a vision of thought and practice that currently exists within the discipline of nursing. This article attempts to elucidate the social and political construction of nursing knowledge with a view to self-care.