Published models that predict hospital readmission: a critical appraisal.

INTRODUCTION: The number of readmission risk prediction models available has increased rapidly, and these models are used extensively for health decision-making. Unfortunately, readmission models can be subject to flaws in their development and validation, as well as limitations in their clinical usefulness. OBJECTIVE: To critically appraise readmission models in the published literature using Delphi-based recommendations for their development and validation. METHODS: We used the modified Delphi process to create Critical Appraisal of Models that Predict Readmission (CAMPR), which lists expert recommendations focused on development and validation of readmission models. Guided by CAMPR, two researchers independently appraised published readmission models in two recent systematic reviews and concurrently extracted data to generate reference lists of eligibility criteria and risk factors. RESULTS: We found that published models (n=81) followed 6.8 recommendations (45%) on average. Many models had weaknesses in their development, including failure to internally validate (12%), failure to account for readmission at other institutions (93%), failure to account for missing data (68%), failure to discuss data preprocessing (67%) and failure to state the model's eligibility criteria (33%). CONCLUSIONS: The high prevalence of weaknesses in model development identified in the published literature is concerning, as these weaknesses are known to compromise predictive validity. CAMPR may support researchers, clinicians and administrators to identify and prevent future weaknesses in model development.

Physician Perspectives on Training for an EHR Implementation.

In 2017, a US academic medical center switched to a commercial EHR system using the "specialist training the specialist" model, which combines peer-to-peer training, classroom based training, and web-based training. We conducted semi-structured interviews with physicians at multiple training levels to investigate the impact of this EHR switch and to explore the training experience of physicians and their perception of the training quality pre and post Go-Live. Our team used Grounded Theory methodology to classify the interview information. Themes that emerged from the interviews included stress and anxiety, the desire for more realistic training environments tailored to specialty needs, and concerns about the duration of time between training and implementation. In future implementations, we recommend more data-rich test patients and the demonstration of real-world workflows during training.

Xenopus mutant reveals necessity of rax for specifying the eye field which otherwise forms tissue with telencephalic and diencephalic character.

The retinal anterior homeobox (rax) gene encodes a transcription factor necessary for vertebrate eye development. rax transcription is initiated at the end of gastrulation in Xenopus, and is a key part of the regulatory network specifying anterior neural plate and retina. We describe here a Xenopus tropicalis rax mutant, the first mutant analyzed in detail from a reverse genetic screen. As in other vertebrates, this nonsense mutation results in eyeless animals, and is lethal peri-metamorphosis. Tissue normally fated to form retina in these mutants instead forms tissue with characteristics of diencephalon and telencephalon. This implies that a key role of rax, in addition to defining the eye field, is in preventing alternative forebrain identities. Our data highlight that brain and retina regions are not determined by the mid-gastrula stage but are by the neural plate stage. An RNA-Seq analysis and in situ hybridization assays for early gene expression in the mutant revealed that several key eye field transcription factors (e.g. pax6, lhx2 and six6) are not dependent on rax activity through neurulation. However, these analyses identified other genes either up- or down-regulated in mutant presumptive retinal tissue. Two neural patterning genes of particular interest that appear up-regulated in the rax mutant RNA-seq analysis are hesx1 and fezf2. These genes were not previously known to be regulated by rax. The normal function of rax is to partially repress their expression by an indirect mechanism in the presumptive retina region in wildtype embryos, thus accounting for the apparent up-regulation in the rax mutant. Knock-down experiments using antisense morpholino oligonucleotides directed against hesx1 and fezf2 show that failure to repress these two genes contributes to transformation of presumptive retinal tissue into non-retinal forebrain identities in the rax mutant.