Pediatric Population Management Classification for Children with Medical Complexity.

Improving the overall care of children with medical complexity (CMC) is often beset by challenges in proactively identifying the population most in need of clinical management and quality improvement. The objective of the current study was to create a system to better capture longitudinal risk for sustained and elevated utilization across time using real-time electronic health record (EHR) data. A new Pediatric Population Management Classification (PPMC), drawn from visit diagnoses and continuity problem lists within the EHR of a tristate health system, was compared with an existing complex chronic conditions (CCC) system for agreement (with weighted κ) on identifying CCMC, as well as persistence of elevated charges and utilization from 2016 to 2019. Agreement of assignment PPMC was lower among primary care provider (PCP) populations than among other children traversing the health system for specialty or hospital services only (weighted κ 62% for PCP vs. 82% for non-PCP). The PPMC classification scheme, displaying greater precision in identifying CMC with persistently high utilization and charges for those who receive primary care within a large integrated health network, may offer a more pragmatic approach to selecting children with CMC for longitudinal care management.

Acceptability of Dyad Care Management After Preterm Birth: A Qualitative Study.

OBJECTIVES: Care management programs for medically complex infants interact with parents after complicated pregnancies, when gaps in maternal health care are well documented. These care managers may have the relationships and skills to promote postpartum and interconception health and health care access. It is unknown whether expanding these care management models to address maternal needs would be acceptable. METHODS: We conducted qualitative interviews with women with a history of preterm birth and clinicians. For women with a history of preterm birth, additional inclusion criteria were Medicaid-insured infant in one health system and English proficiency. We purposively oversampled women whose infants received care management. Clinicians worked in two geographically adjacent health systems. Interviews explored priorities after preterm birth and perceived acceptability of mother-infant dyad care management. Interviews were audio recorded, transcribed, and coded following an integrated approach in which we applied a priori codes and captured emergent themes. RESULTS: We interviewed 33 women (10/2018-7/2021) and 24 clinicians (3/2021-8/2021). Women were predominantly non-Hispanic Black, and 15 had infants receiving care management. Clinicians included physicians, nurses, and social workers from Pediatrics, Obstetrics, and Family Medicine. Subgroups converged thematically, finding care management acceptable. Tailoring programs to address stress and sleep, emphasizing care managers with strong interpersonal skills and shared experiences with care management users, and program flexibility would contribute to acceptability. CONCLUSIONS FOR PRACTICE: Dyad care management after preterm birth is acceptable to potential program end-users and clinicians. Dyad health promotion may contribute to improved birth outcomes, infant, and parent health.

Rapid prototyping of multi-compartment models for urea kinetics in hemodialysis: a System Dynamics approach.

Models of urea kinetics facilitate a mechanistic understanding of urea transfer and provide a tool for optimizing dialysis efficacy. Dual-compartment models have largely replaced single-compartment models as they are able to accommodate the urea rebound on the cessation of dialysis. Modeling the kinetics of urea and other molecular species is frequently regarded as a rarefied academic exercise with little relevance at the bedside. We demonstrate the utility of System Dynamics in creating multi-compartment models of urea kinetics by developing a dual-compartment model that is efficient, intuitive, and widely accessible to a range of practitioners. Notwithstanding its simplicity, we show that the System Dynamics model compares favorably with the performance of a more complex volume-average model in terms of calibration to clinical data and parameter estimation. Its intuitive nature, ease of development/modification, and excellent performance with real-world data may make System Dynamics an invaluable tool in widening the accessibility of hemodialysis modeling.

Orbital and In-Situ Investigation of Periodic Bedrock Ridges in Glen Torridon, Gale Crater, Mars.

Gale crater, the field site for NASA's Mars Science Laboratory Curiosity rover, contains a diverse and extensive record of aeolian deposition and erosion. This study focuses on a series of regularly spaced, curvilinear, and sometimes branching bedrock ridges that occur within the Glen Torridon region on the lower northwest flank of Aeolis Mons, the central mound within Gale crater. During Curiosity's exploration of Glen Torridon between sols ∼2300-3080, the rover drove through this field of ridges, providing the opportunity for in situ observation of these features. This study uses orbiter and rover data to characterize ridge morphology, spatial distribution, compositional and material properties, and association with other aeolian features in the area. Based on these observations, we find that the Glen Torridon ridges are consistent with an origin as wind-eroded bedrock ridges, carved during the exhumation of Mount Sharp. Erosional features like the Glen Torridon ridges observed elsewhere on Mars, termed periodic bedrock ridges (PBRs), have been interpreted to form transverse to the dominant wind direction. The size and morphology of the Glen Torridon PBRs are consistent with transverse formative winds, but the orientation of nearby aeolian bedforms and bedrock erosional features raise the possibility of PBR formation by a net northeasterly wind regime. Although several formation models for the Glen Torridon PBRs are still under consideration, and questions persist about the nature of PBR-forming paleowinds, the presence of PBRs at this site provides important constraints on the depositional and erosional history of Gale crater.

The Effectiveness Of Government Masking Mandates On COVID-19 County-Level Case Incidence Across The United States, 2020.

Evidence for the effectiveness of masking on SARS-CoV-2 transmission at the individual level has accumulated, but the additional benefit of community-level mandates is less certain. In this observational study of matched cohorts from 394 US counties between March 21 and October 20, 2020, we estimated the association between county-level public masking mandates and daily COVID-19 case incidence. On average, the daily case incidence per 100,000 people in masked counties compared with unmasked counties declined by 23 percent at four weeks, 33 percent at six weeks, and 16 percent across six weeks postintervention. The beneficial effect varied across regions of different population densities and political leanings. The most concentrated effects of masking mandates were seen in urban counties; the benefit of the mandates was potentially stronger within Republican-leaning counties. Although benefits were not equally distributed in all regions, masking mandates conferred benefit in reducing community case incidence during an early period of the COVID-19 pandemic.

Evaluating the Clinical Realism of Synthetic Chest X-Rays Generated Using Progressively Growing GANs.

Chest X-rays are a vital diagnostic tool in the workup of many patients. Similar to most medical imaging modalities, they are profoundly multi-modal and are capable of visualising a variety of combinations of conditions. There is an ever pressing need for greater quantities of labelled images to drive forward the development of diagnostic tools; however, this is in direct opposition to concerns regarding patient confidentiality which constrains access through permission requests and ethics approvals. Previous work has sought to address these concerns by creating class-specific generative adversarial networks (GANs) that synthesise images to augment training data. These approaches cannot be scaled as they introduce computational trade offs between model size and class number which places fixed limits on the quality that such generates can achieve. We address this concern by introducing latent class optimisation which enables efficient, multi-modal sampling from a GAN and with which we synthesise a large archive of labelled generates. We apply a Progressive Growing GAN (PGGAN) to the task of unsupervised X-ray synthesis and have radiologists evaluate the clinical realism of the resultant samples. We provide an in depth review of the properties of varying pathologies seen on generates as well as an overview of the extent of disease diversity captured by the model. We validate the application of the Fréchet Inception Distance (FID) to measure the quality of X-ray generates and find that they are similar to other high-resolution tasks. We quantify X-ray clinical realism by asking radiologists to distinguish between real and fake scans and find that generates are more likely to be classed as real than by chance, but there is still progress required to achieve true realism. We confirm these findings by evaluating synthetic classification model performance on real scans. We conclude by discussing the limitations of PGGAN generates and how to achieve controllable, realistic generates going forward. We release our source code, model weights, and an archive of labelled generates.

Facilitating Understanding, Modeling and Simulation of Infectious Disease Epidemics in the Age of COVID-19.

Interest in the mathematical modeling of infectious diseases has increased due to the COVID-19 pandemic. However, many medical students do not have the required background in coding or mathematics to engage optimally in this approach. System dynamics is a methodology for implementing mathematical models as easy-to-understand stock-flow diagrams. Remarkably, creating stock-flow diagrams is the same process as creating the equivalent differential equations. Yet, its visual nature makes the process simple and intuitive. We demonstrate the simplicity of system dynamics by applying it to epidemic models including a model of COVID-19 mutation. We then discuss the ease with which far more complex models can be produced by implementing a model comprising eight differential equations of a Chikungunya epidemic from the literature. Finally, we discuss the learning environment in which the teaching of the epidemic modeling occurs. We advocate the widespread use of system dynamics to empower those who are engaged in infectious disease epidemiology, regardless of their mathematical background.

Gaze tracking dataset for comparison of smooth and saccadic eye tracking.

Pupil tracking data are collected through the use of an infrared camera, and a head-mounted system [1]. The head-mounted system detects the relative pupil position and adjusts the mouse cursor position accordingly. The data are available for comparison of eye tracking with saccadic movements (with the head fixed in space) versus those from smooth movements (with the head moving in space). The analysis comprises two experiments for both types of eye tracking, which are performed with ten trials each for two participants. In the first experiment, the participant attempts to place the cursor into a target boundary of varying sizes. In the second experiment, the participant attempts to move the cursor to a target location within the shortest time.

An Asthma Population Health Improvement Initiative for Children With Frequent Hospitalizations.

OBJECTIVES: A relatively small proportion of children with asthma account for an outsized proportion of health care use. Our goal was to use quality improvement methodology to reduce repeat emergency department (ED) and inpatient care for patients with frequent asthma-related hospitalization. METHODS: Children ages 2 to 17 with ≥3 asthma-related hospitalizations in the previous year who received primary care at 3 in-network clinics were eligible to receive a bundle of 4 services including (1) a high-risk asthma screener and tailored education, (2) referral to a clinic-based asthma community health worker program, (3) facilitated discharge medication filling, and (4) expedited follow-up with an allergy or pulmonology specialist. Statistical process control charts were used to estimate the impact of the intervention on monthly 30-day revisits to the ED or hospital. We then conducted a difference-in-differences analysis to compare changes between those receiving the intervention and a contemporaneous comparison group. RESULTS: From May 1, 2016, to April 30, 2017, we enrolled 79 patients in the intervention, and 128 patients constituted the control group. Among the eligible population, the average monthly proportion of children experiencing a revisit to the ED and hospital within 30 days declined by 38%, from a historical baseline of 24% to 15%. Difference-in-differences analysis demonstrated 11.0 fewer 30-day revisits per 100 patients per month among intervention recipients relative to controls (95% confidence interval: -20.2 to -1.8; P = .02). CONCLUSIONS: A multidisciplinary quality improvement intervention reduced health care use in a high-risk asthma population, which was confirmed by using quasi-experimental methodology. In this study, we provide a framework to analyze broader interventions targeted to frequently hospitalized populations.

Association of State Medicaid Expansion With Hospital Community Benefit Spending.

Importance: Medicaid expansion was widely expected to alleviate the financial stresses faced by hospitals by providing additional revenue in the form of Medicaid reimbursements from patients previously receiving uncompensated care. Among nonprofit hospitals, which receive tax-exempt status in part because of their provision of uncompensated care, Medicaid expansion could have released hospital funds toward other community benefit activities. Objective: To examine changes in nonprofit hospital spending on community benefit activities after Medicaid expansion. Design, Setting, and Participants: This cohort study used difference-in-differences analysis of 1666 US nonprofit hospitals that filed Internal Revenue Service Form 990 Schedule H detailing their community benefit expenditures between 2011 and 2017. The analysis was conducted from February to September 2019. Exposures: State Medicaid expansion between 2011 and 2017. Main Outcomes and Measures: Percentage of hospital operating expenditures attributable to charity care and subsidized care, bad debt (ie, unreimbursed spending for care of patients who did not apply for charity care), unreimbursed Medicaid spending, noncare direct community spending, and total community benefit spending. Results: Of 1478 hospitals in the sample in 2011, nearly half (653 [44.2%]) were small hospitals with fewer than 100 beds, and nearly 70% of hospitals (1023 [69.2%]) were in urban areas. Among the 1666 nonprofit hospitals, Medicaid expansion was associated with a decrease in spending on charity care and subsidized care (-0.68 [95% CI, -0.99 to -0.37] percentage points from a baseline mean [SD] of 3.6% [4.0%] of total hospital expenditures; P < .001) and in bad debt (-0.17 [95% CI, -0.32 to -0.01] percentage points). There was an increase in unreimbursed spending attributable to caring for Medicaid patients (0.85 [95% CI, 0.60 to 1.10] percentage points; P = .04), which canceled out uncompensated care savings from the expansion. Noncare direct community expenditures decreased overall (-0.24 [95% CI, -0.48 to 0.00] percentage points; P = .049). Direct community expenditures remained more stable in small hospitals (-0.07 [95% CI, -0.20 to 0.05] percentage points; P =.26) compared with large hospitals (-0.37 [95% CI, -0.86 to 0.12] percentage points; P = .14) and in nonurban hospitals (0.02 [95% CI, -0.09 to 0.14] percentage points; P = .70) compared with urban hospitals (-0.36 [95% CI, -0.73 to 0.01] percentage points; P = .06). Conclusions and Relevance: In this study, Medicaid expansion was associated with a decrease in nonprofit hospitals' burden of providing uncompensated care, but this financial relief was not redirected toward spending on other community benefits.

Toward Respiratory Support of Critically Ill COVID-19 Patients Using Repurposed Kidney Hollow Fiber Membrane Dialysers to Oxygenate the Blood.

The COVID-19 pandemic has highlighted resource constraints in respiratory support. The oxygen transfer characteristics of a specific hollow fiber membrane dialyser was investigated with a view to repurposing the device as a low-cost, readily available blood oxygenator. Oxygen transfer in a low-flux hollow fiber dialyser with a polysulfone membrane was studied by passing first water and then blood through the dialyser in countercurrent to high-purity oxygen. Oxygen transfer rates of about 15% of the nominal 250 ml (STP)/min of a typical adult oxygen consumption rate were achieved for blood flow rates of 500 ml/min. Using two such dialysis devices in parallel could provide up to 30% of the nominal oxygen consumption. Specific hollow fiber dialysis devices operating with suitable pumps in a veno-venous access configuration could provide a cost-effective and readily available supplementation of respiratory support in the face of severe resource constraints.

Association of a Targeted Population Health Management Intervention with Hospital Admissions and Bed-Days for Medicaid-Enrolled Children.

Importance: As the proportion of children with Medicaid coverage increases, many pediatric health systems are searching for effective strategies to improve management of this high-risk population and reduce the need for inpatient resources. Objective: To estimate the association of a targeted population health management intervention for children eligible for Medicaid with changes in monthly hospital admissions and bed-days. Design, Setting, and Participants: This quality improvement study, using difference-in-differences analysis, deployed integrated team interventions in an academic pediatric health system with 31 in-network primary care practices among children enrolled in Medicaid who received care at the health system's hospital and primary care practices. Data were collected from January 2014 to June 2017. Data analysis took place from January 2018 to June 2019. Exposures: Targeted deployment of integrated team interventions, each including electronic medical record registry development and reporting alongside a common longitudinal quality improvement framework to distribute workflow among interdisciplinary clinicians and community health workers. Main Outcomes and Measures: Trends in monthly inpatient admissions and bed-days (per 1000 beneficiaries) during the preimplementation period (ie, January 1, 2014, to June 30, 2015) compared with the postimplementation period (ie, July 1, 2015, to June 30, 2017). Results: Of 25 460 children admitted to the hospital's health system during the study period, 8418 (33.1%) (3869 [46.0%] girls; 3308 [39.3%] aged ≤1 year; 5694 [67.6%] black) were from in-network practices, and 17 042 (67.9%) (7779 [45.7%] girls; 6031 [35.4%] aged ≤1 year; 7167 [41.2%] black) were from out-of-network practices. Compared with out-of-network patients, in-network patients experienced a decrease of 0.39 (95% CI, 0.10-0.68) monthly admissions per 1000 beneficiaries (P = .009) and 2.20 (95% CI, 0.90-3.49) monthly bed-days per 1000 beneficiaries (P = .001). Accounting for disproportionate growth in the number of children with medical complexity who were in-network to the health system, this group experienced a monthly decrease in admissions of 0.54 (95% CI, 0.13-0.95) per 1000 beneficiaries (P = .01) and in bed-days of 3.25 (95% CI, 1.46-5.04) per 1000 beneficiaries (P = .001) compared with out-of-network patients. Annualized, these differences could translate to a reduction of 3600 bed-days for a population of 93 000 children eligible for Medicaid. Conclusions and Relevance: In this quality improvement study, a population health management approach providing targeted integrated care team interventions for children with medical and social complexity being cared for in a primary care network was associated with a reduction in service utilization compared with an out-of-network comparison group. Standardizing the work of care teams with quality improvement methods and integrated information technology tools may provide a scalable strategy for health systems to mitigate risk from a growing population of children who are eligible for Medicaid.

Data from wearable wireless instrumentation device taken during simulated CPR with and without intentional error toward a quality feedback device.

Data of Cardiopulmonary Resuscitation performed on a mannequin was collected via wearable instrumentation (using the MYO device). The data were collected for both "good" CPR and for performance of CPR with common errors introduced intentionally for this study. The data are labelled according to the error, and contain a variety of derived measurements. Data collected were used toward "Development of a novel cardiopulmonary resuscitation measurement tool using real-time feedback from wearable wireless instrumentation' (Ward et al., 2019) in which full context is available'. The data are available at Mendeley Data, doi:10.17632/pvjghfjmy4.1 (Ward et al., 2019).

Families With TRICARE Report Lower Health Care Quality And Access Compared To Other Insured And Uninsured Families.

Children in military families, who receive health insurance through the TRICARE program, face barriers to care such as frequent relocations, unique behavioral health needs, increased complex health care needs, and lack of accessible specialty care. How TRICARE-insured families perceive health care access and quality for their children compared to their civilian peers' perceptions remains unknown. Using data from the Medical Expenditure Panel Survey, we found that TRICARE-insured families were less likely to report accessible or responsive care compared to civilian peers, whether commercially or publicly insured or uninsured. Military families whose children had complex health or behavioral health care needs reported worse health care access and quality than similar nonmilitary families. Addressing these gaps may require military leaders to examine barriers to achieving acceptable health care access across military treatment facilities and off-base nonmilitary specialty providers, particularly for children with complex health or behavioral health needs.