Use of Stratified Cascade Learning to predict hospitalization risk with only socioeconomic factors.

BACKGROUND AND OBJECTIVE: Published models predicting health related outcomes rely on clinical, claims and social determinants of health (SDH) data. Addressing the challenge of predicting with only SDH we developed a novel framework termed Stratified Cascade Learning (SCL) and used it for predicting the risk of hospitalization (ROH). MATERIALS AND METHODS: The variable set includes 27 SDH and "age" and "sex" for a cohort of diabetic patients. The SCL model uses three sub-models: SM1 (whole training set) stratifies training set into "predictable" and "unpredictable" subsets, SM2 (built on whole training set) classifies test set patients into "predictable" and "unpredictable", and SM3 (built on only the "predictable" subset) predicts the ROH for the patients classified as "predictable" by SM2. RESULTS: The SCL model does not improve either the AUC or the NPV of the basic classifier, but materially improves accuracy and specificity measures at the expense of lowering sensitivity for the "predictable" subset. Optimization of the risk thresholds of the sub-models does not noticeably change the AUC and NPV but further improves the accuracy and specificity at the expense of further lowering sensitivity. CONCLUSION: Since the SLC model yields low sensitivity it fails to predict high risk patients. But it yields high specificity that can be useful when the objective is to eliminate low-risk patients as candidates for further testing or treatment. The use of the SCL is not limited to healthcare, it can be applied to any predictive modeling problem when reliable predictions can only be made for a fraction of incoming data.

Endoscopic button gastrostomy: Comparing a sutured endoscopic approach to the current techniques.

PURPOSE: Button gastrostomy is the preferred feeding device in children and can be placed open or laparoscopically (LBG). Alternatively, a percutaneous endoscopic gastrostomy (PEG) can be placed initially and exchanged for a button. Endoscopic-assisted button gastrostomy (EBG) combines both techniques, using only one incision and suturing the stomach to the abdominal wall. The long-term outcomes and potential costs for EBG were compared to other techniques. METHODS: Children undergoing EBG, LBG, and PEG (2010-2013) were compared. Patient demographics, procedure duration/complications, and clinic and emergency room (ER) visits for an eight-week follow-up period were compared. RESULTS: Patient demographics were similar (32 patients/group). Mean procedure time (min) for EBG was 38 ± 9, compared to 58 ± 20 for LBG and 31 ± 10 for PEG (p<0.0001). The most common complications were granulation tissue and infection with a trend toward fewer infections in EBG group. Average number of ER visits was similar, but PEG group had fewer clinic visits. 97% of PEG patients had subsequent visits for exchange to button gastrostomy. CONCLUSIONS: EBG is safe and comparable to LBG and PEG in terms of complications. It has a shorter procedure time than LBG and does not require laparoscopy, device exchange, or subsequent fluoroscopic confirmation, potentially reducing costs.

Rising incidence and aggressive nature of cutaneous malignancies after transplantation: An update on epidemiology, risk factors, management and surveillance.

Although immunosuppression has been a key component to the success of solid-organ transplantation, the morbidity associated with long-term immunosuppression remains a substantial burden, particularly as recipients of transplants live longer. Indeed, malignancy is one of the most common reasons for mortality following transplantation and the most common of these cancers are cutaneous in origin. Recently, the incidence of these malignancies has been on the rise, partly due to the fact that recipients of these transplants are living longer as a result of improvements in surgical technique, immunosuppression and perioperative management. Although there have been initiatives to increase awareness of cutaneous malignancies following transplantation, such programs are not standardized and there continues to be gaps in skin cancer education and post-operative surveillance. This review provides an update on the epidemiology, risk factors, clinical management, prevention and surveillance of cutaneous malignancies.

[Accreditation of automated complete blood count by the LH750 Analyzer (Beckman Coulter) in Georges Pompidou Hospital (Paris, France)]. / Vérification de méthode en vue de l'accréditation : exemple de l'hémogramme automatisé sur deux analyseurs LH750 Beckman-Coulter à l'Hôpital européen Georges Pompidou.

Preliminary evaluation of quantitative clinical laboratory measurements is a prerequisite for the accreditation of clinical laboratories, according to the French Committee of Accreditation guidelines following the European reference Standard EN ISO 15189. Numerous papers have been published regarding biochemistry and immunology. However, data are lacking for automated complete blood count accreditation. We report here our experience at Hôpital européen Georges Pompidou hematology laboratory and present the performance characteristics of two mirrored LH750 Beckman-Coulter analysers, including precision, accuracy and uncertainty of measurement.

Costs of congenital diaphragmatic hernia repair in the United States-extracorporeal membrane oxygenation foots the bill.

BACKGROUND: Congenital diaphragmatic hernia (CDH) is the costliest noncardiac congenital defect. Extracorporeal membrane oxygenation (ECMO) is a treatment strategy offered to those babies with CDH who would not otherwise survive on conventional therapy. The primary objective of our study was to identify the leading source of expenditures in CDH care. METHODS: All patients surviving CDH repair were identified in the Kids' Inpatient Database (KID) from 1997 to 2006, with costs converted to 2006 US dollars. Patients were categorized into groups based on severity of disease for comparison including CDH repair only, prolonged ventilator dependence, and ECMO use. Factors associated with greater expenditures in CDH management were analyzed using a regression model. RESULTS: Eight hundred thirty-nine patients from 213 hospitals were studied. Extracorporeal membrane oxygenation use decreased from 18.2% in 1997 to 11.4% in 2006 (P = .002). Congenital diaphragmatic hernia survivors managed with ECMO cost more than 2.4 times as much as CDH survivors requiring only prolonged ventilation postrepair and 3.5 times as much as those with CDH repair only (both P < .001). Age, multiplicity of diagnoses, patient transfer, inhaled nitric oxide use, prolonged ventilation, and ECMO use were all associated with higher costs. Extracorporeal membrane oxygenation use was the single most important factor associated with higher costs, increasing expenditures 2.4-fold (95% confidence interval, 2.1-2.8). Though the CDH repair with ECMO group constituted 12.2% of patients, this group has the highest median costs ($156,499.90/patient) and constitutes 28.5% of national costs based on CDH survivors in the KID. Annual national cost for CDH survivors is $158 million based on the KID, and projected burden for all CDH patients exceeds $250 million/year. CONCLUSIONS: Extracorporeal membrane oxygenation use is the largest contributing factor to the economic burden in CDH. With limited health care resources, judicious resource utilization in CDH care merits further study.

Extracorporeal life support: utilization, cost, controversy, and ethics of trying to save lives.

Since the first successful application of extracorporeal membrane oxygenation (ECMO) in 1972, ECMO's role in the management of respiratory and circulatory collapse continues to be refined and debated. Randomized clinical trials aimed at establishing efficacy and patient selection criteria have been fraught with ethical challenges. Growing concerns over rising health care costs require that careful evaluations of cost, utilization, and ethical issues surrounding heroic life-saving interventions such as ECMO are undertaken. Continued analyses of ECMO's place in the medical management of respiratory and circulatory failure will help ensure that ECMO is used for not only prolonging life but also for providing a chance for "quality of life" following recovery from near-fatal illnesses.