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IMPORTANCE: The Centers for Medicare & Medicaid Services (CMS) Hospital Compare star ratings are widely used summaries of hospital quality that can influence patient choice and organizational reputation. OBJECTIVE: To identify the changes in hospital ratings and rankings associated with alternative methodological choices in the calculation of the 2021 CMS Hospital Compare star ratings. DESIGN SETTING AND PARTICIPANTS: This cross-sectional study used publicly available 2021 Hospital Compare data for 3339 US hospitals from the October 2020 data release. Change in apparent hospital performance was assessed, arising when plausible alternatives to current methods are used for calculating star ratings in relation to individual measure standardization, domain derivation, and domain weighting. Three example changes were examined in detail, with more comprehensive changes considered using Monte Carlo simulation. Changes in centile of hospital ranks and in star rating overall were examined, as well as separately in CMS peer groupings defined by the number of reported quality domains. MAIN OUTCOMES AND MEASURES: Proportion of hospitals receiving a different star rating under the alternative technical specifications than under the current (2021) CMS approach and mean absolute change in centile rank of hospitals under alternative technical specifications compared with the current (2021) CMS approach. RESULTS: A total of 3339 US hospitals were included in the analysis. Of the specific changes to current specifications considered, the alternative method of standardization was associated with the most substantial changes, with 55.4% (95% CI, 53.7%-57.1%) of hospitals having their star rating reclassified. The change in domain weights was associated with the smallest differences, but even that resulted in reclassification of the star rating in approximately 1 in 4 (24.5%; 95% CI, 23.0%-26.0%) hospitals. In the simulation study, which covered a range of possible changes, on average half of hospitals (51.8%; IQR, 44.2%-59.7%) were assigned a different star rating from that produced by the current specification, usually into an adjacent star category. CONCLUSIONS AND RELEVANCE: In this cross-sectional study of data on US hospitals, CMS Hospital Compare star ratings were found to be highly sensitive to how performance ratings are calculated, demonstrating the need for transparent justification of the technical approaches used in calculating composite performance ratings.

Two of the most misunderstood words in the New Testament are “the Jews”! Unfortunately, this misperception of historical reality has resulted in merciless persecution and ethnic cleansing of millions of innocent people. Judaism—both during and after the lifetime of Jesus—was a diverse movement, represented in part by those various and varied groups of Jews who were the earliest followers of a Jew named Jesus. Careful attention to both the historical and contextual setting of each occurrence of this phrase in the New Testament will enable the translator to generate both a more accurate and a more sensitive text than the fallacious—and often fatal—perpetuation of a “literal” rendering.

The primary types of Onciderini Thomson, 1860 deposited at The Natural History Museum (BMNH), London, United Kingdom, are catalogued and illustrated. Data on the original combination, current name, and type locality are verified and presented. There are 39 primary types of Onciderini including 11 in Oncideres Lacordaire, 1830; and three each in Hesycha Fairmaire & Germain, 1859; Hypselomus Perty, 1832; Lamia Fabricius, 1775; and Tybalmia Thomson, 1868. Of the 39 primary types, 17 were described by H. W. Bates and seven by F. P. Pascoe. Five lectotypes are designated. Notes on additional Onciderini types once believed to be deposited at the BMNH are presented.

Genome-wide association studies and follow-up meta-analyses in Crohn's disease (CD) and ulcerative colitis (UC) have recently identified 163 disease-associated loci that meet genome-wide significance for these two inflammatory bowel diseases (IBD). These discoveries have already had a tremendous impact on our understanding of the genetic architecture of these diseases and have directed functional studies that have revealed some of the biological functions that are important to IBD (e.g. autophagy). Nonetheless, these loci can only explain a small proportion of disease variance (~14% in CD and 7.5% in UC), suggesting that not only are additional loci to be found but that the known loci may contain high effect rare risk variants that have gone undetected by GWAS. To test this, we have used a targeted sequencing approach in 200 UC cases and 150 healthy controls (HC), all of French Canadian descent, to study 55 genes in regions associated with UC. We performed follow-up genotyping of 42 rare non-synonymous variants in independent case-control cohorts (totaling 14,435 UC cases and 20,204 HC). Our results confirmed significant association to rare non-synonymous coding variants in both IL23R and CARD9, previously identified from sequencing of CD loci, as well as identified a novel association in RNF186. With the exception of CARD9 (OR = 0.39), the rare non-synonymous variants identified were of moderate effect (OR = 1.49 for RNF186 and OR = 0.79 for IL23R). RNF186 encodes a protein with a RING domain having predicted E3 ubiquitin-protein ligase activity and two transmembrane domains. Importantly, the disease-coding variant is located in the ubiquitin ligase domain. Finally, our results suggest that rare variants in genes identified by genome-wide association in UC are unlikely to contribute significantly to the overall variance for the disease. Rather, these are expected to help focus functional studies of the corresponding disease loci. © 2013 Beaudoin et al., 0, SCOPUS: ar.j, info:eu-repo/semantics/published

Crohn's disease and ulcerative colitis, the two common forms of inflammatory bowel disease (IBD), affect over 2.5 million people of European ancestry, with rising prevalence in other populations(1). Genome-wide association studies and subsequent meta-analyses of these two diseases(2,3) as separate phenotypes have implicated previously unsuspected mechanisms, such as autophagy(4), in their pathogenesis and showed that some IBD loci are shared with other inflammatory diseases(5). Here we expand on the knowledge of relevant pathways by undertaking a meta-analysis of Crohn's disease and ulcerative colitis genome-wide association scans, followed by extensive validation of significant findings, with a combined total of more than 75,000 cases and controls. We identify 71 new associations, for a total of 163 IBD loci, that meet genome-wide significance thresholds. Most loci contribute to both phenotypes, and both directional (consistently favouring one allele over the course of human history) and balancing (favouring the retention of both alleles within populations) selection effects are evident. Many IBD loci are also implicated in other immune-mediated disorders, most notably with ankylosing spondylitis and psoriasis. We also observe considerable overlap between susceptibility loci for IBD and mycobacterial infection. Gene co-expression network analysis emphasizes this relationship, with pathways shared between host responses to mycobacteria and those predisposing to IBD.

Background: Diagnosing suspected left ventricular systolic dysfunction (LVSD) in the community is a challenge for GPs. We developed and validated a clinical prediction rule (CPR) for LVSD based on history, examination and electrocardiogram (ECG). Methods: Prospective cohort studies of 458 symptomatic patients (derivation cohort) and 535 patients (validation cohort) in 26 general practices in Tayside and Fife, Scotland. All patients underwent a structured clinical examination and ECG and the ‘reference standard’ investigation of echocardiography to establish the presence of LVSD. Results: Four elements from the clinical history and examination were all independently associated with LVSD—male sex [adjusted odds ratio (OR) 2.5; 95% CI 1.1, 5.0], presence of orthopnoea (OR 5.4; 1.9, 13.8) history of myocardial infarction (OR 5.6; 2.3, 13.6) and elevated jugular venous pulsations (OR 15.1; 4.6, 49.3). Addition of ECG (OR 20.6; 2.7, 158.6) provides important diagnostic information in terms of probability of LVSD. A CPR based on the presence or absence of these five elements will generate probabilities ranging from 1% to 97% for LVSD when applied to an individual patient. In the validation cohort, the model under-predicted the probability of LVSD, particularly at lower levels of expected risk, reflecting differences in the risk-factor profiles of the derivation and validation cohorts. Conclusions: The derived CPR provides quantitative estimates of post-test probability for LVSD. This rule requires further validation in other populations and settings because of the difficulties encountered in the validation cohort.

Diagnostic echocardiography has poor access for patients with suspected heart failure. Pre-echocardiography screening with electrocardiograms (ECGs) is recommended as a means of targeting this scarce resource. There are data to support this policy when ECGs are interpreted by cardiologists but not by GPs.To assess the value of GP-reported ECGs as a pre-echocardiography screening test for left ventricular systolic dysfunction (LVSD).Cross-sectional study of GPs' ECG reporting skills.General practice, NHS in Scotland.A randomly selected, stratified sample of 123 Scottish GPs reviewed 180 ECGs (100 abnormal, 50 normal and 30 duplicate) from 150 patients with suspected heart failure. Forty-one patients had LVSD on echocardiography. GPs were required to categorise ECGs as normal or abnormal.Mean sensitivity was 0.94 (95% CI = 0.92 to 0.95). Mean specificity 0.58 (95% CI = 0.56 to 0.60). Mean positive predictive value (PPV) was 0.47 (95% CI = 0.46 to 0.48). Mean negative predictive value (NPV) was 0.96 (95% CI = 0.95 to 0.97). Mean likelihood ratio was 2.39 (95% CI = 2.28 to 2.50). Seventy of 123 (57%) GPs achieved sensitivity of 0.9 and specificity of 0.5 for the detection of LVSD.Most Scottish GPs have the skills to perform pre-echocardiography screening ECGs in patients with suspected LVSD. However, differences in ECG reporting performance between individual GPs will result in widely varying referral rates for echocardiography and differences in the detection rate of LVSD. The implications of these findings need to be considered when heart failure diagnostic services are being developed.

Background: ECG and BNP have been assessed as screening tests for LVSD and heart failure. However, echocardiography also provides information about valvular disease and LVH. We assessed how good these screening tests are in identifying whether the subsequent echocardiogram will have any significant abnormality. Aims: To re-appraise the ECG and BNP as screening tests for echocardiography since there are important practical deficiencies in our current knowledge in this area. Methods: General practitioners referred suspected heart failure patients for clinical assessment, echocardiography, electrocardiography, and BNP measurement. The accuracy of each screening test and combinations of screening tests were calculated for LVSD, heart failure, valvular disease, and LVH. Results: The sensitivities of the ECG for LVSD, heart failure, LVH and valvular disease were 97%, 95%, 76%, and 69%, respectively. The corresponding figures for BNP were 86%, 82%, 59%, and 48%, respectively. When patients with atrial fibrillation and murmurs were excluded, the values for ECG were 94%, 87%, 53%, and 55%, while for BNP they were 83%, 73%, 50%, and 32%. Conclusions: ECG interpretation and BNP are adequate screening tests to detect LVSD or heart failure but fail to screen for other echocardiographic abnormalities, like valvular disease and LVH. This remains the case even if patients with atrial fibrillation or heart murmurs are excluded on the basis that they require echocardiography anyway.

There is uncertainty about the safety of anticoagulation with warfarin in the elderly. This cohort study investigated the risk factors for warfarin-related bleeding in a primary care setting. In multiple regression analyses increased risk of bleeding was associated with domiciliary monitoring of international normalised ratio (INR), low proportion of INR tests in the target range, high intensity of anticoagulation, and male sex. Age was not associated with increased risk after adjustment. High levels of dependency, not old age, should raise concerns about the safety of anticoagulation with warfarin.

An integrated image system to provide high-quality image data from cardiology, pulmonary and gastrointestinal endoscopy, pathology, radiology, hematology, and nuclear medicine for hospital information systems has been developed. Images and associated text data are presented to clinicians throughout the hospital on high-resolution workstations which are interfaced to the main hospital system in a client-server architecture. The system's architecture is described, and experience in the first six months of operation is discussed. Initial use has validated the approach and has indicated a number of unanticipated benefits for patient care and teaching. >

The Department of Veterans Affairs has undertaken a project to integrate image management functionality within its hospital information system. One of the goals of this integrated image system is to provide high-quality image data from cardiology, pulmonary and gastrointestinal endoscopy, pathology, radiology, hematology, and nuclear medicine to clinicians throughout the hospital. Images are presented to clinicians on high-resolution workstations simultaneously with associated text data. This DHCP Integrated Imaging System is currently being installed and tested at the Washington DC VA Medical Center. Initial use has revealed a number of expected as well as unanticipated benefits for patient care and medical teaching.

The effective delivery of health care has become increasingly dependent on a wide range of medical data that includes a variety of images. Manual and computer-based medical records ordinarily do not contain image data, leaving the physician to deal with a fragmented patient record widely scattered throughout the hospital. The Department of Veterans Affairs is currently installing a prototype hospital information system workstation network to demonstrate the feasibility of providing image management and communications functionality as an integral part of an existing hospital information system. The core of this system is a data base management system adapted to handle images as a new data type. A general model for this network-based integration is discussed and various alternative architectures are examined.

Background and aims: New systems for monitoring anticoagulation in routine clinical practice should be evaluated to inform future service development. The aim of this study was to investigate the workload, patient characteristics and bleeding complications in a nurse run, near patient monitoring service serving a population of 23,368. Methods: Retrospective review of coagulometer and general practice case records. Results: Between 1995 and 2000 workload increased from 154 to 269 consultations per month. Three hundred and forty four patients were followed up during a cumulative period of 664.8 years. The 8 week period prevalence of anticoagulation was 8.6 per thousand patients at the close of the study. The median age at enrolment was 71 years. Eighteen per cent of treatment episodes were started when patients were 80 years or older. The most common indication was non rheumatic atrial fibrillation (NRAF) in 51% of treatment episodes. During the study 49.6% [95% confidence interval (CI) 47.8%–50.6%] of international normalised ratio (INR) tests were within target range and INR was estimated to be within the target range 62% (95% CI 61.8%–62.2%) of the time. INR control varied markedly between individual patients. There were 4 fatal bleeding events (0.6 per hundred patient years) and 14 major bleeding events (2.1/hundred patient years). Conclusion: Demand for anticoagulant therapy with warfarin has increased substantially. Service development is required to ensure that appropriately selected patients have access to adequately resourced monitoring which promotes optimum INR control and a minimum of bleeding complications.

EDITOR,—Sheena H Macgregor and colleagues conclude that “good therapeutic control” and a “cost effective” anticoagulant service can be provided in the general practice surgery.1 Near patient testing of the international normalised ratio is certainly an attractive means of providing an anticoagulant monitoring service. The authors' paper fails, however, to address the central issue of quality control and does not quantitate …

Forty patients with acquired valvular heart disease who required valve replacement with Starr-Edwards ball valves of the 6320 (mitral) or 2320 (aortic) series were studied intraoperatively to assess the immediate hemodynamic function of the prosthesis. The following conclusions were reached: (1) Reliable hemodynamic data can be obtained intraoperatively immediately after mitral or aortic valve replacement. (2) The hemodynamics of the Starr-Edwards Model 6320 and 2320 ball valves are disappointing and emphasize the need for continued improvement in design of prosthetic valves. (3) The Starr-Edwards ball-valve prostheses of the 6320 and 2320 series have small functional valve areas and are inefficient in vivo. (4) Because of the transvalvular gradients and small functional valve areas, it is recommended that larger valves be used whenever possible.

When public service systems are designed in accordance with a highly aggregated definition of the public interest, their impacts often clash with community welfare as seen from a local perspective. In this article, such conflicts of interest are not viewed as an aberration of planning for large-scale systems, but as an inherent and central issue of designing and evaluating public services in urban areas. This problem is reflected in serious disparities between abstract models of planning, and the more practical processes of decision-making. To explore means of looking at public system impacts from the concrete and unique viewpoint of neighborhoods, this discussion focuses on the nature of evaluation strategies that might best cope with these conflicts. A number of evaluation procedures are reviewed with this requirement in mind, including benefit-cost and cost-effectiveness analysis, computer interaction techniques, and a process suggested under the name of “dialectical scanning.”

The paper describes five economic linkages by which a university might promote regional development. Both theory and empirical evidence are considered In general, the benefits of a university are found to dissipate too quickly outside of a local region to have very decisive local effects; however, there are exceptions which suggest ways to make the university a more powerful agent of regional development. Major attention is given to the possibility of enhancing the ‘amenity’ effects and the ‘expenditure’ effects of a university. Basic issues of cause-and-effect are also reviewed in light of their policy implications.

This article reviews shortcomings in the synoptic, or rational comprehensive planning tradition, as well as in other, countervailing theories that have attempted to fill specific deficiencies in th...

As the Development Decade of the 1960s came to a close in the summer of 1969, the Institute of Development Studies at the University of Sussex brought together a group of planning practitioners and theorists to compare notes on the rather dismal record of postwar development plans and to discuss what, if anything, could be done for the future. The two published volumes that resulted from the effort are a nicely balanced and well-edited record of frustrations, growth pains, and glimmers of hope. Few new issues were raised at the conference, and few clear achievements were cited. The papers presented were justly critical of planners, and justifiably foreboding about the future of lesser developed countries. Nevertheless, these two volumes are a significant benchmark in the chronicles of economic history. As a retrospective on the Development Decade itself, they are a recitation of unfilled plans, naive theories, and intransigent social structures. In a larger historical perspective, however, the shortcomings of the past decade shrink beside the more important fact that for the first time in history the social sciences have been mobilized on a truly global scale to deal with problems of peace rather than international conflict.

Individuals and institutions often encounter thresholds of accumulated risks, involving discrete and decisive turning points toward success or failure. Binomial probabilities offer a way to model these situations and explain how an otherwise undistinguished event can combine with other, parallel developments to precipitate major discontinuous change. The paper begins with a numerical example to illustrate key parameters of the model. The model describes the probability of success for an undertaking which incurs a series of inherent opportunities and risks. The undertaking might be the completion of a hazardous mission, the accomplishment of a win-or-lose venture, the attainment of a Nobel Prize-winning research proof, or some other vindication of a prolonged struggle. The binomial model deals with all-or-nothing outcomes, rather than performance along a normal curve. The either/or definition of success and failure might seem limited to few situations, but it is argued that: (a) those situations are the most interesting and critical for decision-making; (b) they are characteristic of complex social systems ; and (c) historical trends are moving toward binomial mechanics of yes/no choices as opposed to normal curve outcomes along a smooth continuum. The quantitative example discussed in the paper reveals some counter-intuitive findings, which nevertheless help to explain some familiar patterns of abrupt change in the way people and institutions deal with increasingly complex environments. Specifically, the model shows how some activities apparantly favorable to a mission's success can simply present more things to go wrong, when the total combination of parallel activities is taken into account. The concluding section of the paper is addressed to policy implications. In particular, it deals with ways for individuals and institutions to avoid needless risks, absorb small failures, or choose more predictable environments, so that opportunities for exploratory risk-taking can be preserved without jeopardizing more fundamental goals or the overall viability of complex undertakings.

This paper reviews some of the possible effects that a slowdown in national rates of economic growth might have on levels of unemployment in an economically advanced nation. The consequences of three types of growth ceilings are considered; “zero population growth”, “limited growth” and “restricted growth”.