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BACKGROUND: Although risk adjustment remains a cornerstone for comparing outcomes across hospitals, optimal strategies continue to evolve in the presence of many confounders. We compared conventional regression-based model to approaches particularly suited to leveraging big data. METHODS AND RESULTS: We assessed hospital all-cause 30-day excess mortality risk among 8952 adults undergoing percutaneous coronary intervention between October 1, 2011, and September 30, 2012, in 24 Massachusetts hospitals using clinical registry data linked with billing data. We compared conventional logistic regression models with augmented inverse probability weighted estimators and targeted maximum likelihood estimators to generate more efficient and unbiased estimates of hospital effects. We also compared a clinically informed and a machine-learning approach to confounder selection, using elastic net penalized regression in the latter case. Hospital excess risk estimates range from -1.4% to 2.0% across methods and confounder sets. Some hospitals were consistently classified as low or as high excess mortality outliers; others changed classification depending on the method and confounder set used. Switching from the clinically selected list of 11 confounders to a full set of 225 confounders increased the estimation uncertainty by an average of 62% across methods as measured by confidence interval length. Agreement among methods ranged from fair, with a κ statistic of 0.39 (SE: 0.16), to perfect, with a κ of 1 (SE: 0.0). CONCLUSIONS: Modern causal inference techniques should be more frequently adopted to leverage big data while minimizing bias in hospital performance assessments.

BackgroundInsured adults receive invasive cardiovascular procedures more frequently than uninsured adults. We examined the impact of healthcare reform in Massachusetts on use of coronary revascularization procedures and in-hospital and 1-year mortality by race/ethnicity, education, and sex.Methods and resultsUsing hospital claims data, we compared differences in coronary revascularization rates (coronary artery bypass grafting or percutaneous coronary intervention) and in-hospital mortality by race/ethnicity, education, and sex among Massachusetts residents aged 21 to 64 years hospitalized with a principal discharge diagnosis of ischemic heart disease before (November 1, 2004, to July 31, 2006) and after (December 1, 2006, to September 30, 2008) reform; 1-year mortality was calculated for those undergoing revascularization. Adjusted logistic regression assessed 24 216 discharges before reform and 20 721 discharges after reform. Blacks had 30% lower odds of receiving coronary revascularization than whites in the prereform period. Compared with whites in the postreform period, blacks (odds ratio=0.73; 95% confidence interval, 0.63-0.84) and Hispanics (odds ratio= 0.84; 95% confidence interval, 0.74-0.97) were less likely and Asians (odds ratio=1.29; 95% confidence interval, 1.01-1.65) were more likely to receive coronary revascularization. Patients living in more educated communities, men, and persons with private insurance were more likely to receive coronary revascularization before and after reform. Compared with the prereform period, the adjusted odds of in-hospital mortality were higher in patients living in less-educated communities in the postreform period. No differences in 1-year mortality by race/ethnicity, education, or sex for revascularized patients were observed before or after reform.ConclusionsReducing insurance barriers to receipt of coronary revascularization procedures has not yet eliminated preexisting demographic and educational disparities in access to these procedures.

Describes and evaluates a holistic resocialization program used by the Texas Youth Commission that has been integrated into the state's education, treatment, and correctional programs for incarcerated youth. Goals of the program are to help ensure that the youth can generalize the skills they gain through these processes to situations outside the facility. (Author/GCP)

This module provides information designed to enable individuals to facilitate one- to two-hour training sessions appropriate for teachers, other professionals, and parents. It focuses on specific strategies intended to empower students with challenging behaviors to help themselves. It describes service learning, examines factors in developing these activities, explains benefits, and outlines steps for implementing service learning activities. (Author/JDM)

Supplies information necessary to facilitate an educators' workshop on promoting self respect in children and youth who exhibit challenging behaviors. Claims that service learning, the integration of community service with academic skills, and structural-reflection activities help students develop self-respect. (MKA)

Describes a training module that helps teachers and others working with children to address challenging behaviors. Discusses ways to assess problem behaviors, elements that influence behavior, and components of functional assessment. Offers questions that can help decode behavior. (RJM)

A study aims to compare and establish the efficacy of drug-eluting stents as against bare-metal stents in the treatment of patients with acute myocardial infarction. Results concluded that treatment with drug-eluting stents was found to result in decreased 2-year mortality rates as well as a reduced need for repeat revascularization procedures as compared to bare-metal stents.