Data-Driven Decisions for Reducing Readmissions for Heart Failure: General Methodology and Case Study

Background

Several studies have focused on stratifying patients according to their level of readmission risk, fueled in part by incentive programs in the U.S. that link readmission rates to the annual payment update by Medicare. Patient-specific predictions about readmission have not seen widespread use because of their limited accuracy and questions about the efficacy of using measures of risk to guide clinical decisions. We construct a predictive model for readmissions for congestive heart failure (CHF) and study how its predictions can be used to perform patient-specific interventions. We assess the cost-effectiveness of a methodology that combines prediction and decision making to allocate interventions. The results highlight the importance of combining predictions with decision analysis.

Methods

We construct a statistical classifier from a retrospective database of 793 hospital visits for heart failure that predicts the likelihood that patients will be rehospitalized within 30 days of discharge. We introduce a decision analysis that uses the predictions to guide decisions about post-discharge interventions. We perform a cost-effectiveness analysis of 379 additional hospital visits that were not included in either the formulation of the classifiers or the decision analysis. We report the performance of the methodology and show the overall expected value of employing a real-time decision system.

Findings

For the cohort studied, readmissions are associated with a mean cost of $13,679 with a standard error of $1,214. Given a post-discharge plan that costs $1,300 and that reduces 30-day rehospitalizations by 35%, use of the proposed methods would provide an 18.2% reduction in rehospitalizations and save 3.8% of costs.

Conclusions

Classifiers learned automatically from patient data can be joined with decision analysis to guide the allocation of post-discharge support to CHF patients. Such analyses are especially valuable in the common situation where it is not economically feasible to provide programs to all patients.     

Velocity-dependent cost function for the prediction of force sharing among synergistic muscles in a one degree of freedom model

Prediction of accurate and meaningful force sharing among synergistic muscles is a major problem in biomechanics research. Given a resultant joint moment, a unique set of muscle forces can be obtained from this mathematically redundant system using nonlinear optimization. The classical cost functions for optimization involve a normalization of the muscle forces to the absolute force capacity of the target muscles, usually by the cross-sectional area or the maximal isometric force. In a one degree of freedom model this leads to a functional relationship between moment arms and the predicted muscle forces, such that for constant moment arms, or constant ratios of moment arms, agonistic muscle forces increase or decrease in unison. Experimental studies have shown however that the relationship between muscle forces is highly task-dependent often causing forces to increase in one muscle while decreasing in a functional agonist, likely because of the contractile conditions and contractile properties of the involved muscles. We therefore, suggest a modified cost function that accounts for the instantaneous contraction velocity of the muscles and its effect on the instantaneous maximal force. With this novel objective function, a task-dependent prediction of muscle force distribution is obtained that allows, even in a one degree of freedom system, the prediction of force sharing loops, and simultaneously increasing and decreasing forces for agonist pairs of muscles.     

Unexpected smoking-linked high MMP-9 in induced sputum of hazardous dust-exposed workers

We investigated whether metalloproteinase-9 (MMP-9) values in induced sputum (IS) and pulmonary function tests can serve as a marker of damage and intensity of exposure to hazardous dust. Thirty-nine factory employees (28 workers exposed to metal particles and 11 supposedly nonexposed office workers) underwent IS induction. Samples were processed by conventional methods within 2 hours. The proportion of particles with diameters of 0-2 mu in IS samples was significantly higher in nonexposed than exposed workers and in smoker compared to nonsmoker workers. MMP-9 and TIMP-1 levels were similar for both groups. A linear regression model for MMP-9 based on exposure, smoking habits, and proportion of particles < 5 mu revealed a positive correlation between each of the explanatory variables and MMP-9 values. MMP-9 may serve as a marker for pulmonary injury.     

Unexpected Population Distribution in a Microbial Mat Community: Sulfate-Reducing Bacteria Localized to the Highly Oxic Chemocline in Contrast to a Eukaryotic Preference for Anoxia

The distribution and abundance of sulfate-reducing bacteria (SRB) and eukaryotes within the upper 4 mm of a hypersaline cyanobacterial mat community were characterized at high resolution with group-specific hybridization probes to quantify 16S rRNA extracted from 100-μm depth intervals. This revealed a preferential localization of SRB within the region defined by the oxygen chemocline. Among the different groups of SRB quantified, including members of the provisional families “Desulfovibrionaceae” and “Desulfobacteriaceae,” Desulfonema-like populations dominated and accounted for up to 30% of total rRNA extracted from certain depth intervals of the chemocline. These data suggest that recognized genera of SRB are not necessarily restricted by high levels of oxygen in this mat community and the possibility of significant sulfur cycling within the chemocline. In marked contrast, eukaryotic populations in this community demonstrated a preference for regions of anoxia.     

Infectivity of beetle spiroplasmas for new host species

Five beetle spiroplasmas, the Colorado potato beetlespiroplasma (CPBS, strain LD-1), the Cantharis carolinusspiroplasma (CCBS, strain CC-1), the Ellychnia corrusca fireflyspiroplasma (FS, strain EC-1), the Diabrotica undecimpunctatacorn rootworm spiroplasma (CRS, strain DU-1), and the Spiroplasmafloricola fall flower spiroplasma (FFS), all associated withbeetles, were fed to beetles (Maladera matrida and Carpophilushumeralis) and mosquitoes (Aedes aegypti and Culex pipiens). CPBSand CCBS were also injected into M. matrida. Attempts to recoverspiroplasmas from regurgitates and hemolymph were conducted 1–10days after their introduction. After day 1, orally administeredspiroplasmas could not be recovered from M. matrida beetles;however, at 2–5 days, four out of five spiroplasmas wererecovered from adult C. humeralis. Injected spiroplasmas survivedin the hemolymph of M. matrida beetles for a relatively longperiod (at least 22 days). All five spiroplasmas were recoveredfrom mosquitoes 1 day post feeding, but only two (CCBS and CRS)survived for five or more days. The results show short andvariable persistence in orally challenged non-host insects, withgeneral failure to pass the gut barrier. Such evidence should beconsidered when attempting to use these microbes in biocontrolprograms.     

In vivo modulation of brain cholesterol level and learning performance by a novel plant lipid: indications for interactions between hippocampal-cortical cholesterol and learning

In this account we report in vivo effects of a plant lipid preparation (MMPL) on brain cholesterol and the activity and learning performance of aging male rats. Three-month-old rats were fed for 3 months with a diet that was enriched with 3% MMPL. Another group of 18 month-old rats was fed for 6 months with a 3% MMPL-enriched diet. This food regime lowered markedly the cholesterol level in the hippocampal and cortical regions and increased their lipid membrane fluidity. The animals of both age groups also responded to MMPL with a higher activity and their learning performances, compared to normal diet-fed animals, improved notably. This improvement continued at least 4 months after terminating the supply of MMPL. Significant inverse correlationships were obtained between the length of the training period required to attain proper criteria and cholesterol levels of the hippocampal and cortical brain fractions.     

Disease resistance in cool-season forage range and turf grasses II

The potential and proven disease resistance of various cool season cultivars of common forage, range, and turfgrasses to fungi, bacteria, and viruses is reviewed. Included are certain grass species ofAgropyron, Agrostis, Arrhenatherum, Bromus, Dactylis, Elymus, Festuca, Lolium, Phalaris, Phleum, andPoa. These cultivars may be useful in crop improvement programs and for germplasm exchange.