Luck of the draw: Role of chance in the assignment of medicare readmissions penalties

Pay-for-performance programs are one strategy used by health plans to improve the efficiency and quality of care delivered to beneficiaries. Under such programs, providers are often compared against their peers in order to win bonuses or face penalties in payment. Yet luck has the potential to affect performance assessment through randomness in the sorting of patients among providers or through random events during the evaluation period. To investigate the impact luck can have on the assessment of performance, we investigated its role in assigning penalties under Medicare’s Hospital Readmissions Reduction Policy (HRRP), a program that penalizes hospitals with excess readmissions. We performed simulations that estimated program hospitals’ 2015 readmission penalties in 1,000 different hypothetical fiscal years. These hypothetical fiscal years were created by: (a) randomly varying which patients were admitted to each hospital and (b) randomly varying the readmission status of discharged patients. We found significant differences in penalty sizes and probability of penalty across hypothetical fiscal years, signifying the importance of luck in readmission performance under the HRRP. Nearly all of the impact from luck arose from events occurring after hospital discharge. Luck played a smaller role in determining penalties for hospitals with more beds, teaching hospitals, and safety-net hospitals.

Psychological Assessment of Control and Coping with Neuropathic Pain in the Lumbar Spine

Background: Pain in the lumbar spine is an increasingly common problem, not only neurological or orthopaedic, but also psychological. In epidemiological studies on the prevalence of neuropathic pain, conducted in countries such as the United Kingdom, the United States France, and Brazil, it has been shown that the prevalence of chronic pain with neuropathic properties is estimated at 7-10%. Chronic neuropathic pain is more common in women (8% versus 5.7% in men) and in patients > 50 years of age (8.9% versus 5.6% in women < 49 years old). It most frequently concerns the lumbar region and lower limbs. However, in Germany, it has been revealed that 40% of all patients experience at least some features of neuropathic pain such as burning, numbness and/or tingling, especially those with chronic pain in the lumbar spine and radiculopathy. Chronic pain not only hinders a patient's daily life activities, but over time, it has negative impact on the patient's psyche: it reduces his/her well-being, causing anxiety, fear, helplessness, regret and even hostility. It should be emphasized that each of these reactions is an individual feature. Objectives: The aim of the study is to assess pain control as well as the strategies of coping with neuropathic pain in the lumbar spine. Material and methods: The study comprised 50 people with neuropathic pain in the lumbar region, including 41 women and 19 men. The average age of the respondents was 56 years, the average duration of the symptoms was 8 years. The following questionnaires were used to assess neuropathic pain: Lanss Pain Scale and DN4, and the Visual Analogue Scale (VAS) to assess pain intensity. For Pain Control Assessment - the Beliefs Questionnaire for Pain Control (BPCQ) and Pain Coping Strategy Questionnaire (CSQ). Results: Among the 3 measured factors of pain control, internal control dominates in young people, external control in middle-aged individuals, and the attitude towards random events in the elderly. There was significant statistical dependence between pain coping strategy and type of pain control. Conclusions: With the duration of pain and the age of the patient, random events play an increasingly important role in pain control. Hence, tests on pain control and coping should be carried out among patients as this would determine the most favourable treatment method.

An Analysis of the Operation of Distribution Networks Using Kernel Density Estimators

Efficiency in the operation of distribution networks is one of the commonly recognised goals of the Smart Grid aspect. Novel approaches are needed to assess the level of energy loss and reliability in electricity distribution. Transmission of electricity in the power system is invariably accompanied by certain physical phenomena and random events causing losses. Identifying areas where excessive energy losses or excessive grid failure occur is a key element for energy companies in resource management. The study presented in the article is based on data obtained from distribution system operators concerning 41 distribution regions in Poland for a period of 5 years. The first part of the article presents an analysis of the distribution of values for the introduced energy density and energy losses in the lines of medium- and low-voltage networks and in transformers supplying the low-voltage network. The second part of the article presents the assessment of the network reliability of the same distribution regions based on analysis of the distributions of System Average Interruption Duration Index (SAIDI) and System Average Interruption Frequency Index (SAIFI) values for planned and unplanned outages. Data analysis is performed by non-parametric methods by means of kernel estimators.

Łukasiewicz Logic and the Divisible Extension of Probability Theory

We show that measurable fuzzy sets carrying the multivalued Łukasiewicz logic lead to a natural generalization of the classical Kolmogorovian probability theory. The transition from Boolean logic to Łukasiewicz logic has a categorical background and the resulting divisible probability theory possesses both fuzzy and quantum qualities. Observables of the divisible probability theory play an analogous role as classical random variables: to convey stochastic information from one system to another one. Observables preserving the Łukasiewicz logic are called conservative and characterize the “classical core” of divisible probability theory. They send crisp random events to crisp random events and Dirac probability measures to Dirac probability measures. The nonconservative observables send some crisp random events to genuine fuzzy events and some Dirac probability measures to nondegenerated probability measures. They constitute the added value of transition from classical to divisible probability theory.

Randomness and Political Complexity in the Contemporary Arab Novel

This essay examines the concept of randomness in three novels by contemporary Arab novelists, employing chaos theory and complexity theory. The three novels are Lebanese Rabie Gaber's dystopian novel Beirutus: Underground City ( Beirutus: Madīna Taḥt al-Arḍ, 2005), Egyptian Ezzedine Choukri Fishere's realistic novel Exit ( Bāb al-Khurūj, 2012), and Algerian Yasmina Khadra's detective novel What are Monkeys Waiting for? ( Qu'attendent les singes, 2014). Although they belong to different genres, all three are speculative novels and present different forms of political-security complexity and chaos in the contemporary Arab world. They represent unpredictable, random events that both resonate with and anticipate forthcoming events and political changes in the Arab world. Exit, for instance, represents the unexpected downfall of the Muslim Brotherhood in Egypt and the return of the military rule after the 2011 revolution, and Beirutus the unexpected rubbish and environmental crisis in 2016 in Lebanon, while What are Monkeys Waiting for? anticipates the contemporary political turmoil in Algeria. Randomness and unpredictability in the three novels are used as a means of political projection and prediction, and as narrative strategies of literary activism against repressive realities and authoritarianism. By representing the unpredictable, Gaber, Fishere and Khadra implicitly incite resistance by warning of appalling forthcoming realities.

Resource Capacity Requirement for Multi-Terminal Cooperation in Container Ports

Capacity sharing among neighboring terminals offer a means to meet increasing or unexpected demand for cargo-handling without additional capital investment. This study proposes a model for capacity requirement planning of major resources, such as quay cranes (QCs), storage space, and gate, in multiterminal port operations where demand is time dependent. A resource profile simulation is run to generate random events across the terminals and estimate the capacity requirement in the form of workload distributions on port resources over time-shifts. The effects on workload requirement, arising from multiterminal cooperation, are subsequently evaluated in consideration of different container flows among terminals. Experimental results suggest that higher transferring rate between terminals will reduce the QC intensity and storage space requirements but increase gate congestion. Variabilities in the QC intensity and storage space requirements also increase due to shorter stays and more movements in container inventory at the yard. The interaction effect between transferring and trans-shipment rates further shows that the average resource requirements for a terminal can be greatly reduced when the interterminal transferring of containers contributes positively to a more even workload redistribution across terminals. The most significant improvements occur when trans-shipment rate is 85% and transferring rate is 75% for QC intensity; trans-shipment rate is 90% and transferring rate is 60% for storage capacity; and trans-shipment rate is 80% and transferring rate is 75% for gate congestion.

Concept of universality within the framework of the second order cybernetics

Ideological essence of the second-order cybernetics is generally understood as a “view from within”. This requires certain conceptual revision of most fundamental notions. Particularly, an interpretation of a ‘universal law’ is subject to such a revision. Formally speaking, any universal law may be coded in the form АхР(х), where Ax is the universal quantifier. However, its meaning changes significantly, for it could be shown that it must be treated probabilistically. The reason for this is in that the standard phrase ‘for any x’, which discloses the meaning of the formula Ax, must be seen here as an arbitrariness of choice, while ‘the choice arbitrariness’ must be seen as a constructive procedure within the second-order cybernetics. Otherwise, basic presumption of the second-order cybernetics will not hold. Indeed, classical science assumes that when one says ‘Let us pick up an arbitrary x from the model M’ then the very procedure of ‘picking up an arbitrary x’ is not assumed to be a part of model M. Classical scientists think of this act as of some agent’s act who is completely external to model M. Second order scientists take it differently. All agent’s acts — observations, measurements, picks, experiment organizations, etc — must be seen as a part of an appropriate model. This is the core of the ‘view from within’: theoretical agents, their acts as well as their theories must be considered as internal events, or properties, of the intended models. Going back to formula Ax, it is easier to see now that an intention ‘to pick up an arbitrary x’ must be treated as a real process within an appropriate model M. The only way to do it is to assume that such models have (truly) random events generators G as a necessary part of their structure. All above implies that an interpretation of AxP(x) within the framework of the second-order cybernetics must be the following: P(x) is universally true on M iff there exists G in M such that at any time t G may randomly choose any element from M with probability р(х)≠0, and P(x) will appear to be true. As a result of this, we may claim that the very idea of justifiable universality is inconsistent with deterministic ontologies (in the second-order science framework). Indeed, deterministic ontologies do not assume that at any time t it is possible to pick up an arbitrary x from the model M, for, by definition, they are limited only to certain choices through time, which are pre-determined by deterministic schedule of choices.

Advanced Metering Infrastructure—Towards a Reliable Network

In order to ensure continuous energy supply, Distribution System Operators (DSOs) have to monitor and analyze the condition of the power grid, especially checking for random events, such as breakdowns or other disturbances. Still, relatively little information is available on the operation of the Low Voltage (LV) grid. This can be improved thanks to digital tools, offering online processing of data, which ultimately increases effectiveness of the power grid. Among those tools, the use of the Advanced Metering Infrastructure (AMI) is especially conducive for improving reliability. AMI is one of the elements of the system Supervisory Control and Data Acquisition (SCADA) for the LV grid. Exact knowledge of the reliability conditions of a power grid is also indispensable for optimizing investment. AMI is also key in providing operational capacity for carrying out energy balance in virtual power plants (VPPs). This paper deals with methodology of identification and location of faults in the AMI-supervised LV grid and with calculating the System Average Interruption Duration Index (SAIDI) and System Average Interruption Frequency Index (SAIFI) on the basis of the recorded events. The results presented in the paper are based on data obtained from seven MV/LV transformer stations that supply over 2000 customers.