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We identify optimal producer-selected coverage options across all marketing months and insurable commodities within Livestock Risk Protection Insurance. Optimal contracts are defined as those having combinations of coverage length and level that have historically provided the highest probability of a positive net return and the highest average net return. Using probabilistic modeling, we evaluate the effect of producer size on the likelihood of purchasing optimal contracts. Results indicate that (i) optimal contracts generally have relatively higher coverage levels, (ii) producers often purchase contracts not identified as optimal, and (iii) producers are categorized within two distinct groups when considering optimal contract selection.

Background A fundamental concept in biology is that heritable material is passed from parents to offspring, a process called vertical gene transfer. An alternative mechanism of gene acquisition is through horizontal gene transfer (HGT), which involves movement of genetic materials between different species. Horizontal gene transfer has been found prevalent in prokaryotes but very rare in eukaryote. In this paper, we investigate horizontal gene transfer in the human genome. Results From the pair-wise alignments between human genome and 53 vertebrate genomes, 1,467 human genome regions (2.6 M bases) from all chromosomes were found to be more conserved with non-mammals than with most mammals. These human genome regions involve 642 known genes, which are enriched with ion binding. Compared to known horizontal gene transfer regions in the human genome, there were few overlapping regions, which indicated horizontal gene transfer is more common than we expected in the human genome. Conclusions Horizontal gene transfer impacts hundreds of human genes and this study provided insight into potential mechanisms of HGT in the human genome.

We derive confidence interval procedures for the intraclass correlation coefficient [sigma] based on the likelihood score, the bias corrected score and the bias and skewness corrected score. These procedures are then compared, through simulation, with six other procedures, compared by Donner and Wells (1986), in terms of coverage probabilities and coverage lengths. A methods due to Thomas and Hultquist (1978, the BAL method) and the method based on the maximum likelihood estimate of [sigma] (the ML method) provide, on the average, the shortest lengths. Both these methods are overly liberal. Another method of Thomas and Hultquist (the TH method) and the method based on Fisher's Z-transform (the F method) provide largest lengths, on the average. The TH method is liberal and the F method is overly conservative. The remaining methods, on the average, clump together in terms of average coverage lengths. However, the bias corrected score procedure (the BAB Method) performs best in terms of coverage probabilities, in the sense that the coverage probabilities are closest, on the average, to the nominal confidence coefficient. A closer look at the simulation results indicate that when [sigma] is very small (i.e. [sigma] <= .1) the BAL method is best, otherwise the BAB method is best. [PUBLICATION ABSTRACT]

Physicians make critical time-constrained decisions every day. Clinical predictive models can help physicians and administrators make decisions by forecasting clinical and operational events. Existing structured data-based clinical predictive models have limited use in everyday practice owing to complexity in data processing, as well as model development and deployment 1 – 3 . Here we show that unstructured clinical notes from the electronic health record can enable the training of clinical language models, which can be used as all-purpose clinical predictive engines with low-resistance development and deployment. Our approach leverages recent advances in natural language processing 4 , 5 to train a large language model for medical language (NYUTron) and subsequently fine-tune it across a wide range of clinical and operational predictive tasks. We evaluated our approach within our health system for five such tasks: 30-day all-cause readmission prediction, in-hospital mortality prediction, comorbidity index prediction, length of stay prediction, and insurance denial prediction. We show that NYUTron has an area under the curve (AUC) of 78.7–94.9%, with an improvement of 5.36–14.7% in the AUC compared with traditional models. We additionally demonstrate the benefits of pretraining with clinical text, the potential for increasing generalizability to different sites through fine-tuning and the full deployment of our system in a prospective, single-arm trial. These results show the potential for using clinical language models in medicine to read alongside physicians and provide guidance at the point of care. A clinical language model trained on unstructured clinical notes from the electronic health record enhances prediction of clinical and operational events.

Background India launched a national health insurance scheme named Ayushman Bharat Pradhan Mantri Jan Arogya Yojana (AB-PMJAY) in 2018 as a key policy for universal health coverage. The ambitious scheme covers 100 million poor households. None of the studies have examined its impact on the quality of care. The existing studies on the impact of AB-PMJAY on financial protection have been limited to early experiences of its implementation. Since then, the government has improved the scheme’s design. The current study was aimed at evaluating the impact of AB-PMJAY on improving utilisation, quality, and financial protection for inpatient care after four years of its implementation. Methods Two annual waves of household surveys were conducted for years 2021 and 2022 in Chhattisgarh state. The surveys had a sample representative of the state’s population, covering around 15,000 individuals. Quality was measured in terms of patient satisfaction and length of stay. Financial protection was measured through indicators of catastrophic health expenditure at different thresholds. Multivariate adjusted models and propensity score matching were applied to examine the impacts of AB-PMJAY. In addition, the instrumental variable method was used to address the selection problem. Results Enrollment under AB-PMJAY was not associated with increased utilisation of inpatient care. Among individuals enrolled under AB-PMJAY who utilised private hospitals, the proportion incurring catastrophic health expenditure at the threshold of 10% of annual consumption expenditure was 78.1% and 70.9% in 2021 and 2022, respectively. The utilisation of private hospitals was associated with greater catastrophic expenditure irrespective of AB-PMJAY coverage. Enrollment under AB-PMJAY was not associated with reduced out-of-pocket expenditure or catastrophic health expenditure. Conclusions AB-PMJAY has achieved a large coverage of the population but after four years of implementation and an evidence-based increase in reimbursement prices for hospitals, it has not made an impact on improving utilisation, quality, or financial protection. The private hospitals contracted under the scheme continued to overcharge patients, and purchasing was ineffective in regulating provider behaviour. Further research is recommended to assess the impact of publicly funded health insurance schemes on financial protection in other low- and middle-income countries.

Relative efficiency of estimators of the common mean of possibly different normal populations N(μ, σ i 2 ) is investigated empirically. A weighted least squares estimator , with weights based on a modification of minimum norm quadratic unbiased (MINQU) estimators of the σ i 2 , is found to be substantially more efficient than the maximum likelihood (ML) estimator of μ when the heterogeneity in the σ i , is small to moderate and the number of sample observations from a population is small. The jackknife t statistic for performed well in regard to both coverage probability and expected length of the confidence interval.

Objectives. To quantify the inflation-adjusted costs associated with initial hospitalizations for firearm-related injuries in the United States. Methods. We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify patients admitted for firearm-related injuries from 2006 to 2014. We converted charges from hospitalization to costs, which we inflation-adjusted to 2014 dollars. We used survey weights to create national estimates. Results. Costs for the initial inpatient hospitalization totaled$6.61 billion. The largest proportion was for patients with governmental insurance coverage, totaling $ 2.70 billion (40.8%) and was divided between Medicaid ( $2.30 billion) and Medicare ($ 0.40 billion). Self-pay individuals accounted for$1.56 billion (23.6%) in costs. Conclusions. From 2006 to 2014, the cost of initial hospitalizations for firearm-related injuries averaged $ 734.6 million per year. Medicaid paid one third and self-pay patients one quarter of the financial burden. These figures substantially underestimate true health care costs. Public health implications. Firearm-related injuries are costly to the US health care system and are particularly burdensome to government insurance and the self-paying poor.

Colorectal cancer (CRC) care costs the Australian healthcare system more than any other cancer. We estimated costs and days in hospital for CRC cases, stratified by site (colon/rectal cancer) and disease stage, to inform detailed analyses of CRC-related healthcare. Incident CRC patients were identified using the Australian 45 and Up Study cohort linked with cancer registry records. We analysed linked hospital admission records, emergency department records, and reimbursement records for government-subsidised medical services and prescription medicines. Cases' health system costs (2020 Australian dollars) and hospital days were compared with those for cancer-free controls (matched by age, sex, geography, smoking) to estimate excess resources by phase of care, analysed by sociodemographic, health, and disease characteristics. 1200 colon and 546 rectal cancer cases were diagnosed 2006-2013, and followed up to June 2016. Eighty-nine percent of cases had surgery, chemotherapy or radiotherapy, and excess costs were predominantly for hospitalisations. Initial phase (12 months post-diagnosis) mean excess health system costs were $50,434 for colon and $60,877 for rectal cancer cases, with means of 16 and 18.5 excess hospital days, respectively. The annual continuing mean excess costs were $6,779 (colon) and $8,336 (rectal), with a mean of 2 excess hospital days each. Resources utilised (costs and days) in these phases increased with more advanced disease, comorbidities, and younger age. Mean excess costs in the year before death were $74,952 (colon) and $67,733 (rectal), with means of 34 and 30 excess hospital days, respectively-resources utilised were similar across all characteristics, apart from lower costs for cases aged ≥75 at diagnosis. Health system costs and hospital utilisation for CRC care are greater for people with more advanced disease. These findings provide a benchmark, and will help inform future cost-effectiveness analyses of potential approaches to CRC screening and treatment.

Abstract Rationale The around-the-clock presence of an in-house attending critical care physician (24/7 coverage) is purported to be associated with improved outcomes among high-risk children with critical illness. Objectives To evaluate the association of 24/7 in-house coverage with outcomes in children with critical illness. Methods Patients younger than 18 years of age in the Virtual Pediatric Systems Database (2009–2014) were included. The main analysis was performed using generalized linear mixed effects multivariable regression models. In addition, multiple sensitivity analyses were performed to test the robustness of our findings. Measurements and Main Results A total of 455,607 patients from 125 hospitals were included (24/7 group: 266,319 patients; no 24/7 group: 189,288 patients). After adjusting for patient and center characteristics, the 24/7 group was associated with lower mortality in the intensive care unit (ICU) (24/7 vs. no 24/7; odds ratio [OR], 0.52; 95% confidence interval [CI], 0.33–0.80; P = 0.002), a lower incidence of cardiac arrest (OR, 0.73; 95% CI, 0.54–0.99; P = 0.04), lower mortality after cardiac arrest (OR, 0.56; 95% CI, 0.340–0.93; P = 0.02), a shorter ICU stay (mean difference, −0.51 d; 95% CI, −0.93 to −0.09), and shorter duration of mechanical ventilation (mean difference, −0.68 d; 95% CI, −1.23 to −0.14). Conclusions In this large observational study, we demonstrated that pediatric critical care provided in the ICUs staffed with a 24/7 intensivist presence is associated with improved overall patient survival and survival after cardiac arrest compared with patients treated in ICUs staffed with discretionary attending coverage. However, results from a few sensitivity analyses leave some ambiguity in these results.

Background Although bariatric surgery is the most effective obesity treatment, few nationwide cohort studies have evaluated its safety. This study aimed to evaluate surgical trends after insurance coverage implementation and analyze the surgical outcomes of bariatric surgery. Methods A retrospective analysis of bariatric surgery in patients with obesity was conducted using data from Korean National Health Insurance System (NHIS) claims. We evaluated short-term outcomes. Results We enrolled 7,360 patients who underwent bariatric surgery for obesity between January 2019 and December 2021 in this study. Before the introduction of insurance coverage, approximately 500 bariatric surgeries were performed annually, which increased to around 2,000 procedures per year following the implementation of coverage. There were 5,139 sleeve gastrectomies (69.8%), 927 Roux-en-Y gastric bypasses (12.6%), 375 biliopancreatic diversions with duodenal switch (5.1%), and 895 gastric banding–related surgeries (12.2%), including revision surgeries. The mean postoperative hospital stay was 5.9 days, and patients with higher body mass indexes (≥ 50 kg/m 2 ) experienced longer hospital stays (8.0 ± 6.4 days, p < 0.001). Major complications and mortality rates within 30 days postoperatively were 2.6% and 0.01%, respectively. The readmission rate within 30 days postoperatively was 5.5%, and the rate of major complications after readmission was 2.8% during the entire period. Conclusions The NHIS’s coverage of bariatric surgery in 2019 led to greater numbers of bariatric procedures performed in South Korea, with acceptable surgical outcomes concerning complication rates and hospital stay durations. These findings highlight the positive impact of national insurance coverage on the accessibility and safety of bariatric surgery in South Korea.