Customized clinical case management for chronically ill patients. Health system sees remarkable results with teams of case managers,physicians, patients

Securing excellent care and positive outcomes for seriously ill, high-risk patients requires extraordinary measures. A health system in Georgia is experiencing strong results by taking a team approach to health care with case managers, physicians and patients working together.     

The right-to-die movement: extrapolating from the National Hemlock Society U.S.A. membership survey

A national membership survey of Hemlock Society USA was conducted by Fox and Kamakahi (1995). Respondents (N=6398) were asked a variety of questions, but in this paper we perform a longitudinal analysis of the characteristics of Hemlock Society USA members. Hemlock Society USA members are divided into three 5-year cohorts: Early Joiners (11 or more years of membership), Middle Joiners (6 to 10 years membership), and Late Joiners (5 or fewer years of membership). Differences between cohorts are examined and extrapolations made regarding Hemlock Society USA and the Right-to-Die Movement. A series of one-way ANOVAs were used with Scheme post-hoc comparisons as heuristic tools for assessing between-cohort differences. Late Joiners are different from earlier members, but are more like other Hemlock Society USA members than the adult U.S. population at large. Hemlock Society USA members are essentially societal "elites" (based on socio-demographic variables) who work in social environments that are decidedly split on the issue of voluntary suicide and euthanasia.     

Application of the Hyper‐Poisson Generalized Linear Model for Analyzing Motor Vehicle Crashes

The hyper‐Poisson distribution can handle both over‐ and underdispersion, and its generalized linear model formulation allows the dispersion of the distribution to be observation‐specific and dependent on model covariates. This study's objective is to examine the potential applicability of a newly proposed generalized linear model framework for the hyper‐Poisson distribution in analyzing motor vehicle crash count data. The hyper‐Poisson generalized linear model was first fitted to intersection crash data from Toronto, characterized by overdispersion, and then to crash data from railway‐highway crossings in Korea, characterized by underdispersion. The results of this study are promising. When fitted to the Toronto data set, the goodness‐of‐fit measures indicated that the hyper‐Poisson model with a variable dispersion parameter provided a statistical fit as good as the traditional negative binomial model. The hyper‐Poisson model was also successful in handling the underdispersed data from Korea; the model performed as well as the gamma probability model and the Conway‐Maxwell‐Poisson model previously developed for the same data set. The advantages of the hyper‐Poisson model studied in this article are noteworthy. Unlike the negative binomial model, which has difficulties in handling underdispersed data, the hyper‐Poisson model can handle both over‐ and underdispersed crash data. Although not a major issue for the Conway‐Maxwell‐Poisson model, the effect of each variable on the expected mean of crashes is easily interpretable in the case of this new model.     

Diesel Engine Exhaust and Lung Cancer Mortality: Time‐Related Factors in Exposure and Risk

To develop a quantitative exposure‐response relationship between concentrations and durations of inhaled diesel engine exhaust (DEE) and increases in lung cancer risks, we examined the role of temporal factors in modifying the estimated effects of exposure to DEE on lung cancer mortality and characterized risk by mine type in the Diesel Exhaust in Miners Study (DEMS) cohort, which followed 12,315 workers through December 1997. We analyzed the data using parametric functions based on concepts of multistage carcinogenesis to directly estimate the hazard functions associated with estimated exposure to a surrogate marker of DEE, respirable elemental carbon (REC). The REC‐associated risk of lung cancer mortality in DEMS is driven by increased risk in only one of four mine types (limestone), with statistically significant heterogeneity by mine type and no significant exposure‐response relationship after removal of the limestone mine workers. Temporal factors, such as duration of exposure, play an important role in determining the risk of lung cancer mortality following exposure to REC, and the relative risk declines after exposure to REC stops. There is evidence of effect modification of risk by attained age. The modifying impact of temporal factors and effect modification by age should be addressed in any quantitative risk assessment (QRA) of DEE. Until there is a better understanding of why the risk appears to be confined to a single mine type, data from DEMS cannot reliably be used for QRA.     

Evaluation of Inhaled Versus Deposited Dose Using the Exponential Dose‐Response Model for Inhalational Anthrax in Nonhuman Primate,Rabbit, and Guinea Pig

The application of the exponential model is extended by the inclusion of new nonhuman primate (NHP), rabbit, and guinea pig dose‐lethality data for inhalation anthrax. Because deposition is a critical step in the initiation of inhalation anthrax, inhaled doses may not provide the most accurate cross‐species comparison. For this reason, species‐specific deposition factors were derived to translate inhaled dose to deposited dose. Four NHP, three rabbit, and two guinea pig data sets were utilized. Results from species‐specific pooling analysis suggested all four NHP data sets could be pooled into a single NHP data set, which was also true for the rabbit and guinea pig data sets. The three species‐specific pooled data sets could not be combined into a single generic mammalian data set. For inhaled dose, NHPs were the most sensitive (relative lowest LD₅₀) species and rabbits the least. Improved inhaled LD₅₀s proposed for use in risk assessment are 50,600, 102,600, and 70,800 inhaled spores for NHP, rabbit, and guinea pig, respectively. Lung deposition factors were estimated for each species using published deposition data from Bacillus spore exposures, particle deposition studies, and computer modeling. Deposition was estimated at 22%, 9%, and 30% of the inhaled dose for NHP, rabbit, and guinea pig, respectively. When the inhaled dose was adjusted to reflect deposited dose, the rabbit animal model appears the most sensitive with the guinea pig the least sensitive species.     

Reanalysis of the DEMS Nested Case‐Control Study of Lung Cancer and Diesel Exhaust: Suitability for Quantitative Risk Assessment

The International Agency for Research on Cancer (IARC) in 2012 upgraded its hazard characterization of diesel engine exhaust (DEE) to “carcinogenic to humans.” The Diesel Exhaust in Miners Study (DEMS) cohort and nested case‐control studies of lung cancer mortality in eight U.S. nonmetal mines were influential in IARC's determination. We conducted a reanalysis of the DEMS case‐control data to evaluate its suitability for quantitative risk assessment (QRA). Our reanalysis used conditional logistic regression and adjusted for cigarette smoking in a manner similar to the original DEMS analysis. However, we included additional estimates of DEE exposure and adjustment for radon exposure. In addition to applying three DEE exposure estimates developed by DEMS, we applied six alternative estimates. Without adjusting for radon, our results were similar to those in the original DEMS analysis: all but one of the nine DEE exposure estimates showed evidence of an association between DEE exposure and lung cancer mortality, with trend slopes differing only by about a factor of two. When exposure to radon was adjusted, the evidence for a DEE effect was greatly diminished, but was still present in some analyses that utilized the three original DEMS DEE exposure estimates. A DEE effect was not observed when the six alternative DEE exposure estimates were utilized and radon was adjusted. No consistent evidence of a DEE effect was found among miners who worked only underground. This article highlights some issues that should be addressed in any use of the DEMS data in developing a QRA for DEE.     

Evaluation of the Food and Agriculture Sector Criticality Assessment Tool (FASCAT) and the Collected Data

To protect and secure food resources for the United States, it is crucial to have a method to compare food systems’ criticality. In 2007, the U.S. government funded development of the Food and Agriculture Sector Criticality Assessment Tool (FASCAT) to determine which food and agriculture systems were most critical to the nation. FASCAT was developed in a collaborative process involving government officials and food industry subject matter experts (SMEs). After development, data were collected using FASCAT to quantify threats, vulnerabilities, consequences, and the impacts on the United States from failure of evaluated food and agriculture systems. To examine FASCAT's utility, linear regression models were used to determine: (1) which groups of questions posed in FASCAT were better predictors of cumulative criticality scores; (2) whether the items included in FASCAT's criticality method or the smaller subset of FASCAT items included in DHS's risk analysis method predicted similar criticality scores. Akaike's information criterion was used to determine which regression models best described criticality, and a mixed linear model was used to shrink estimates of criticality for individual food and agriculture systems. The results indicated that: (1) some of the questions used in FASCAT strongly predicted food or agriculture system criticality; (2) the FASCAT criticality formula was a stronger predictor of criticality compared to the DHS risk formula; (3) the cumulative criticality formula predicted criticality more strongly than weighted criticality formula; and (4) the mixed linear regression model did not change the rank‐order of food and agriculture system criticality to a large degree.     

Modeling Finite‐Time Failure Probabilities in Risk Analysis Applications

In this article, we introduce a framework for analyzing the risk of systems failure based on estimating the failure probability. The latter is defined as the probability that a certain risk process, characterizing the operations of a system, reaches a possibly time‐dependent critical risk level within a finite‐time interval. Under general assumptions, we define two dually connected models for the risk process and derive explicit expressions for the failure probability and also the joint probability of the time of the occurrence of failure and the excess of the risk process over the risk level. We illustrate how these probabilistic models and results can be successfully applied in several important areas of risk analysis, among which are systems reliability, inventory management, flood control via dam management, infectious disease spread, and financial insolvency. Numerical illustrations are also presented.     

Further Beyond the Basic Background Check: Predicting Future Unethical Behavior

In this paper, we analyze the ethical issues of using honesty and integrity tests in employment screening. Our focus will be on the United States context: legal requirements related to applicant privacy differ in other countries, but we posit that our proposed balancing test is broadly applicable. We start by discussing why companies have ethical and legal obligations, based on a stakeholder analysis, to assess the integrity of potential employees. We then move to a consideration of how companies currently use background checks as a pre‐employment screening tool, noting their limitations. We then take up honesty and integrity testing, focusing particularly on the problems of false positives and due process. We offer a balancing test for the use of honesty and integrity testing that takes in three factors: (1) the potential harm posed by a dishonest employee in a particular job, (2) the linkage between the test and the assessment process, and (3) the accuracy and validity of the honesty and integrity test. We conclude with implications for practice and future research.