Emergency Health Services (EHS) : demand and service delivery models. monograph 3 : patients’ reasons and perceptions

Executive Summary Emergency health is a critical component of Australia’s health system and emergency departments (EDs) are increasingly congested from growing demand and blocked access to inpatient beds. The Emergency Health Services Queensland (EHSQ) study aims to identify the factors driving increased demand for emergency health and to evaluate strategies which may safely reduce the future demand growth. This monograph addresses the perspectives of users of both ambulance services and EDs. The research reported here aimed to identify the perspectives of users of emergency health services, both ambulance services and public hospital Emergency Departments and to identify the factors that they took into consideration when exercising their choice of location for acute health care. A cross-sectional survey design was used involving a survey of patients or their carers presenting to the EDs of a stratified sample of eight hospitals. A specific purpose questionnaire was developed based on a novel theoretical model which had been derived from analysis of the literature (Monograph 1). Two survey versions were developed: one for adult patients (self-complete); and one for children (to be completed by parents/guardians). The questionnaires measured perceptions of social support, health status, illness severity, self-efficacy; beliefs and attitudes towards ED and ambulance services; reasons for using these services, and actions taken prior to the service request. The survey was conducted at a stratified sample of eight hospitals representing major cities (four), inner regional (two) and outer regional and remote (two). Due to practical limitations, data were collected for ambulance and ED users within hospital EDs, while patients were waiting for or under treatment. A sample size quota was determined for each ED based on their 2009/10 presentation volumes. The data collection was conducted by four members of the research team and a group of eight interviewers between March and May 2011 (corresponding to autumn season). Of the total of 1608 patients in all eight emergency departments the interviewers were able to approach 1361 (85%) patients and seek their consent to participate in the study. In total, 911 valid surveys were available for analysis (response rate= 67%). These studies demonstrate that patients elected to attend hospital EDs in a considered fashion after weighing up alternatives and there is no evidence of deliberate or ill-informed misuse. • Patients attending ED have high levels of social support and self-efficacy that speak to the considered and purposeful nature of the exercise of choice. • About one third of patients have new conditions while two thirds have chronic illnesses • More than half the attendees (53.1%) had consulted a healthcare professional prior to making the decision. • The decision to seek urgent care at an ED was mostly constructed around the patient’s perception of the urgency and severity of their illness, reinforced by a strong perception that the hospital ED was the correct location for them (better specialised staff, better care for my condition, other options not as suitable). • 33% of the respondent held private hospital insurance but nevertheless attended a public hospital ED. Similarly patients exercised considered and rational judgements in their choice to seek help from the ambulance service. • The decision to call for ambulance assistance was based on a strong perception about the severity of the illness (too severe to use other means of transport) and that other options were not considered appropriate. • The decision also appeared influenced by a perception that the ambulance provided appropriate access to the ED which was considered most appropriate for their particular condition (too severe to go elsewhere, all facilities in one spot, better specialised and better care). • In 43.8% of cases a health care professional advised use of the ambulance. • Only a small number of people perceived that ambulance should be freely available regardless of severity or appropriateness. These findings confirm a growing understanding that the choice of professional emergency health care services is not made lightly but rather made by reasonable people exercising a judgement which is influenced by public awareness of the risks of acute health and which is most often informed by health professionals. It is also made on the basis of a rational weighing up of alternatives and a deliberate and considered choice to seek assistance from a service which the patient perceived was most appropriate to their needs at that time. These findings add weight to dispensing with public perceptions that ED and ambulance congestion is a result of inappropriate choice by patients. The challenge for health services is to better understand the patient’s needs and to design and validate services that meet those needs. The failure of our health system to do so should not be grounds for blaming the patient, claiming inappropriate patient choices.

Stochastic growth models for analyzing crustacean data

The contemporary methodology for growth models of organisms is based on continuous trajectories and thus it hinders us from modelling stepwise growth in crustacean populations. Growth models for fish are normally assumed to follow a continuous function, but a different type of model is needed for crustacean growth. Crustaceans must moult in order for them to grow. The growth of crustaceans is a discontinuous process due to the periodical shedding of the exoskeleton in moulting. The stepwise growth of crustaceans through the moulting process makes the growth estimation more complex. Stochastic approaches can be used to model discontinuous growth or what are commonly known as "jumps" (Figure 1). However, in stochastic growth model we need to ensure that the stochastic growth model results in only positive jumps. In view of this, we will introduce a subordinator that is a special case of a Levy process. A subordinator is a non-decreasing Levy process, that will assist in modelling crustacean growth for better understanding of the individual variability and stochasticity in moulting periods and increments. We develop the estimation methods for parameter estimation and illustrate them with the help of a dataset from laboratory experiments. The motivational dataset is from the ornate rock lobster, Panulirus ornatus, which can be found between Australia and Papua New Guinea. Due to the presence of sex effects on the growth (Munday et al., 2004), we estimate the growth parameters separately for each sex. Since all hard parts are shed too often, the exact age determination of a lobster can be challenging. However, the growth parameters for the aforementioned moult processes from tank data being able to estimate through: (i) inter-moult periods, and (ii) moult increment. We will attempt to derive a joint density, which is made up of two functions: one for moult increments and the other for time intervals between moults. We claim these functions are conditionally independent given pre-moult length and the inter-moult periods. The variables moult increments and inter-moult periods are said to be independent because of the Markov property or conditional probability. Hence, the parameters in each function can be estimated separately. Subsequently, we integrate both of the functions through a Monte Carlo method. We can therefore obtain a population mean for crustacean growth (e. g. red curve in Figure 1). [GRAPHICS]

Appropriate Institutions and Economic Growth - one size fits no-one

Modern-day economics is increasingly biased towards believing that institutions matter for growth, an argument that has been further enforced by the recent economic crisis. There is also a wide consensus on what these growth-promoting institutions should look like, and countries are periodically ranked depending on how their institutional structure compares with the best-practice institutions, mostly in place in the developing world. In this paper, it is argued that ”non-desirable” or “second-best” institutions can be beneficial for fostering investment and thus providing a starting point for sustained growth, and that what matters is the appropriateness of institutions to the economy’s distance to the frontier or current phase of development. Anecdotal evidence from Japan and South-Korea is used as a motivation for studying the subject and a model is presented to describe this phenomenon. In the model, the rigidity or non-rigidity of the institutions is described by entrepreneurial selection. It is assumed that entrepreneurs are the ones taking part in the imitation and innovation of technologies, and that decisions on whether or not their projects are refinanced comes from capitalists. The capitalists in turn have no entrepreneurial skills and act merely as financers of projects. The model has two periods, and two kinds of entrepreneurs: those with high skills and those with low skills. The society’s choice of whether an imitation or innovation – based strategy is chosen is modeled as the trade-off between refinancing a low-skill entrepreneur or investing in the selection of the entrepreneurs resulting in a larger fraction of high-skill entrepreneurs with the ability to innovate but less total investment. Finally, a real-world example from India is presented as an initial attempt to test the theory. The data from the example is not included in this paper. It is noted that the model may be lacking explanatory power due to difficulties in testing the predictions, but that this should not be seen as a reason to disregard the theory – the solution might lie in developing better tools, not better just better theories. The conclusion presented is that institutions do matter. There is no one-size-fits-all-solution when it comes to institutional arrangements in different countries, and developing countries should be given space to develop their own institutional structures that cater to their specific needs.

Effects of initial height on the steady-state persistence probability of linear growth models

The effects of the initial height on the temporal persistence probability of steady-state height fluctuations in up-down symmetric linear models of surface growth are investigated. We study the (1 + 1)-dimensional Family model and the (1 + 1)-and (2 + 1)-dimensional larger curvature (LC) model. Both the Family and LC models have up-down symmetry, so the positive and negative persistence probabilities in the steady state, averaged over all values of the initial height h(0), are equal to each other. However, these two probabilities are not equal if one considers a fixed nonzero value of h(0). Plots of the positive persistence probability for negative initial height versus time exhibit power-law behavior if the magnitude of the initial height is larger than the interface width at saturation. By symmetry, the negative persistence probability for positive initial height also exhibits the same behavior. The persistence exponent that describes this power-law decay decreases as the magnitude of the initial height is increased. The dependence of the persistence probability on the initial height, the system size, and the discrete sampling time is found to exhibit scaling behavior.

Trend analysis in two standard growth models

This paper analyzes the trend processes characterized by two standard growth models using simple econometrics. The first model is the basic neoclassical growth model that postulates a deterministic trend for output. The second model is the Uzawa-Lucas model that postulates a stochastic trend for output. The aim is to understand how the different trend processes for output assumed by these two standard growth models determine the ability of each model to explain the observed trend processes of other macroeconomic variables such as consumption and investment. The results show that the two models reproduce the output trend process. Moreover, the results show that the basic growth model captures properly the consumption trend process, but fails in characterizing the investment trend process. The reverse is true for the Uzawa-Lucas model.

Age and growth of spiny dogfish (Squalus acanthias) in the Gulf of Alaska: analysis of alternative growth models

Ten growth models were fitted to age and growth data for spiny dogfish (Squalus acanthias) in the Gulf of Alaska. Previous studies of spiny dogfish growth have all fitted the t0 formulation of the von Bertalanffy model without examination of alternative models. Among the alternatives, we present a new two-phase von Bertalanffy growth model formulation with a logistically scaled k parameter and which estimates L0. A total of 1602 dogfish were aged from opportunistic collections with longline, rod and reel, set net, and trawling gear in the eastern and central Gulf of Alaska between 2004 and 2007. Ages were estimated from the median band count of three independent readings of the second dorsal spine plus the estimated number of worn bands for worn spines. Owing to a lack of small dogfish in the samples, lengths at age of small individuals were back-calculated from a subsample of 153 dogfish with unworn spines. The von Bertalanffy, two-parameter von Bertalanffy, two-phase von Bertalanffy, Gompertz, two-parameter Gompertz, and logistic models were fitted to length-at-age data for each sex separately, both with and without back-calculated lengths at age. The two-phase von Bertalanffy growth model produced the statistically best fit for both sexes of Gulf of Alaska spiny dogfish, resulting in L∞ = 87.2 and 102.5 cm and k= 0.106 and 0.058 for males and females, respectively.

A one-year investigation of the relationship between serum GH levels and the growth of F-4 transgenic and non-transgenic common carp Cyprinus carpio

It has been demonstrated that growth hormone (GH) transgenic fish often posses a trait for fast growth. Here, we investigated the growth of F-4 'all-fish' GH transgenic carp Cyprinus carpio and their serum GH levels for a year. The results showed that F-4 all-fish GH transgenic carp were significantly larger in body mass (c. two-fold, P < 0 center dot 001) and body length (c. 1 center dot 3 fold, P < 0 center dot 001), compared with the non-transgenic group. The discrepancy of serum GH levels between the transgenic carp group and control group is 54 fold, when the water temperature was 12-34 degrees C. When the water temperature decreased to 3 center dot 5 degrees C in January, the discrepancy was 256 fold. The serum GH level of the transgenic group was relatively constant, while that of control varied greatly based on month and water temperature. The changes of growth rates between the transgenic group and the control group were similar for a year. Taken together, the results indicated that F-4 all-fish GH transgenic carp had not only higher and constant serum GH levels but also a significant fast-growing effect, compared with the control. To our knowledge, this is the first report on a one-year investigation of growth trait and serum growth hormone level in F-4 all-fish GH transgenic carp.

Late Holocene sea-level fall and turn-off of reef flat carbonate production: Rethinking bucket fill and coral reef growth models

Relative sea-level rise has been a major factor driving the evolution of reef systems during the Holocene. Most models of reef evolution suggest that reefs preferentially grow vertically during rising sea level then laterally from windward to leeward, once the reef flat reaches sea level. Continuous lagoonal sedimentation ("bucket fill") and sand apron progradation eventually lead to reef systems with totally filled lagoons. Lagoonal infilling of One Tree Reef (southern Great Barrier Reef) through sand apron accretion was examined in the context of late Holocene relative sea-level change. This analysis was conducted using sedimentological and digital terrain data supported by 50 radiocarbon ages from fossil microatolls, buried patch reefs, foraminifera and shells in sediment cores, and recalibrated previously published radiocarbon ages. This data set challenges the conceptual model of geologically continuous sediment infill during the Holocene through sand apron accretion. Rapid sand apron accretion occurred between 6000 and 3000 calibrated yr before present B.P. (cal. yr B.P.); followed by only small amounts of sedimentation between 3000 cal. yr B.P. and present, with no significant sand apron accretion in the past 2 k.y. This hiatus in sediment infill coincides with a sea-level fall of similar to 1-1.3 m during the late Holocene (ca. 2000 cal. yr B.P.), which would have caused the turn-off of highly productive live coral growth on the reef flats currently dominated by less productive rubble and algal flats, resulting in a reduced sediment input to back-reef environments and the cessation in sand apron accretion. Given that relative sea-level variations of similar to 1 m were common throughout the Holocene, we suggest that this mode of sand apron development and carbonate production is applicable to most reef systems.

Labor supply, biased technological change and economic growth

Se utiliza un modelo de innovaciones sesgadas para estudiar los efectos de cambios exógenos en la oferta laboral. En un contexto de innovaciones sesgadas, a medida que las economías acumulan capital, el trabajo se hace relativamente más escaso y más caro, por este motivo, hay incentivos para adoptar tecnologías ahorradoras de trabajo. Del mismo modo un cambio en la oferta laboral afecta la abundancia de factores y sus precios relativos. En general, una reducción de la oferta laboral, hace que el trabajo sea más caro y genera incentivos para cambio tecnológico ahorrador de trabajo. Así, el efecto inicial que tiene el cambio en la oferta laboral sobre los precios de los factores es mitigado por el cambio tecnológico. Finalmente, los movimientos en la remuneración a los factores afectan las decisiones de ahorro y, por lo tanto, la dinámica del crecimiento. En este trabajo se exploran las consecuencias de una reducción de la oferta laboral en dos contextos teóricos diferentes: un modelo de agentes homogéneos y horizonte infinito y un modelo de generaciones traslapadas.

Endothelin-1 and fibroblast growth factors stimulate the mitogen-activated protein kinase signaling cascade in cardiac myocytes. The potential role of the cascade in the integration of two signaling pathways leading to myocyte hypertrophy.

Maximally effective concentrations of endothelin-1 (ET-1), acidic FGF (aFGF), or 12-O-tetradecanoylphorbol-13-acetate (TPA) activated mitogen-activated protein kinase (MAPK) by 3-4-fold in crude extracts of myocytes cultured from neonatal rat heart ventricles. Maximal activation was achieved after 5 min. Thereafter, MAPK activity stimulated by ET-1 or aFGF declined to control values within 1-2 h, whereas activation by TPA was more sustained. Two peaks of MAPK activity (a 42- and a 44-kDa MAPK) were resolved in cells exposed to ET-1 or aFGF by fast protein liquid chromatography on a Mono Q column. One major and one minor peak of MAPK kinase (MAPKK) was stimulated by ET-1 or aFGF. Cardiac myocytes expressed protein kinase C (PKC)-alpha, -delta, -epsilon and -zeta as shown immunoblotting. Exposure to 1 microM TPA for 24 h down-regulated PKC-alpha, -delta, and -epsilon, but not PKC-zeta. This maneuver wholly abolished the activation of MAPK on re-exposure to TPA but did not affect the response to aFGF. The effect of ET-1 was partially down-regulated. ET-1 stimulated phospho[3H]inositide hydrolysis 18-fold, whereas aFGF stimulated by only 30%. Agonists which initially utilize dissimilar signaling pathways may therefore converge at the level of MAPKK/MAPK and this may be relevant to the hypertrophic response of the heart.

Solving the non-convexity problem in some shopping-time and human-capital models

Several works in the shopping-time and in the human-capital literature, due to the nonconcavity of the underlying Hamiltonian, use Örst-order conditions in dynamic optimization to characterize necessity, but not su¢ ciency, in intertemporal problems. In this work I choose one paper in each one of these two areas and show that optimality can be characterized by means of a simple aplication of Arrowís (1968) su¢ ciency theorem.

Breeding value accuracy estimates for growth traits using random regression and multi-trait models in Nelore cattle

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Structural change and productivity growth, 20 years later: old problems, new opportunities

Includes bibliography

Effective carrying capacity and analytical solution of a particular case of the Richards-like two-species population dynamics model

We consider a generalized two-species population dynamic model and analytically solve it for the amensalism and commensalism ecological interactions. These two-species models can be simplified to a one-species model with a time dependent extrinsic growth factor. With a one-species model with an effective carrying capacity one is able to retrieve the steady state solutions of the previous one-species model. The equivalence obtained between the effective carrying capacity and the extrinsic growth factor is complete only for a particular case, the Gompertz model. Here we unveil important aspects of sigmoid growth curves, which are relevant to growth processes and population dynamics. (C) 2011 Elsevier B.V. All rights reserved.

Performance evaluation of low environmental impact asphalt concretes using the mechanistic empirical design method based on laboratory fatigue and permanent deformation models

The "sustainability" concept relates to the prolonging of human economic systems with as little detrimental impact on ecological systems as possible. Construction that exhibits good environmental stewardship and practices that conserve resources in a manner that allow growth and development to be sustained for the long-term without degrading the environment are indispensable in a developed society. Past, current and future advancements in asphalt as an environmentally sustainable paving material are especially important because the quantities of asphalt used annually in Europe as well as in the U.S. are large. The asphalt industry is still developing technological improvements that will reduce the environmental impact without affecting the final mechanical performance. Warm mix asphalt (WMA) is a type of asphalt mix requiring lower production temperatures compared to hot mix asphalt (HMA), while aiming to maintain the desired post construction properties of traditional HMA. Lowering the production temperature reduce the fuel usage and the production of emissions therefore and that improve conditions for workers and supports the sustainable development. Even the crumb-rubber modifier (CRM), with shredded automobile tires and used in the United States since the mid 1980s, has proven to be an environmentally friendly alternative to conventional asphalt pavement. Furthermore, the use of waste tires is not only relevant in an environmental aspect but also for the engineering properties of asphalt [Pennisi E., 1992]. This research project is aimed to demonstrate the dual value of these Asphalt Mixes in regards to the environmental and mechanical performance and to suggest a low environmental impact design procedure. In fact, the use of eco-friendly materials is the first phase towards an eco-compatible design but it cannot be the only step. The eco-compatible approach should be extended also to the design method and material characterization because only with these phases is it possible to exploit the maximum potential properties of the used materials. Appropriate asphalt concrete characterization is essential and vital for realistic performance prediction of asphalt concrete pavements. Volumetric (Mix design) and mechanical (Permanent deformation and Fatigue performance) properties are important factors to consider. Moreover, an advanced and efficient design method is necessary in order to correctly use the material. A design method such as a Mechanistic-Empirical approach, consisting of a structural model capable of predicting the state of stresses and strains within the pavement structure under the different traffic and environmental conditions, was the application of choice. In particular this study focus on the CalME and its Incremental-Recursive (I-R) procedure, based on damage models for fatigue and permanent shear strain related to the surface cracking and to the rutting respectively. It works in increments of time and, using the output from one increment, recursively, as input to the next increment, predicts the pavement conditions in terms of layer moduli, fatigue cracking, rutting and roughness. This software procedure was adopted in order to verify the mechanical properties of the study mixes and the reciprocal relationship between surface layer and pavement structure in terms of fatigue and permanent deformation with defined traffic and environmental conditions. The asphalt mixes studied were used in a pavement structure as surface layer of 60 mm thickness. The performance of the pavement was compared to the performance of the same pavement structure where different kinds of asphalt concrete were used as surface layer. In comparison to a conventional asphalt concrete, three eco-friendly materials, two warm mix asphalt and a rubberized asphalt concrete, were analyzed. The First Two Chapters summarize the necessary steps aimed to satisfy the sustainable pavement design procedure. In Chapter I the problem of asphalt pavement eco-compatible design was introduced. The low environmental impact materials such as the Warm Mix Asphalt and the Rubberized Asphalt Concrete were described in detail. In addition the value of a rational asphalt pavement design method was discussed. Chapter II underlines the importance of a deep laboratory characterization based on appropriate materials selection and performance evaluation. In Chapter III, CalME is introduced trough a specific explanation of the different equipped design approaches and specifically explaining the I-R procedure. In Chapter IV, the experimental program is presented with a explanation of test laboratory devices adopted. The Fatigue and Rutting performances of the study mixes are shown respectively in Chapter V and VI. Through these laboratory test data the CalME I-R models parameters for Master Curve, fatigue damage and permanent shear strain were evaluated. Lastly, in Chapter VII, the results of the asphalt pavement structures simulations with different surface layers were reported. For each pavement structure, the total surface cracking, the total rutting, the fatigue damage and the rutting depth in each bound layer were analyzed.