Introducing consultant outpatient clinics to community settings to improve access to paediatrics:an observational impact study

Objectives - In line with a national policy to move care ‘closer to home’, a specialist children's hospital in the National Health Service in England introduced consultant-led ‘satellite’ clinics to two community settings for general paediatric outpatient services. Objectives were to reduce non-attendance at appointments by providing care in more accessible locations and to create new physical clinic capacity. This study evaluated these satellite clinics to inform further development and identify lessons for stakeholders. Methods - Impact of the satellite clinics was assessed by comparing community versus hospital-based clinics across the following measures: (1) non-attendance rates and associated factors (including patient characteristics and travel distance) using a logistic regression model; (2) percentage of appointments booked within local catchment area; (3) contribution to total clinic capacity; (4) time allocated to clinics and appointments; and (5) clinic efficiency, defined as the ratio of income to staff-related costs. Results - Satellite clinics did not increase attendance beyond their contribution to shorter travel distance, which was associated with higher attendance. Children living in the most-deprived areas were 1.8 times more likely to miss appointments compared with those from least-deprived areas. The satellite clinics’ contribution to activity in catchment areas and to total capacity was small. However, one of the two satellite clinics was efficient compared with most hospital-based clinics. Conclusions - Outpatient clinics were relocated in pragmatically chosen community settings using a ‘drag and drop’ service model. Such clinics have potential to improve access to specialist paediatric healthcare, but do not provide a panacea. Work is required to improve attendance as part of wider efforts to support vulnerable families. Satellite clinics highlight how improved management could contribute to better use of existing capacity.

A comparative analysis of school satisfaction and dropout risk of middle school students attending programs for students with emotional handicaps, severe emotional disturbance and general education students attending center schools and satellite schools

This study evaluated school satisfaction as an indicator of dropout risk of students with Emotional Handicaps (EH) and students with Severe Emotional Disturbance (SED). The students attended two different kinds of middle schools in a largely urban school district in South Florida. One hundred eight students in grade 8 (ages 13-16) participated in this study. Participants were administered the National Dropout Prevention Assessment (NDPA). Forty participants with EH and SED attended a special center school. Thirty-one participants with EH and SED attended satellite programs in a regular middle school. Thirty-seven general education participants attended the same regular middle school. Overall school satisfaction scores were generated, as well as three primary factors (school, environment and personal) and 16 subscales (school atmosphere, future income, difficulty level of classwork, teacher relationships, peer relationships, intrinsic interest in classwork, school hours, classwork stress, general attitude towards school, family influence, perceived opportunity for career, future goals, travel distance, leisure time, self-appraisal of performance, and self-esteem).^ Comparison of students with EH and SED revealed that both groups of students were rated at "low risk" of becoming dropouts on the Environmental factor and the Difficulty of Schoolwork subscale. Students with EH were rated at "caution risk" risk on the Travel Distance subscale. Students with SED were rated at "high risk" on this subscale.^ There were no significant differences in school satisfaction and dropout risk between different program delivery models. There were also no significant differences for category of students (EH, SED) by school type (center school, satellite program). All students were rated at "low risk" of dropping out of school.^ There were significant differences between general education students and students with EH and SED attending satellite programs. Students with EH and SED were rated at "caution risk" for dropping out on the Travel Distance and the Leisure Time subscales. Discussion of results, implications for practice and recommendations for further research are included. ^

Simulation Optimization of the Crossdock Door Assignmnet Problem

The purpose of this report is to present the Crossdock Door Assignment Problem, which involves assigning destinations to outbound dock doors of Crossdock centres such that travel distance by material handling equipment is minimized. We propose a two fold solution; simulation and optimization of the simulation model - simulation optimization. The novel aspect of our solution approach is that we intend to use simulation to derive a more realistic objective function and use Memetic algorithms to find an optimal solution. The main advantage of using Memetic algorithms is that it combines a local search with Genetic Algorithms. The Crossdock Door Assignment Problem is a new domain application to Memetic Algorithms and it is yet unknown how it will perform.

Simulation Optimization of the Crossdock Door Assignmnet Problem

The purpose of this report is to present the Crossdock Door Assignment Problem, which involves assigning destinations to outbound dock doors of Crossdock centres such that travel distance by material handling equipment is minimized. We propose a two fold solution; simulation and optimization of the simulation model - simulation optimization. The novel aspect of our solution approach is that we intend to use simulation to derive a more realistic objective function and use Memetic algorithms to find an optimal solution. The main advantage of using Memetic algorithms is that it combines a local search with Genetic Algorithms. The Crossdock Door Assignment Problem is a new domain application to Memetic Algorithms and it is yet unknown how it will perform.

Coaching or gaming? Implications of strategy choice for home based stroke rehabilitation

Background: The enduring aging of the world population and prospective increase of age-related chronic diseases urge the implementation of new models for healthcare delivery. One strategy relies on ICT (Information and Communications Technology) home-based solutions allowing clients to pursue their treatments without institutionalization. Stroke survivors are a particular population that could strongly benefit from such solutions, but is not yet clear what the best approach is for bringing forth an adequate and sustainable usage of home-based rehabilitation systems. Here we explore two possible approaches: coaching and gaming. Methods: We performed trials with 20 healthy participants and 5 chronic stroke survivors to study and compare execution of an elbow flexion and extension task when performed within a coaching mode that provides encouragement or within a gaming mode. For each mode we analyzed compliance, arm movement kinematics and task scores. In addition, we assessed the usability and acceptance of the proposed modes through a customized self-report questionnaire. Results: In the healthy participants sample, 13/20 preferred the gaming mode and rated it as being significantly more fun (p < .05), but the feedback delivered by the coaching mode was subjectively perceived as being more useful (p < .01). In addition, the activity level (number of repetitions and total movement of the end effector) was significantly higher (p <.001) during coaching. However, the quality of movements was superior in gaming with a trend towards shorter movement duration (p=.074), significantly shorter travel distance (p <.001), higher movement efficiency (p <.001) and higher performance scores (p <.001). Stroke survivors also showed a trend towards higher activity levels in coaching, but with more movement quality during gaming. Finally, both training modes showed overall high acceptance. Conclusions: Gaming led to higher enjoyment and increased quality in movement execution in healthy participants. However, we observed that game mechanics strongly determined user behavior and limited activity levels. In contrast, coaching generated higher activity levels. Hence, the purpose of treatment and profile of end-users has to be considered when deciding on the most adequate approach for home based stroke rehabilitation.

Coaching or gaming? Implications of strategy choice for home based stroke rehabilitation

Background: The enduring aging of the world population and prospective increase of age-related chronic diseases urge the implementation of new models for healthcare delivery. One strategy relies on ICT (Information and Communications Technology) home-based solutions allowing clients to pursue their treatments without institutionalization. Stroke survivors are a particular population that could strongly benefit from such solutions, but is not yet clear what the best approach is for bringing forth an adequate and sustainable usage of home-based rehabilitation systems. Here we explore two possible approaches: coaching and gaming. Methods: We performed trials with 20 healthy participants and 5 chronic stroke survivors to study and compare execution of an elbow flexion and extension task when performed within a coaching mode that provides encouragement or within a gaming mode. For each mode we analyzed compliance, arm movement kinematics and task scores. In addition, we assessed the usability and acceptance of the proposed modes through a customized self-report questionnaire. Results: In the healthy participants sample, 13/20 preferred the gaming mode and rated it as being significantly more fun (p < .05), but the feedback delivered by the coaching mode was subjectively perceived as being more useful (p < .01). In addition, the activity level (number of repetitions and total movement of the end effector) was significantly higher (p <.001) during coaching. However, the quality of movements was superior in gaming with a trend towards shorter movement duration (p=.074), significantly shorter travel distance (p <.001), higher movement efficiency (p <.001) and higher performance scores (p <.001). Stroke survivors also showed a trend towards higher activity levels in coaching, but with more movement quality during gaming. Finally, both training modes showed overall high acceptance. Conclusions: Gaming led to higher enjoyment and increased quality in movement execution in healthy participants. However, we observed that game mechanics strongly determined user behavior and limited activity levels. In contrast, coaching generated higher activity levels. Hence, the purpose of treatment and profile of end-users has to be considered when deciding on the most adequate approach for home based stroke rehabilitation.

Timeliness, efficiency and public procurement in hip surgery in Italy

Considering different perspectives, the scope of this thesis is to investigate how to improve healthcare resources allocation and the provision efficiency for hip surgeries, a resource-intensive operation, among the most frequently performed on the elderly, with a trend in volume that is increasing in years due to population aging. Firstly, the effect of Time-To-Surgery (TTS) on mortality for hip fracture patients is investigated. The analysis attempts to account for TTS endogeneity due to the inability to fully control for variables affecting patient delay – e.g. patient severity. Exploiting an instrumental variable model, where being admitted on Friday or Saturday predicts longer TTS, findings show exogenous TTS does not have a significant effect on mortality. Thus suggesting surgeons prioritize patients effectively, neutralizing the adverse impact of longer TTS. Then, the volume-outcome relation for total hip replacement surgery is analyzed, seeking to account for selective referral, which may be present in elective surgery context, and induce reverse causality issue in the volume-outcome relation. The analysis employs a conditional choice model where patient travel distance from all regions' hospitals is used as a hospital choice predictor. Findings show the exogenous hospital volume significantly decreases adverse outcomes probability, especially in the short run. Finally, the change in public procurement design enforced in the Romagna LHA (Italy) is exploited to assess its impact on hip prostheses cost, surgeons' implant choice, and patient health outcomes. Hip prostheses are the major cost-driver of hip replacement surgeries, hence it is crucial to design the public tender such that implant prices are minimized, but cost-containment policies have to be weighted with patient well-being. Evidence shows that a cost reduction occurred without a significant surgeons’ choices impact. Positive or no effect of surgeons specialization is found on patients outcomes after the new procurement introduction.

Virtual (dis) connectivities : mobile intimacy and presence for women in long distance relationships

Nous vivons dans une époque où la mobilité internationale est une pratique très courante; ainsi, de plus en plus de partenaires doivent maintenir leurs relations à distance. Le phénomène va de pair avec le développement des nouvelles technologies, qui introduisent de nouvelles formes et de pratiques pour maintenir l’intimité. Cela soulève des questions sur les pratiques de connexion (ou déconnexion) lorsque les couples sont séparés par la distance et le temps. Ce mémoire propose d’explorer comment les femmes dans des relations amoureuses à distance utilisent divers modes d’expression (visuels, textuels, oraux et tactiles) ainsi que plusieurs sens à travers de multiples technologies mobiles, qui lui permettent de reconstruire la présence et l’intimité avec l’autre. Inspiré par le new mobilities paradigm (Sheller & Urry, 2006), ainsi que les concepts de mobile intimacy (Hjorth & Lim, 2012; Elliott & Urry, 2010) et la présence imaginée (Chayko, 2002; Elliott & Urry, 2010), je propose les notions de (dé) connectivité virtuelle, le lieu virtuel, ainsi que la présence/absence technologique. Utilisant une approche méthodologique mixte, venant des données d’entrevues semi-dirigées, de l’autoethnographie, de la recherche création et de journaux de bord multimédias, certaines pratiques de contrôle et de surveillance, des formes émergentes de travail, l’immédiateté et la réciprocité émergent dans une époque d’interconnectivité.

Evolution of coronal mass ejection morphology with increasing heliocentric distance. II. In Situ observations

Interplanetary coronal mass ejections (ICMEs) are often observed to travel much faster than the ambient solar wind. If the relative speed between the two exceeds the fast magnetosonic velocity, then a shock wave will form. The Mach number and the shock standoff distance ahead of the ICME leading edge is measured to infer the vertical size of an ICME in a direction that is perpendicular to the solar wind flow. We analyze the shock standoff distance for 45 events varying between 0.5 AU and 5.5 AU in order to infer their physical dimensions. We find that the average ratio of the inferred vertical size to measured radial width, referred to as the aspect ratio, of an ICME is 2.8 ± 0.5. We also compare these results to the geometrical predictions from Paper I that forecast an aspect ratio between 3 and 6. The geometrical solution varies with heliocentric distance and appears to provide a theoretical maximum for the aspect ratio of ICMEs. The minimum aspect ratio appears to remain constant at 1 (i.e., a circular cross section) for all distances. These results suggest that possible distortions to the leading edge of ICMEs are frequent. But, these results may also indicate that the constants calculated in the empirical relationship correlating the different shock front need to be modified; or perhaps both distortions and a change in the empirical formulae are required.

Distance from forest edge affects bee pollinators in oilseed rape fields

Wild pollinators have been shown to enhance the pollination of Brassica napus(oilseed rape) and thus increase its market value. Several studies have previously shown that pollination services are greater in crops adjoining forest patches or other seminatural habitats than in crops completely surrounded by other crops. In this study, we investigated the specific importance of forest edges in providing potential pollinators in B. napus fields in two areas in France. Bees were caught with yellow pan traps at increasing distances from both warm and cold forest edges into B. napus fields during the blooming period. A total of 4594 individual bees, representing six families and 83 taxa, were collected. We found that both bee abundance and taxa richness were negatively affected by the distance from forest edge. However, responses varied between bee groups and edge orientations. The ITD (Inter-Tegular distance) of the species, a good proxy for bee foraging range, seems to limit how far the bees can travel from the forest edge. We found a greater abundance of cuckoo bees (Nomada spp.) of Andrena spp. and Andrena spp. males at forest edges, which we assume indicate suitable nesting sites, or at least mating sites, for some abundant Andrena species and their parasites (Fig. 1). Synthesis and Applications. This study provides one of the first examples in temperate ecosystems of how forest edges may actually act as a reservoir of potential pollinators and directly benefit agricultural crops by providing nesting or mating sites for important early spring pollinators. Policymakers and land managers should take forest edges into account and encourage their protection in the agricultural matrix to promote wild bees and their pollination services.

Distance measure and the p-median problem in rural areas

The p-median model is used to locate P facilities to serve a geographically distributed population. Conventionally, it is assumed that the population patronize the nearest facility and that the distance between the resident and the facility may be measured by the Euclidean distance. Carling, Han, and Håkansson (2012) compared two network distances with the Euclidean in a rural region witha sparse, heterogeneous network and a non-symmetric distribution of thepopulation. For a coarse network and P small, they found, in contrast to the literature, the Euclidean distance to be problematic. In this paper we extend their work by use of a refined network and study systematically the case when P is of varying size (2-100 facilities). We find that the network distance give as gooda solution as the travel-time network. The Euclidean distance gives solutions some 2-7 per cent worse than the network distances, and the solutions deteriorate with increasing P. Our conclusions extend to intra-urban location problems.

(Table 1) Two-way travel times and depths of picked internal reflection horizons (IRHs) of the NGRIP ice core

During the summer of 2003, a ground-penetrating radar survey around the North Greenland Icecore Project (NorthGRIP) deep ice-core drilling site (75°06' N, 42°20' W; 2957 m a.s.l.) was carried out using a shielded 250 MHz radar system. The drill site is located on an ice divide, roughly 300 km north-northwest of the summit of the Greenland ice sheet. More than 430 km of profiles were measured, covering a 10 km by 10 km area, with a grid centered on the drilling location, and eight profiles extending beyond this grid. Seven internal horizons within the upper 120 m of the ice sheet were continuously tracked, containing the last 400 years of accumulation history. Based on the age-depth and density-depth distribution of the deep core, the internal layers have been dated and the regional and temporal distribution of accumulation rate in the vicinity of NorthGRIP has been derived. The distribution of accumulation shows a relatively smoothly increasing trend from east to west from 145 kg/m**2/a to 200 kg/m**2/a over a distance of 50 km across the ice divide. The general trend is overlain by small-scale variations on the order of 2.5 kg/m**2/a/km, i.e. around 1.5% of the accumulation mean. The temporal variations of the seven periods defined by the seven tracked isochrones are on the order of +-4% of the mean of the last 400 years, i.e. at NorthGRIP ±7 kg/m**2/a. If the regional accumulation pattern has been stable for the last several thousand years during the Holocene, and ice flow has been comparable to today, advective effects along the particle trajectory upstream of NorthGRIP do not have a significant effect on the interpretation of climatically induced changes in accumulation rates derived from the deep ice core over the last 10 kyr.

Travel time and speed of gray whales and amphipod abundance along Chukotka Peninsula in 2006

The purpose of this study was to evaluate summer and fall residency and habitat selection by gray whales, Eschrichtius robustus, together with the biomass of benthic amphipod prey on the coastal feeding grounds along the Chukotka Peninsula. Thirteen gray whales were instrumented with satellite transmitters in September 2006 near the Chukotka Peninsula, Russia. Nine transmitters provided positions from whales for up to 81 days. The whales travelled within 5 km of the Chukotka coast for most of the period they were tracked with only occasional movements offshore. The average daily travel speeds were 23 km/day (range 9-53 km/day). Four of the whales had daily average travel speeds <1 km/day suggesting strong fidelity to the study area. The area containing 95% of the locations for individual whales during biweekly periods was on average 13,027 km**2 (range 7,097-15,896 km**2). More than 65% of all locations were in water <30 m, and between 45 and 70% of biweekly kernel home ranges were located in depths between 31 and 50 m. Benthic density of amphipods within the Bering Strait at depths <50 m was on average ~54 g wet wt/m**2 in 2006. It is likely that the abundant benthic biomass is more than sufficient forage to support the current gray whale population. The use of satellite telemetry in this study quantifies space use and movement patterns of gray whales along the Chukotka coast and identifies key feeding areas.

Modelling the relationship between urban environment and travel behaviour: policy and indicators

Due to the necessity to undertake activities, every year people increase their standards of travelling (distance and time). Urban sprawl development plays an important role in these "enlargements". Thus, governments invest money in an exhaustiva search for solutions to high levels of congestion and car-trips. The complex relationship between urban environment and travel behaviour has been studied in a number of cases. Thus, the objective of this paper is to answer the important question of which land-use attributes influence which dimensions of travel behaviour, and to verify to what extent specific urban planning measures affect the individual decision process, by exhaustiva statistical and systematic tests. This paper found that a crucial issue in the analysis of the relationship between the built environment and travel behaviour is the definition of indicators. As such, we recommend a feasible list of indicators to analyze this relationship.