Comparing Patient-Centered Medical Home Implementation in Urban and Rural VHA Clinics: Results from the Patient Aligned Care Team (PACT) Initiative

Thesis (Master's)--University of Washington, 2016-06

Increased risk of psychosis in rural-born individuals: An Australian catchment-area study

The aim of the Brisbane Psychosis Study was to examine a range of candidate genetic and nongenetic risk factors in a large, representative sample of patients with psychosis and well controls. The patients (n=310) were drawn from a census conducted as part of the National Survey of Mental Health and Wellbeing. An age and sex-matched well control group (n = 303) was drawn from the same catchment area. Candidate risk factors assessed included migrant status of proband and proband's parents, occupation of father at time of proband's birth, place of birth and place of residence during the first 5 years of life (urbanicity), self-reported pregnancy and birth complications, season of birth and family history. The main analyses were group (cases versus controls) comparisons, with planned subgroup analyses (1) group comparisons for Australian-born subjects only, (2) within-patient comparisons of affective versus nonaffective psychoses. Of the individuals with psychosis, 68% had DSMIII-R schizophrenia. In the main analyses, there were no significant group differences on season of birth, place of birth, place of residency in the first 5 years, occupation of fathers at time of birth or pregnancy and birth complications. Patients had significantly more family members with schizophrenia. Significantly fewer of the patients were migrants or offspring of migrants compared to the controls. When only Australianborn subjects were assessed (n=457), the findings were essentially unchanged apart from a significant excess of cases born in rural sites (chi-square=9.54, df3, p=0.02). There were no significant differences in the risk factors for the comparison involving affective versus nonaffective psychoses. Potential explanations for the inverse urban-rural risk gradient are reviewed. The Stanley Foundation supported this project

Derivaciones en los centros de salud de Andalucía según el sexo de profesionales y pacientes: un análisis de género.

BACKGROUND It has been identified differences of medical care practice in primary care related to physician's sex. Simultaneously, there are gender inequalities in the assignment of health resources. Both aspects give rise to an increasing growing interest in the management and provision of health services. OBJECTIVES To examine the differences in the referral practice made by female and male primary care physicians working in health centers in Andalusia, to consider whether there are disparities in referrals received by men and women, and to examine the interaction between patient's sex and physician's sex. METHODS Observational, cross-sectional, and multicenter study. POPULATION 4 health districts in Andalucía and their physicians. SAMPLE 382 physicians. MEASUREMENTS referral rate per visit (RV), referral rate per patient quota (RQ), patient's sex, physician: sex, age, postgraduate family medicine specialty, size of the patient quota by sex, mean number of patients/day by sex, mean age of the patient quota by sex, and proportion of men in the quota. Health center: urban / rural, size of the team, enrolled population, and postgraduate family medicine specialty's accreditation. SOURCES databases of health districts. PERIOD OF STUDY 2010. ANALYSIS Bivariate and multivariate multilevel analysis of the referral rate per visit with mixed Poisson model. RESULTS In 2010 382 physicians made 129,161 referrals to specialized care. The RQ was 23.47 and the RV was 4.92. The RQ in women and men was 27.23 and 19.78 for women physicians, being 27.37 and 19.51 for male physicians. The RV in women and men was 4.92 and 5.48 for women physicians, being 4.54 and 4.93 for male physicians. CONCLUSION There are no differences in referral according to physician's sex. However, there are signs that might indicate the existence of gender inequality, and women patient received less referrals. There are no physician-patient's sex interaction.

Thr54 allele carriers of the Ala54Thr variant of FABP2 gene have associations with metabolic syndrome and hypertriglyceridemia in urban South Indians

The intestinal fatty acid-binding protein gene is proposed as a candidate gene for diabetes because the protein it codes is involved in fatty acid absorption and metabolism. This study investigates the association of the Ala54Thr variant of the intestinal fatty acid-binding protein gene on type 2 diabetes mellitus and other related metabolic traits in Asian Indians. Ala54Thr polymorphism was genotyped by using polymerase chain reaction-restriction fragment length polymorphism in unrelated 773 type 2 diabetic and 899 normal glucose-tolerant (NGT) subjects, randomly chosen from the Chennai Urban Rural Epidemiology Study, an ongoing population-based study in South India. The Ala54Thr polymorphism was not associated with type 2 diabetes mellitus or obesity. However, genotype-phenotype study revealed that the NGT subjects carrying the Thr54 allele had significantly higher 2-hour plasma glucose (P = .007), glycated hemoglobin (P = .004), 2-hour insulin (P = .027), and fasting low-density lipoprotein cholesterol (P = .032) levels compared with those with the Ala54 allele. Normal glucose-tolerant subjects with Ala54Thr and Thr54Thr genotypes had significantly higher fasting serum triglyceride levels (P = .003) compared with those with Ala54Ala. The subjects were stratified into those with hypertriglyceridemia (serum triglyceride levels >or=150 mg/dL) and those without. The odds ratio for hypertriglyceridemia for the individuals carrying the Ala54Thr genotype was 1.491 (95% confidence interval [CI], 1.22-1.83, P < .0001), and for those carrying the Thr54Thr genotype, it was 1.888 (95% CI, 1.34-2.67; P < .0001). Subjects were also stratified into those with metabolic syndrome (MS) and those without, according to modified Adult Treatment Panel III guidelines. The odds ratio (adjusted for age and sex) for MS for the individuals carrying the Ala54Thr genotype was 1.240 (95% CI, 1.02-1.51; P = .03), whereas for those carrying the Thr54Thr genotype, it was 1.812 (95% CI, 1.28-2.57; P = .001). Carriers of the Thr54 allele have associations with MS and hypertriglyceridemia in this urban South Indian population.

Subsurface urban heat island and its effects on horizontal ground-source heat pump potential under climate change

Recent urban air temperature increase is attributable to the climate change and heat island effects due to urbanization. This combined effects of urbanization and global warming can penetrate into the underground and elevate the subsurface temperature. In the present study, over-100 years measurements of subsurface temperature at a remote rural site were analysed, and an increasing rate of 0.17⁰C per decade at soil depth of 30cm due to climate change was identified in the UK, but the subsurface warming in an urban site showed a much higher rate of 0.85⁰C per decade at a 30cm depth and 1.18⁰C per decade at 100cm. The subsurface urban heat island (SUHI) intensity obtained at the paired urban-rural stations in London showed an unique 'U-shape', i.e. lowest in summer and highest during winter. The maximum SUHII is 3.5⁰C at 6:00 AM in December, and the minimum UHII is 0.2⁰C at 18:00PM in July. Finally, the effects of SUHI on the energy efficiency of the horizontal ground source heat pump (GSHP) were determined. Provided the same heat pump used, the installation at an urban site will maintain an overall higher COP compared with that at a rural site in all seasons, but the highest COP improvement can be achieved in winter.

Using phenology to assess urban heat islands in tropical and temperate regions

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Population mixing and the risk of childhood leukaemia in Switzerland: a census-based cohort study.

Childhood leukaemia (CL) may have an infectious cause and population mixing may therefore increase the risk of CL. We aimed to determine whether CL was associated with population mixing in Switzerland. We followed children aged <16 years in the Swiss National Cohort 1990-2008 and linked CL cases from the Swiss Childhood Cancer Registry to the cohort. We calculated adjusted hazard ratios (HRs) for all CL, CL at age <5 years and acute lymphoblastic leukaemia (ALL) for three measures of population mixing (population growth, in-migration and diversity of origin), stratified by degree of urbanisation. Measures of population mixing were calculated for all municipalities for the 5-year period preceding the 1990 and 2000 censuses. Analyses were based on 2,128,012 children of whom 536 developed CL. HRs comparing highest with lowest quintile of population growth were 1.11 [95 % confidence interval (CI) 0.65-1.89] in rural and 0.59 (95 % CI 0.43-0.81) in urban municipalities (interaction: p = 0.271). Results were similar for ALL and for CL at age <5 years. For level of in-migration there was evidence of a negative association with ALL. HRs comparing highest with lowest quintile were 0.60 (95 % CI 0.41-0.87) in urban and 0.61 (95 % CI 0.30-1.21) in rural settings. There was little evidence of an association with diversity of origin. This nationwide cohort study of the association between CL and population growth, in-migration and diversity of origin provides little support for the population mixing hypothesis.

Social support, health status and health services utilization among the noninstitutionalized elderly: An analysis of the Supplement on Aging to the 1984 national health interview survey

The association between Social Support, Health Status, and Health Services Utilization of the elderly, was explored based on the analysis of data from the Supplement on Aging to the National Health Interview Survey, 1984 (N = 11,497) using a modified framework of Aday and Andersen's Expanded Behavioral Model. The results suggested that Social Support as operationalized in this study was an independent determinant of the use of health services. The quantity of social activities and the use of community services were the two most consistent determinants across different types of health services use.^ The effects of social support on the use of health services were broken down into three components to facilitate explanations of the mechanisms through which social support operated. The Predisposing and Enabling component of Social Support had independent, although not uniform, effects on the use of health services. Only slight substitute effects of social support were detected. These included the substitution of the use of senior centers for longer stay in the hospital and the substitution of help with IADL problems for the use of formal home care services.^ The effect of financial support on the use of health services was found to be different for middle and low income populations. This differential effect was also found for the presence of intimate networks, the frequencies of interaction with children and the perceived availability of support among urban/rural, male/female and white/non-white subgroups.^ The study also suggested that the selection of appropriate Health Status measures should be based on the type of Health Services Utilization in which a researcher is interested. The level of physical function limitation and role activity limitation were the two most consistent predictors of the volume of physician visits, number of hospital days, and average length of stay in the hospital during the past year.^ Some alternative hypotheses were also raised and evaluated, when possible. The impacts of the complex sample design, the reliability and validity of the measures and other limitations of this analysis were also discussed. Finally, a revised framework was proposed and discussed based on the analysis. Some policy implications and suggestions for future study were also presented. ^

An assessment of risk of osteogenic sarcoma from exposure to radium

The etiology of the vast majority of osteosarcoma deaths has not been explained. A possible explanation might be lifetime ingestion of radium from environmental sources which might give rise to differential risk. This study was an effort toward understanding the role of naturally occurring radium in the etiology of bone cancer. Furthermore, there was an interest in the interaction of between radionuclides and selenium; the latter believed to be a potential anticarcinogen.^ Two approaches were used to evaluate the association between environmental radium, selenium and osteogenic sarcoma: (1) spatial and temporal patterns of osteogenic sarcoma mortality in Texas were described for the period from 1969 to 1988; and (2) a case-control study was performed using 974 osteosarcoma deaths and category-matched controls selected from other deaths to evaluate the association between this disease and residency history as an indirect measure of radium and selenium exposures.^ Analyses and comparison of mortality in a population exposed to regions of elevated levels of radium 226,228 and elevated levels of selenium in drinking water with those in a matched control population have resulted in three observations: (1) there appeared to be a slight protective effect for residing in areas high in radium; (2) there were no significant differences between cases and controls when observed for length of residence or residence in urban/rural regions of high or low radium; and (3) although regions high in selenium appeared to have a decreased risk for bone cancer and urban areas in regions of elevated selenium showed an increased risk of bone cancer, these differences were not significant. ^

Empresarialidad y desarrollo local en la región rural periurbana de La Plata

El artículo se centra en la reflexión analítica de los participantes de un programa de desarrollo emprendedor en la Región Rural Periurbana centrada en el municipio de La Plata. El programa partió de una acción de extensión de la Universidad Nacional de La Plata (Olmos Emprende), cuyo desarrollo derivó en la articulación con programas más abarcativos de orden nacional y provincial. El primer objetivo es describir las condiciones específicas en las que se desarrolla la empresarialidad en América Latina y contextualizar la experiencia presentada. Posteriormente se hace una consideración del contexto territorial local que habría facilitado la participación en el programa teniendo en cuenta dos ámbitos regionales: por un lado la Región Rural Periurbana en general y por el otro lado, una serie de dimensiones locales que, además de factores tecno-económicos y marcos regulatorios estatales, incluyera circunstancias sociales y culturales. La pregunta que atraviesa el texto, focaliza la ubicación de la empresarialidad en el territorio, enfocado en sus posibilidades de desarrollo local. Observamos entonces las situaciones de interfase entre diversos actores territoriales, entre grupos de ciudadanos, diversas agencias estatales y la participación asimismo diversa de los agentes privados

Empresarialidad y desarrollo local en la región rural periurbana de La Plata

El artículo se centra en la reflexión analítica de los participantes de un programa de desarrollo emprendedor en la Región Rural Periurbana centrada en el municipio de La Plata. El programa partió de una acción de extensión de la Universidad Nacional de La Plata (Olmos Emprende), cuyo desarrollo derivó en la articulación con programas más abarcativos de orden nacional y provincial. El primer objetivo es describir las condiciones específicas en las que se desarrolla la empresarialidad en América Latina y contextualizar la experiencia presentada. Posteriormente se hace una consideración del contexto territorial local que habría facilitado la participación en el programa teniendo en cuenta dos ámbitos regionales: por un lado la Región Rural Periurbana en general y por el otro lado, una serie de dimensiones locales que, además de factores tecno-económicos y marcos regulatorios estatales, incluyera circunstancias sociales y culturales. La pregunta que atraviesa el texto, focaliza la ubicación de la empresarialidad en el territorio, enfocado en sus posibilidades de desarrollo local. Observamos entonces las situaciones de interfase entre diversos actores territoriales, entre grupos de ciudadanos, diversas agencias estatales y la participación asimismo diversa de los agentes privados

Empresarialidad y desarrollo local en la región rural periurbana de La Plata

El artículo se centra en la reflexión analítica de los participantes de un programa de desarrollo emprendedor en la Región Rural Periurbana centrada en el municipio de La Plata. El programa partió de una acción de extensión de la Universidad Nacional de La Plata (Olmos Emprende), cuyo desarrollo derivó en la articulación con programas más abarcativos de orden nacional y provincial. El primer objetivo es describir las condiciones específicas en las que se desarrolla la empresarialidad en América Latina y contextualizar la experiencia presentada. Posteriormente se hace una consideración del contexto territorial local que habría facilitado la participación en el programa teniendo en cuenta dos ámbitos regionales: por un lado la Región Rural Periurbana en general y por el otro lado, una serie de dimensiones locales que, además de factores tecno-económicos y marcos regulatorios estatales, incluyera circunstancias sociales y culturales. La pregunta que atraviesa el texto, focaliza la ubicación de la empresarialidad en el territorio, enfocado en sus posibilidades de desarrollo local. Observamos entonces las situaciones de interfase entre diversos actores territoriales, entre grupos de ciudadanos, diversas agencias estatales y la participación asimismo diversa de los agentes privados

Rural electrification revisited : the case of Bihar, India

This study describes the dynamic processes of electrification. Some electrified villages have experienced de-electrification, mainly due to technical issues. Some villages were re-electrified through various efforts. Our econometric exercise indicates that small villages in remote locations tend to not be prioritized in the electrification process. It also finds that the cumulative number of ever-electrified villages is higher among villages having a higher ratio of socially advanced classes. However, some of these experienced de-electrification, rendering ambiguous the impact of village social characteristics on electrification.

Análisis espacio-temporal del gradiente urbano-rural del sur de la Región Metropolitana de Madrid y su entorno. Caracterización de los procesos y patrones paisajísticos acaecidos en el período 1990-2006

El objetivo de esta tesis es proponer una metodología capaz de cuantificar la dinámica paisajística a lo largo del gradiente urbano – rural perteneciente al sur de la Región Metropolitana de Madrid y su entorno. Esta tesis se estructura en ocho capítulos, planos y anejos. El primero se refiere a los antecedentes tanto conceptuales como metodológicos. Los primeros se centran en los diversos enfoques existentes en relación al estudio de la dinámica paisajística, con el objetivo de encontrar los puntos en común existentes entre el enfoque del metabolismo social, el de la ecología del paisaje y el humanista, para obtener un diagnóstico que permita entender la complejidad de la realidad a la que esta Tesis se enfrenta. Los segundos se centran en los antecedentes de carácter metodológico que también desde diversos enfoques han abordado el análisis de la dinámica paisajística. El segundo capítulo se centra en los objetivos concretos derivados del objetivo general ya expresado, la tesis considera que para comprender y cuantificar la dinámica hay que identificar en primer lugar los procesos de transformación, como manifestación espacial de los factores socioeconómicos y naturales responsables en última instancia de la variación de los patrones paisajísticos existentes. En segundo lugar se identifican los patrones paisajísticos con el objetivo de analizar sus características espaciales y su evolución en el período analizado. Por último se identifican los procesos paisajísticos, es decir qué tipos de variaciones espaciales se producen en los patrones paisajísticos como consecuencia de los procesos de transformación identificados así como su pauta de distribución a lo largo del gradiente urbano ‐ rural. El tercer capítulo se dedica a la caracterización del ámbito de estudio, ésta se extiende al sur del límite del suelo urbano de la capital madrileña en el año 1990, comprende la totalidad de los municipios madrileños que contactan con los municipios castellano – manchegos que se encuentran en el área de influencia de la capital, abarcando el área 9.968 km2. El cuarto capítulo se centra en la metodología. Como material de partida se ha utilizado en la cartografía del Corine Land Cover y como herramienta de análisis se ha utilizado los Sistemas de Información Geográfica. En primer lugar se identifican los procesos de transformación, acaecidos en los períodos 1990 – 2000 y 2000 – 2006, mediante la aplicación de matrices de transición. Se han identificado cuatro tipos de procesos dinámicos: Urbanización, abandono, renaturalización y agrarización. Se ha realizado un análisis de indicadores compuestos lo que ha permitido identificar los tipos de patrones paisajísticos existentes a lo largo del gradiente urbano – rural. Del mismo modo se ha calculado la variación de los indicadores individuales para identificar los procesos paisajísticos mediante el análisis de indicadores compuestos que se produjeron en el período 1990 – 2000 y 2000 – 2006. En el quinto capítulo se aportan los resultados tanto de carácter cuantitativo como gráfico de los tres componentes analizados tanto de forma independiente como integrada. En el sexto capítulo se describen las conclusiones producto de la investigación realizada. En el séptimo capítulo se identifican qué líneas de investigación podrían desarrollarse en el futuro para continuar la línea de investigación iniciada con esta tesis. ABSTRACT The aim of this thesis was to propose a methodology to characterize landscape dynamics along the urban – rural gradient in the south Madrid area. It´s structured in eight chapters, planes and annexes: the first one describes previous research. Firstly to make a diagnosis of the effects of landscape dynamic we have performed an integrated analysis from social metabolism, landscape ecology and the humanistic point of view. Secondly we have focused on previous methodological research mainly developped by landscape ecology. The second chapter focuses on specific objectives derived from the general objective. The thesis considers that to understand and quantify landscape dynamics must first identify the transformation processes: spatial manifestation of natural and socioeconomics factors that induce the change of landscape patterns. Secondly landscape patterns have been identified in order to analyze their spatial characteristics and evolution. Finally the landscape processes have been identified, i.e. what kind of spatial variations cause changes in landscape patterns along urban – rural gradient. The third chapter describes the study area. The study area occupies 9968 km2. It covers the area to the south of Madrid’s 1990 urban land area, and takes in the southeast of the Madrid Autonomous Region plus all the municipal areas of the Castilla–La Mancha Autonomous Region directly influenced by the expansion of Madrid. The fourth chapter contains the methodology. To identify the changes in the landscape of the study area, the land cover data for the area held in the CORINE LandCover Project Database was examined. To characterize the transformations processes in the period 1990 ‐ 2000 and 2000 – 2006, transition matrices were constructed. We have identified four clear changes: Urbanization, renaturalization, abandonment and agrarianization. We have characterized landscape patterns using composite indicators by integrating individual spatial metrics. Similarly we have characterized landscape processes using composite indicators by integrating the variation of individual spatial metrics. Chapter fifth includes the results, both for each component and its final integration. The conclusions of this research have been described in the sixth chapter. The seventh chapter describes what kind of investigations could be done in the future.

Análisis espacio-temporal del gradiente urbano-rural del sur de la Región Metropolitana de Madrid y su entorno. Caracterización de los procesos y patrones paisajísticos acaecidos en el período 1990-2006 (versión revisada y corregida)

El objetivo de esta tesis es proponer una metodología capaz de cuantificar la dinámica paisajística a lo largo del gradiente urbano – rural perteneciente al sur de la Región Metropolitana de Madrid y su entorno. Esta tesis se estructura en ocho capítulos, planos y anejos. El primero se refiere a los antecedentes tanto conceptuales como metodológicos. Los primeros se centran en los diversos enfoques existentes en relación al estudio de la dinámica paisajística, con el objetivo de encontrar los puntos en común existentes entre el enfoque del metabolismo social, el de la ecología del paisaje y el humanista, para obtener un diagnóstico que permita entender la complejidad de la realidad a la que esta Tesis se enfrenta. Los segundos se centran en los antecedentes de carácter metodológico que también desde diversos enfoques han abordado el análisis de la dinámica paisajística. El segundo capítulo se centra en los objetivos concretos derivados del objetivo general ya expresado, la tesis considera que para comprender y cuantificar la dinámica hay que identificar en primer lugar los procesos de transformación, como manifestación espacial de los factores socioeconómicos y naturales responsables en última instancia de la variación de los patrones paisajísticos existentes. En segundo lugar se identifican los patrones paisajísticos con el objetivo de analizar sus características espaciales y su evolución en el período analizado. Por último se identifican los procesos paisajísticos, es decir qué tipos de variaciones espaciales se producen en los patrones paisajísticos como consecuencia de los procesos de transformación identificados así como su pauta de distribución a lo largo del gradiente urbano ‐ rural. El tercer capítulo se dedica a la caracterización del ámbito de estudio, ésta se extiende al sur del límite del suelo urbano de la capital madrileña en el año 1990, comprende la totalidad de los municipios madrileños que contactan con los municipios castellano – manchegos que se encuentran en el área de influencia de la capital, abarcando el área 9.968 km2. El cuarto capítulo se centra en la metodología. Como material de partida se ha utilizado en la cartografía del Corine Land Cover y como herramienta de análisis se ha utilizado los Sistemas de Información Geográfica. En primer lugar se identifican los procesos de transformación, acaecidos en los períodos 1990 – 2000 y 2000 – 2006, mediante la aplicación de matrices de transición. Se han identificado cuatro tipos de procesos dinámicos: Urbanización, abandono, renaturalización y agrarización. Se ha realizado un análisis de indicadores compuestos lo que ha permitido identificar los tipos de patrones paisajísticos existentes a lo largo del gradiente urbano – rural. Del mismo modo se ha calculado la variación de los indicadores individuales para identificar los procesos paisajísticos mediante el análisis de indicadores compuestos que se produjeron en el período 1990 – 2000 y 2000 – 2006. En el quinto capítulo se aportan los resultados tanto de carácter cuantitativo como gráfico de los tres componentes analizados tanto de forma independiente como integrada. En el sexto capítulo se describen las conclusiones producto de la investigación realizada. En el séptimo capítulo se identifican qué líneas de investigación podrían desarrollarse en el futuro para continuar la línea de investigación iniciada con esta tesis. ABSTRACT The aim of this thesis was to propose a methodology to characterize landscape dynamics along the urban – rural gradient in the south Madrid area. It´s structured in eight chapters, planes and annexes: the first one describes previous research. Firstly to make a diagnosis of the effects of landscape dynamic we have performed an integrated analysis from social metabolism, landscape ecology and the humanistic point of view. Secondly we have focused on previous methodological research mainly developped by landscape ecology. The second chapter focuses on specific objectives derived from the general objective. The thesis considers that to understand and quantify landscape dynamics must first identify the transformation processes: spatial manifestation of natural and socioeconomics factors that induce the change of landscape patterns. Secondly landscape patterns have been identified in order to analyze their spatial characteristics and evolution. Finally the landscape processes have been identified, i.e. what kind of spatial variations cause changes in landscape patterns along urban – rural gradient. The third chapter describes the study area. The study area occupies 9968 km2. It covers the area to the south of Madrid’s 1990 urban land area, and takes in the southeast of the Madrid Autonomous Region plus all the municipal areas of the Castilla–La Mancha Autonomous Region directly influenced by the expansion of Madrid. The fourth chapter contains the methodology. To identify the changes in the landscape of the study area, the land cover data for the area held in the CORINE LandCover Project Database was examined. To characterize the transformations processes in the period 1990 ‐ 2000 and 2000 – 2006, transition matrices were constructed. We have identified four clear changes: Urbanization, renaturalization, abandonment and agrarianization. We have characterized landscape patterns using composite indicators by integrating individual spatial metrics. Similarly we have characterized landscape processes using composite indicators by integrating the variation of individual spatial metrics. Chapter fifth includes the results, both for each component and its final integration. The conclusions of this research have been described in the sixth chapter. The seventh chapter describes what kind of investigations could be done in the future.