Primary care physician supply and other key determinants of health care utilisation: The case of Switzerland

Background The Swiss government decided to freeze new accreditations for physicians in private practice in Switzerland based on the assumption that demand-induced health care spending may be cut by limiting care offers. This legislation initiated an ongoing controversial public debate in Switzerland. The aim of this study is therefore the determination of socio-demographic and health system-related factors of per capita consultation rates with primary care physicians in the multicultural population of Switzerland. Methods The data were derived from the complete claims data of Swiss health insurers for 2004 and included 21.4 million consultations provided by 6564 Swiss primary care physicians on a fee-for-service basis. Socio-demographic data were obtained from the Swiss Federal Statistical Office. Utilisation-based health service areas were created and were used as observational units for statistical procedures. Multivariate and hierarchical models were applied to analyze the data. Results Models within the study allowed the definition of 1018 primary care service areas with a median population of 3754 and an average per capita consultation rate of 2.95 per year. Statistical models yielded significant effects for various geographical, socio-demographic and cultural factors. The regional density of physicians in independent practice was also significantly associated with annual consultation rates and indicated an associated increase 0.10 for each additional primary care physician in a population of 10,000 inhabitants. Considerable differences across Swiss language regions were observed with reference to the supply of ambulatory health resources provided either by primary care physicians, specialists, or hospital-based ambulatory care. Conclusion The study documents a large small-area variation in utilisation and provision of health care resources in Switzerland. Effects of physician density appeared to be strongly related to Swiss language regions and may be rooted in the different cultural backgrounds of the served populations.

Groundwater age distributions at a public drinking water supply well field derived from multiple age tracers (⁸⁵Kr, ³H/³He, and ³⁹Ar)

Groundwater age is a key aspect of production well vulnerability. Public drinking water supply wells typically have long screens and are expected to produce a mixture of groundwater ages. The groundwater age distributions of seven production wells of the Holten well field (Netherlands) were estimated from tritium-helium (3H/3He), krypton-85 (85Kr), and argon-39 (39Ar), using a new application of a discrete age distribution model and existing mathematical models, by minimizing the uncertainty-weighted squared differences of modeled and measured tracer concentrations. The observed tracer concentrations fitted well to a 4-bin discrete age distribution model or a dispersion model with a fraction of old groundwater. Our results show that more than 75 of the water pumped by four shallow production wells has a groundwater age of less than 20 years and these wells are very vulnerable to recent surface contamination. More than 50 of the water pumped by three deep production wells is older than 60 years. 3H/3He samples from short screened monitoring wells surrounding the well field constrained the age stratification in the aquifer. The discrepancy between the age stratification with depth and the groundwater age distribution of the production wells showed that the well field preferentially pumps from the shallow part of the aquifer. The discrete groundwater age distribution model appears to be a suitable approach in settings where the shape of the age distribution cannot be assumed to follow a simple mathematical model, such as a production well field where wells compete for capture area.

Addressing Obesity: Fear of Crime, Perceptions of Disorder and Disaparities in Child and Adolescent Use of Public Parks

Abstract The objectives of this study were: 1) To determine factors which inhibit and facilitate child and adolescent use of outdoor spaces for healthy physical activity by race and ethnicity in four Houston communities and 2) To propose guidelines for encouraging and maintaining child and adolescent outdoor physical activity. Using local health data and Houston Police Department crime statistics, four communities were identified for the study that had the highest concentration of crime and the racial/ ethnic groups of interest. The researchers then identified public parks in the communities. At least two parks were observed in each of the four communities from 2010 to 2011 during spring, summer, fall and winter. The parks were observed for use by children and adolescents and to describe the condition of the park spaces. The communities were Alief (Asian), Sunnyside (Black), Eldridge- West Oaks (White) and Northside- Northline (Hispanic). Observations were made at varying hours of both day and night, weekdays and weekends. Photographs were taken and the condition of the spaces noted in detail. One hundred and twenty persons, 18 years and over, using the spaces or otherwise in these communities were conveniently sampled and interviewed about their health and the extent to which they, or any children or adolescents under their care, used the outdoor spaces of interest. Data were analyzed qualitatively and with basic descriptive statistics. The photographs, journal notes and observation notes of all investigators and key personnel were analyzed. Interview data were also coded to identify patterns and themes in the responses. The findings indicate disparities in the quality and quantity of park equipment and the maintenance of the areas. Where perceptions of disorder were described, there was often visible evidence to support the perceptions. In many cases, residents' perceptions of crime were corroborated by police data. While interview reports did not seem to support the expectation that the condition of the parks was a significant deterrent to their use by children and adolescents, the condition of the parks might be said to limit the extent of that use. Specific reports of disorder that inhibited use included hearing gunfire, seeing drug dependent homeless persons and/or suspected prostitutes in an area.

Book Review: Public Service Media and Policy in Europe

Much has happened in the past fifty years, and the broadcasting system and in fact the entire media landscape have changed in many significant ways. Yet, the debate on the role of public service media and the involvement of the state in them still perseveres. It has indeed been reinvigorated due to the tectonic shifts in media production, distribution, access and consumption caused by digital technologies in general, and the Internet in particular. The gist of the debates has however curiously remained almost the same and is still focused on a set of economic arguments that call for state intervention in public media, and not unimportantly, on the various political interpretations of these economic arguments. In Europe, the debate has another essential core too, as Public Service Broadcasting (PSB) has been traditionally entrusted to serve some higher goals intrinsically related to key democratic and cultural processes. Accordingly, PSB in Western Europe has developed as the core media institution at the national level and has become deeply embedded in many facets of the nation’s economic, political, social and cultural life. Against the backdrop of PSB’s history, its vital tasks in society, as well as the dramatic changes brought about by the digitally networked environment, the question on the future of PSB and its transition into Public Service Media (PSM) is very interesting, to say the least, and highly challenging at the same time. The book by Karen Donders, Public Service Media and Policy in Europe (Palgrave, 2012), makes an essential contribution to these complex debates, and more importantly, adds some new value to an otherwise saturated discourse.

Contemplating a ‘public service navigator’: In search of new (and better) functioning public service media

This is a paper contemplating a tool of public editorial intelligence, so that key media policy objectives can be attained in the complex and multi-faceted environment of digital media. The paper is meant to be an article of a special issue of the International Journal of Communication on "Public Media and Exposure Diversity", co-edited by Natali Helberger and Mira Burri.

Public Commons for Geospatial Data: A Conceptual Model

A wide variety of spatial data collection efforts are ongoing throughout local, state and federal agencies, private firms and non-profit organizations. Each effort is established for a different purpose but organizations and individuals often collect and maintain the same or similar information. The United States federal government has undertaken many initiatives such as the National Spatial Data Infrastructure, the National Map and Geospatial One-Stop to reduce duplicative spatial data collection and promote the coordinated use, sharing, and dissemination of spatial data nationwide. A key premise in most of these initiatives is that no national government will be able to gather and maintain more than a small percentage of the geographic data that users want and desire. Thus, national initiatives depend typically on the cooperation of those already gathering spatial data and those using GIs to meet specific needs to help construct and maintain these spatial data infrastructures and geo-libraries for their nations (Onsrud 2001). Some of the impediments to widespread spatial data sharing are well known from directly asking GIs data producers why they are not currently involved in creating datasets that are of common or compatible formats, documenting their datasets in a standardized metadata format or making their datasets more readily available to others through Data Clearinghouses or geo-libraries. The research described in this thesis addresses the impediments to wide-scale spatial data sharing faced by GIs data producers and explores a new conceptual data-sharing approach, the Public Commons for Geospatial Data, that supports user-friendly metadata creation, open access licenses, archival services and documentation of parent lineage of the contributors and value- adders of digital spatial data sets.

Free Riders, Holdouts, and Public Use: A Tale of Two Externalities

Free riders and holdouts are market failures that potentially impede the completion of otherwise beneficial transactions. The key difference is that the free rider problem is a demand side externality that requires taxation to compel payment for a public good, while the holdout problem is a supply side externality that requires eminent domain to force the sale of land for large scale projects. This paper highlights that distinction between these two problems and uses the resulting insights to clarify the meaning of the public use requirement of the Fifth Amendment takings clause.

An analysis of Texas's school based HPV vaccine mandate: A public health risk communication failure: HPVETO!

Genital human papillomavirus (HPV) is of public health concern because persistent infection with certain HPV types can cause cervical cancer. In response to a nationwide push for cervical cancer legislation, Texas Governor Rick Perry bypassed the traditional legislative process and issued an executive order mandating compulsory HPV vaccinations for all female public school students prior to their entrance in the sixth grade. By bypassing the legislative process Governor Perry did not effectively mitigate the risk perception issues that arose around the need for and usefulness of the vaccine mandate. This policy paper uses a social policy paradigm to identify perception as the key intervening factor on how the public responds to risk information. To demonstrate how the HPV mandate failed, it analyzes four factors, economics, politics, knowledge and culture, that shape perception and influence the public's response. By understanding the factors that influence the public's perception, public health practitioners and policy makers can more effectively create preventive health policy at the state level. ^

Effects of congressional modernization laws on public access to innovative medical device technologies

The Federal Food and Drug Administration (FDA) and the Centers for Medicare and Medicaid (CMS) play key roles in making Class III, medical devices available to the public, and they are required by law to meet statutory deadlines for applications under review. Historically, both agencies have failed to meet their respective statutory requirements. Since these failures affect patient access and may adversely impact public health, Congress has enacted several “modernization” laws. However, the effectiveness of these modernization laws has not been adequately studied or established for Class III medical devices. ^ The aim of this research study was, therefore, to analyze how these modernization laws may have affected public access to medical devices. Two questions were addressed: (1) How have the FDA modernization laws affected the time to approval for medical device premarket approval applications (PMAs)? (2) How has the CMS modernization law affected the time to approval for national coverage decisions (NCDs)? The data for this research study were collected from publicly available databases for the period January 1, 1995, through December 31, 2008. These dates were selected to ensure that a sufficient period of time was captured to measure pre- and post-modernization effects on time to approval. All records containing original PMAs were obtained from the FDA database, and all records containing NCDs were obtained from the CMS database. Source documents, including FDA premarket approval letters and CMS national coverage decision memoranda, were reviewed to obtain additional data not found in the search results. Analyses were conducted to determine the effects of the pre- and post-modernization laws on time to approval. Secondary analyses of FDA subcategories were conducted to uncover any causal factors that might explain differences in time to approval and to compare with the primary trends. The primary analysis showed that the FDA modernization laws of 1997 and 2002 initially reduced PMA time to approval; after the 2002 modernization law, the time to approval began increasing and continued to increase through December 2008. The non-combined, subcategory approval trends were similar to the primary analysis trends. The combined, subcategory analysis showed no clear trends with the exception of non-implantable devices, for which time to approval trended down after 1997. The CMS modernization law of 2003 reduced NCD time to approval, a trend that continued through December 2008. This study also showed that approximately 86% of PMA devices do not receive NCDs. ^ As a result of this research study, recommendations are offered to help resolve statutory non-compliance and access issues, as follows: (1) Authorities should examine underlying causal factors for the observed trends; (2) Process improvements should be made to better coordinate FDA and CMS activities to include sharing data, reducing duplication, and establishing clear criteria for “safe and effective” and “reasonable and necessary”; (3) A common identifier should be established to allow tracking and trending of applications between FDA and CMS databases; (4) Statutory requirements may need to be revised; and (5) An investigation should be undertaken to determine why NCDs are not issued for the majority of PMAs. Any process improvements should be made without creating additional safety risks and adversely impacting public health. Finally, additional studies are needed to fully characterize and better understand the trends identified in this research study.^

Re-emerging Vitamin D deficiency epidemic and its implications on the public health in the US

Vitamin D is essential in maintaining the bone health and Calcium homeostasis in the body. These actions are mediated through the Vitamin D receptors (VDR) present in cells through which the activated vitamin D acts [1]. In the past, it was known that these receptors existed in the intestine and bone cell. However, recent discovery of VDR in other tissues as well, has broadened the action of Vitamin D and increased its adequate intake [1].^ In the past, Vitamin D deficiency was most common among institutionalized, elderly patients and children and thought to be extinct in the healthy population. However, recent evidence has shown that, prevalence of vitamin D deficiency is increasing into an epidemic status in the overall population of the United States, including the healthy individuals [2-3]. The increased daily-recommended requirement and other multiple factors are responsible for the re-emergence of this epidemic [4-5]. Some of these factors could be used to control the epidemic. Studies have also shown the association between vitamin D deficiency and increased risk for developing chronic diseases such as diabetes, hypertension, multiple sclerosis, arthritis, and some fatal cancers like prostate, colon and breast cancers [1, 4, 6-14]. This issue results in increased disease burden, morbidity and mortality in the community [15-20].^ Methods: The literature search was conducted using the University of Texas Health Science Center at Houston (UTHSC) and University of Texas Southwestern Medical Center (UTSW) online library. The key search terms used are “vitamin D deficiency And prevalence Or epidemiology”, “vitamin D deficiency And implication And public health” using PubMed and Mesh database and “vitamin D deficiency” using systematic reviews. The search is limited to Humans and the English language. The articles considered for the review are limited to Healthy US population to avoid health conditions that predispose the population to vitamin D deficiency. Only US population is considered to narrow down the study.^ Results: There is an increased prevalence of low levels of Vitamin D levels below the normal range in the US population regardless of age and health status. Vitamin D deficiency is also associated with increased risk of chronic illnesses and fatal cancers.^ Conclusion: This increased prevalence and the association of the deficiency with increased all-cause mortality has increased the economic burden and compromised the quality of life among the population. This necessitates the health care providers to routinely screen their patients for the Vitamin D status and counsel them to avoid the harmful effects of the Vitamin D deficiency. ^

Report on the practice based culminating experience as teaching assistant for "Pathology and Public Health" class taught at University of Texas School of Public Health, Houston

Objectives. The objectives of this report were to describe current best standards in online education, class competencies, class objectives, class activities and to compare the class competencies, objectives and activities undertaken with the current best practices in online teaching and to provide a list of recommendations based on the most efficacious practices. ^ Methods. Utilizing the key words- online teaching, national standards, quality, online courses, I: (1) conducted a search on Google to find the best standard for quality online courses; the search yielded National Standards for Quality Online Teaching as the gold standard in online course quality; (2) specified class objectives and competencies as well as major activities undertaken as a part of the class. Utilizing the Southern Regional Education Board evaluation checklist for online courses, I: (1) performed an analysis comparing the class activities, objectives, and competencies with the current best standards; (2) utilized the information obtained from the analysis and class experiences to develop recommendations for the most efficacious online teaching practices. ^ Results. The class met the criteria set by the Southern Regional Education Board for evaluating online classes completely in 75%, partially in 16% and did not meet the criteria in 9% cases. The majority of the parameters in which the class did not meet the standards (4 of 5) were due to technological reasons beyond the scope of the class instructor, teaching assistant and instructional design. ^ Discussion. Successful online teaching requires awareness of technology, good communication, methods, collaboration, reflection and flexibility. Creation of an online community, engaging online learners and utilizing different learning styles and assessment methods promote learning. My report proposes that online teaching should actively engage the students and teachers with multiple interactive strategies as evidenced from current best standards of online education and my “hands-on” work experience. ^ Conclusion. The report and the ideas presented are intended to create a foundation for efficacious practice on the online teaching platform. By following many of the efficacious online practices described in the report and adding from their own experiences, online instructors and teaching assistants can contribute to effective online learning. ^

Should Texas use public funding for bariatric surgery?

Background. Obesity in America has increased exponentially since the 1970s with no sign of slowing down. It is a major public health problem, and is currently the second leading cause of preventable deaths in America (Flegal et al., 2010). Bariatric surgery is currently the only approved therapy that has shown to have a lasting impact on obese patients. While the initial cost of the surgery remains high, numerous cost-benefit analyses have demonstrated an overall cost saving within two to five years (McEwen et al., 2010). Only three states, including Texas, do not currently fund bariatric surgery through Medicare and Medicaid. ^ Objectives. To determine whether the current data on the cost-benefit analysis of bariatric surgery supports Texas' decision to not publicly fund bariatric surgery through its Medicare and Medicaid programs. ^ Methods. We conducted literature reviews to determine the current cost of obesity in Texas as well as the methods being employed to treat obesity currently. We then analyzed the history of bariatric surgery and its current implementation, looking at safety and the future benefits of bariatric surgery. We then looked at key cost-benefit analyses and meta-analyses to determine the cost effectiveness of bariatric surgery. We then analyzed both direct medical expenditures and indirect benefits of bariatric surgery. ^ Conclusions. If the obesity epidemic continues unabated, it will become one of the leading health expenditures in Texas within decades. Given that surgery is currently the only approved therapy for obesity that has been shown to be effective in the majority of patients, Texas' decision not to publicly fund bariatric surgery is short sighted.^

Public support for the deployment of next generation access networks-Common themes, methodological caveats and further research

Next generation telecommunications infrastructures are considered as a principal example of a new technology for sustainable economic growth. From their deployment it is expected that a wealth of innovations – hopefully converted into economic growth – new sources of employment and improved quality of life will result. In line with these prospects, public administrations at supranational, national, regional and local levels have encouraged the development of these new infrastructures. Moreover, in times of economic crisis, public assistance to deploy such networks encompasses the promise of placing a weak economy on the road to prosperity. However, such arguments and political claims clearly require rigorous assessment. In particular, any such assessment must adequately address the appropriate form of modelling that best captures key elements for identifiable progress from next generation access networks (NGAN).

Key quality factors and travellers profiles at interurban interchanges

La planificación y las políticas de transporte no pueden descuidar la calidad del servicio, considerando que influye notablemente en el cambio modal del coche hacia otros medios de transporte más sostenibles. El concepto se aplica también a los intercambiadores de transporte público, los nodos del sistema donde se cruzan las distintas redes del transporte público y privado. Aunque se han logrado numerosos avances para medir y evaluar la calidad en el sector del transporte público, se han dedicado relativamente pocos esfuerzos a investigar estos aspectos relacionados con la calidad de los intercambiadores del transporte público. Este trabajo de investigación se concentra en la calidad del servicio de la transferencia modal en los intercambiadores interurbanos, según la perspectiva de los viajeros. Su objetivo es identificar los factores clave de la calidad del servicio y los perfiles de los viajeros en los intercambiadores. La investigación es exploratoria y ofrece información acerca de la percepción de los viajeros intermodales relacionada con los aspectos de la calidad, aportando nuevos elementos y datos para adentrarse en estudios más detallados. La metodología del trabajo combina técnicas de análisis estadístico multivariante para analizar los datos de las encuestas sobre la satisfacción de los clientes y se subdivide en tres etapas. En primer lugar, se ha implementado el análisis de correspondencias múltiples para explorar los constructos latentes relacionados con la satisfacción de las características cualitativas de los intercambiadores interurbanos, identificando así los factores clave de la calidad. En segundo lugar, se ha aplicado un análisis de conglomerados de k-medias sobre los factores clave de calidad para clasificar a los viajeros en grupos de usuarios de transportes homogéneos, de acuerdo con su percepción de satisfacción, identificando de este modo los perfiles de los viajeros. Por último, se han formulado sugerencias y recomendaciones sobre la calidad para respaldar la formulación de políticas, estableciendo las prioridades para los intercambiadores interurbanos. La metodología se aplicó en cuatro intercambiadores interurbanos (estaciones de ferrocarriles o de autobuses ) en Madrid, Zaragoza, Gothenburg y Lion, analizando los datos recogidos mediante una encuesta de satisfacción del cliente llevada a cabo en 2011 en los cuatro casos de estudio, donde se interconectan distintos medios de transporte público y privado, de corta y larga distancia. Se recogieron datos sobre la satisfacción de los viajeros con 26 criterios de calidad, así como información sobre aspectos socio-económicos y pautas de comportamiento de viajes. Mediante el análisis de correspondencias múltiples se identificaron 4-5 factores clave de calidad en cada intercambiador, que se asocian principalmente con el sistema de emisión de billetes, el confort y la interconexión, mientras que los viajeros no perciben los temas clásicos como la información. Mediante el análisis de conglomerados se identificaron 2-5 perfiles de viajeros en cada intercambiador. Se reconocieron dos grupos de viajeros en casi todos los casos de estudio: viajeros de cercanía/trabajadores y turistas. Por lo que concierne a las prioridades para apoyar a las partes interesadas en la formulación de políticas, la expedición de billetes es el factor clave para los intercambiadores interurbanos españoles, mientras que la interconexión y los aspectos temporales se destacan en los intercambiadores de Francia y Suecia. Quality of Service can not be neglected in public transport planning and policy making, since it strongly influences modal shifts from car to more sustainable modes. This concept is also related to Public Transport interchanges, the nodes of the transport system where the different sub-systems of public passenger transport and personal vehicles meet. Although a lot of progress has been generally done to measure and assess quality in public transport sector, relatively little investigation has been conducted on quality at PT interchanges. This research work focusses on Quality of Service in the use of transfer facilities at interurban interchanges, according to current travellers’ perspective. It aims at identifying key quality factors and travellers profiles at interurban interchanges. The research is exploratory and offers insight into intermodal travellers’ perception on quality aspects, providing new elements and inputs for more definitive investigation. The methodology of the work combines multivariate statistical techniques to analyse data from customer satisfaction surveys and is subdivided in three steps. Firstly, multiple correspondence analysis was performed to explore latent constructs as concern satisfaction of quality attributes at interurban interchanges, thus identifying the so-called Key Quality Factor. Secondly, k-means cluster analysis was implemented on the key quality factors to classify travellers in homogeneous groups of transport users, according to their perception of satisfaction, thus identifying the so-called Travellers Profiles. Finally, hints and recommendations on quality were identified to support policy making, setting priorities for interurban interchanges. The methodology was applied at four interurban interchanges in Madrid, Zaragoza, Gothenburg and Lyon, analysing the data collected through a customer satisfaction survey carried out in 2011 at the four railway or bus stations where different modes of public and private transport are interconnected covering both short and long trips. Data on travellers’ satisfaction with 26 quality attributes were collected, as well as information on socio-economical and travel patterns. Through multiple correspondence analysis were identified 4-5 key quality factors per interchange. They are mainly related to ticketing, comfort and connectivity, while classical issues, as information, are not perceived as important by travellers’. Through cluster analysis were identified 2-5 travellers profiles per interchange. Two groups of travellers can be found in almost all case studies: commuter / business travellers and holiday travellers. As regards the priorities to support stakeholders in policy making, ticketing is the key-issue for the Spanish interurban interchanges, while connectivity and temporal issues emerge in the French and Swedish case studies.

Quantum key distribution based on selective post-processing in passive optical networks

One of the main obstacles to the widespread adoption of quantum cryptography has been the difficulty of integration into standard optical networks, largely due to the tremendous difference in power of classical signals compared with the single quantum used for quantum key distribution. This makes the technology expensive and hard to deploy. In this letter, we show an easy and straightforward integration method of quantum cryptography into optical access networks. In particular, we analyze how a quantum key distribution system can be seamlessly integrated in a standard access network based on the passive optical and time division multiplexing paradigms. The novelty of this proposal is based on the selective post-processing that allows for the distillation of secret keys avoiding the noise produced by other network users. Importantly, the proposal does not require the modification of the quantum or classical hardware specifications neither the use of any synchronization mechanism between the network and quantum cryptography devices.