Using small area estimation and geographic information systems technology to target health services for the uninsured

The three articles that comprise this dissertation describe how small area estimation and geographic information systems (GIS) technologies can be integrated to provide useful information about the number of uninsured and where they are located. Comprehensive data about the numbers and characteristics of the uninsured are typically only available from surveys. Utilization and administrative data are poor proxies from which to develop this information. Those who cannot access services are unlikely to be fully captured, either by health care provider utilization data or by state and local administrative data. In the absence of direct measures, a well-developed estimation of the local uninsured count or rate can prove valuable when assessing the unmet health service needs of this population. However, the fact that these are “estimates” increases the chances that results will be rejected or, at best, treated with suspicion. The visual impact and spatial analysis capabilities afforded by geographic information systems (GIS) technology can strengthen the likelihood of acceptance of area estimates by those most likely to benefit from the information, including health planners and policy makers. ^ The first article describes how uninsured estimates are currently being performed in the Houston metropolitan region. It details the synthetic model used to calculate numbers and percentages of uninsured, and how the resulting estimates are integrated into a GIS. The second article compares the estimation method of the first article with one currently used by the Texas State Data Center to estimate numbers of uninsured for all Texas counties. Estimates are developed for census tracts in Harris County, using both models with the same data sets. The results are statistically compared. The third article describes a new, revised synthetic method that is being tested to provide uninsured estimates at sub-county levels for eight counties in the Houston metropolitan area. It is being designed to replicate the same categorical results provided by a current U.S. Census Bureau estimation method. The estimates calculated by this revised model are compared to the most recent U.S. Census Bureau estimates, using the same areas and population categories. ^

An evaluation of a Lake Houston tributary, Cypress Creek, for contamination and water quality

Introduction. Lake Houston serves as a reservoir for both recreational and drinking water for residents of Houston, Texas, and the metropolitan area. The Texas Commission on Environmental Quality (TCEQ) expressed concerns about the water quality and increasing amounts of pathogenic bacteria in Lake Houston (3). The objective of this investigation is to evaluate water quality for the presence of bacteria, nitrates, nitrites, carbon, phosphorus, dissolved oxygen, pH, turbidity, suspended solids, dissolved solids, and chlorine in Cypress Creek. The aims of this project are to analyze samples of water from Cypress Creek and to render a quantitative and graphical representation of the results. The collected information will allow for a better understanding of the aqueous environment in Cypress Creek.^ Methods. Water samples were collected in August 2009 and analyzed in the field and at UTSPH laboratory by spectrophotometry and other methods. Mapping software was utilized to develop novel maps of the sample sites using coordinates attained with the Global Positioning System (GPS). Sample sites and concentrations were mapped using Geographic Information System (GIS) software and correlated with permitted outfalls and other land use characteristic.^ Results. All areas sampled were positive for the presence of total coliform and Escherichia coli (E. coli). The presences of other water contaminants varied at each location in Cypress Creek but were under the maximum allowable limits designated by the Texas Commission on Environmental Quality. However, dissolved oxygen concentrations were elevated above the TCEQ limit of 5.0 mg/L at majority of the sites. One site had near-limit concentration of nitrates at 9.8 mg/L. Land use above this site included farm land, agricultural land, golf course, parks, residential neighborhoods, and nine permitted TCEQ effluent discharge sites within 0.5 miles upstream.^ Significance. Lake Houston and its tributary, Cypress Creek, are used as recreational waters where individuals may become exposed to microbial contamination. Lake Houston also is the source of drinking water for much of Houston/Harris and Galveston Counties. This research identified the presence of microbial contaminates in Cypress Creek above TCEQ regulatory requirements. Other water quality variables measured were in line with TCEQ regulations except for near-limit for nitrate at sample site #10, at Jarvis and Timberlake in Cypress Texas.^

DISTRIBUTION FUNCTIONS, MEAN SQUARED ERRORS, AND CONFIDENCE LIMITS FOR RIDGE REGRESSION ESTIMATORS

A large number of ridge regression estimators have been proposed and used with little knowledge of their true distributions. Because of this lack of knowledge, these estimators cannot be used to test hypotheses or to form confidence intervals.^ This paper presents a basic technique for deriving the exact distribution functions for a class of generalized ridge estimators. The technique is applied to five prominent generalized ridge estimators. Graphs of the resulting distribution functions are presented. The actual behavior of these estimators is found to be considerably different than the behavior which is generally assumed for ridge estimators.^ This paper also uses the derived distributions to examine the mean squared error properties of the estimators. A technique for developing confidence intervals based on the generalized ridge estimators is also presented. ^

Geographic variation in the utilization and survival associated with oxaliplatin chemotherapy in patients with stage III colon cancer

Background: Overall objectives of this dissertation are to examine the geographic variation and socio-demographic disparities (by age, race and gender) in the utilization and survival of newly FDA-approved chemotherapy agents (Oxaliplatin-containing regimens) as well as to determine the cost-effectiveness of Oxaliplatin in a large nationwide and population-based cohort of Medicare patients with resected stage-III colon cancer. Methods: A retrospective cohort of 7,654 Medicare patients was identified from the Surveillance, Epidemiology and End Results – Medicare linked database. Multiple logistic regression was performed to examine the relationship between receipt of Oxaliplatin-containing chemotherapy and geographic regions while adjusting for other patient characteristics. Cox proportional hazard model was used to estimate the effect of Oxaliplatin-containing chemotherapy on the survival variation across regions using 2004-2005 data. Propensity score adjustments were also made to control for potential bias related to non-random allocation of the treatment group. We used Kaplan-Meier sample average estimator to calculate the cost of disease after cancer-specific surgery to death, loss-to follow-up or censorship. Results: Only 51% of the stage-III patients received adjuvant chemotherapy within three to six months of colon-cancer specific surgery. Patients in the rural regions were approximately 30% less likely to receive Oxaliplatin chemotherapy than those residing in a big metro region (OR=0.69, p=0.033). The hazard ratio for patients residing in metro region was comparable to those residing in big metro region (HR: 1.05, 95% CI: 0.49-2.28). Patients who received Oxalipaltin chemotherapy were 33% less likely to die than those received 5-FU only chemotherapy (adjusted HR=0.67, 95% CI: 0.41-1.11). KMSA-adjusted mean payments were almost 2.5 times higher in the Oxaliplatin-containing group compared to 5-FU only group ($45,378 versus $17,856). When compared to no chemotherapy group, ICER of 5-FU based regimen was $12,767 per LYG, and ICER of Oxaliplatin-chemotherapy was $60,863 per LYG. Oxaliplatin was found economically dominated by 5-FU only chemotherapy in this study population. Conclusion: Chemotherapy use varies across geographic regions. We also observed considerable survival differences across geographic regions; the difference remained even after adjusting for socio-demographic characteristics. The cost-effectiveness of Oxaliplatin in Medicare patients may be over-estimated in the clinical trials. Our study found 5-FU only chemotherapy cost-effective in adjuvant settings in patients with stage-III colon cancer.^

Correlation of tuberculosis and human immunodeficiency virus in Harris County, Texas from 2009 through 2010 using Geographic Information Systems

A population based ecological study was conducted to identify areas with a high number of TB and HIV new diagnoses in Harris County, Texas from 2009 through 2010 by applying Geographic Information Systems to determine whether distinguished spatial patterns exist at the census tract level through the use of exploratory mapping. As of 2010, Texas has the fourth highest occurrence of new diagnoses of HIV/AIDS and TB.[31] The Texas Department of State Health Services (DSHS) has identified HIV infected persons as a high risk population for TB in Harris County.[29] In order to explore this relationship further, GIS was utilized to identify spatial trends. ^ The specific aims were to map TB and HIV new diagnoses rates and spatially identify hotspots and high value clusters at the census tract level. The potential association between HIV and TB was analyzed using spatial autocorrelation and linear regression analysis. The spatial statistics used were ArcGIS 9.3 Hotspot Analysis and Cluster and Outlier Analysis. Spatial autocorrelation was determined through Global Moran's I and linear regression analysis. ^ Hotspots and clusters of TB and HIV are located within the same spatial areas of Harris County. The areas with high value clusters and hotspots for each infection are located within the central downtown area of the city of Houston. There is an additional hotspot area of TB located directly north of I-10 and a hotspot area of HIV northeast of Interstate 610. ^ The Moran's I Index of 0.17 (Z score = 3.6 standard deviations, p-value = 0.01) suggests that TB is statistically clustered with a less than 1% chance that this pattern is due to random chance. However, there were a high number of features with no neighbors which may invalidate the statistical properties of the test. Linear regression analysis indicated that HIV new diagnoses rates (β=−0.006, SE=0.147, p=0.970) and census tracts (β=0.000, SE=0.000, p=0.866) were not significant predictors of TB new diagnoses rates. ^ Mapping products indicate that census tracts with overlapping hotspots and high value clusters of TB and HIV should be a targeted focus for prevention efforts, most particularly within central Harris County. While the statistical association was not confirmed, evidence suggests that there is a relationship between HIV and TB within this two year period.^

Use of a modified delphi process for establishing occupational exposure limits in support of health surveillance for space travelers

On-orbit exposures can come from numerous factors related to the space environment as evidenced by almost 50 years of environmental samples collected for water analysis, air analysis, radiation analysis, and physiologic parameters. For astronauts and spaceflight participants the occupational exposures can be very different from those experienced by workers performing similar tasks in workplaces on Earth, because the duration of the exposure could be continuous for very long orbital, and eventually interplanetary, missions. The establishment of long-term exposure standards is vital to controlling the quality of the spacecraft environment over long periods. NASA often needs to update and revise its prior exposure standards (Spacecrafts Maximum Allowable Concentrations (SMACs)). Traditional standards-setting processes are often lengthy, so a more rapid method to review and establish standards would be a substantial advancement in this area. This project investigates use of the Delphi method for this purpose. ^ In order to achieve the objectives of this study a modified Delphi methodology was tested in three trials executed by doctoral students and a panel of experts in disciplines related to occupational safety and health. During each test/trial modifications were made to the methodology. Prior to submission of the Delphi Questionnaire to the panel of experts a pilot study/trial was conducted using five doctoral students with the goals of testing and adjusting the Delphi questionnaire to improve comprehension, work out any procedural issues and evaluate the effectiveness of the questionnaire in drawing the desired responses. The remainder of the study consisted of two trials of the Modified Delphi process using 6 chemicals that currently have the potential of causing occupational exposures to NASA astronauts or spaceflight participants. To assist in setting Occupational Exposure Limits (OEL), the expert panel was established consisting of experts from academia, government and industry. Evidence was collected and used to create close-ended questionnaires which were submitted to the Delphi panel of experts for the establishment of OEL values for three chemicals from the list of six originally selected (trial 1). Once the first Delphi trial was completed, adjustments were made to the Delphi questionnaires and the process above was repeated with the remaining 3 chemicals (trial 2). ^ Results indicate that experience in occupational safety and health and with OEL methodologies can have a positive effect in minimizing the time experts take in completing this process. Based on the results of the questionnaires and comparison of the results with the SMAC already established by NASA, we conclude that use of the Delphi methodology is appropriate for use in the decision-making process for the selection of OELs.^

Inappropriate imaging utilization in Texas: Geographic variation and predictive factors

Objective::Describe and understand regional differences and associated multilevel factors (patient, provider and regional) to inappropriate utilization of advance imaging tests in the privately insured population of Texas. Methods: We analyzed Blue Cross Blue Shield of Texas claims dataset to study the advance imaging utilization during 2008-2010 in the PPO/PPO+ plans. We used three of CMS "Hospital Outpatient Quality Reporting" imaging efficiency measures. These included ordering MRI for low back pain without prior conservative management (OP-8) and utilization of combined with and without contrast abdominal CT (OP-10) and thorax CT (OP-11). Means and variation by hospital referral regions (HRR) in Texas were measured and a multilevel logistic regression for being a provider with high values for any the three OP measures was used in the analysis. We also analyzed OP-8 at the individual level. A multilevel logistic regression was used to identify predictive factors for having an inappropriate MRI for low back pain. Results: Mean OP-8 for Texas providers was 37.89%, OP-10 was 29.94% and OP-11 was 9.24%. Variation was higher for CT measure. And certain HRRs were consistently above the mean. Hospital providers had higher odds of high OP-8 values (OP-8: OR, 1.34; CI, 1.12-1.60) but had smaller odds of having high OP-10 and OP-11 values (OP-10: OR, 0.15; CI, 0.12-0.18; OP-11: OR, 0.43; CI, 0.34-0.53). Providers with the highest volume of imaging studies performed, were less likely to have high OP-8 measures (OP-8: OR, 0.58; CI, 0.48-0.70) but more likely to perform combined thoracic CT scans (OP-11: OR, 1.62; CI, 1.34-1.95). Males had higher odds of inappropriate MRI (OR, 1.21; CI, 1.16-1.26). Pattern of care in the six months prior to the MRI event was significantly associated with having an inappropriate MRI. Conclusion::We identified a significant variation in advance imaging utilization across Texas. Type of facility was associated with measure performance, but the associations differ according to the type of study. Last, certain individual characteristics such as gender, age and pattern of care were found to be predictors of inappropriate MRIs.^

A geographic information science (GIS) approach to conducting comparative area-level community assessments in the Texas CORD Study

This study assessed and compared sociodemographic and income characteristics along with food and physical activity assets (i.e. grocery stores, fast food restaurants, and park areas) in the Texas Childhood Obesity Research Demonstration (CORD) Study intervention and comparison catchment areas in Houston and Austin, Texas. The Texas CORD Study used a quasi-experimental study design, so it is necessary to establish the interval validity of the study characteristics by confirming that the intervention and comparison catchment areas are statistically comparable. In this ecological study, ArcGIS and Esri Business Analyst were used to spatially relate U.S. Census Bureau and other business listing data to the specific school attendance zones within the catchment areas. T-tests were used to compare percentages of sociodemographic and income characteristics and densities of food and physical activity assets between the intervention and comparison catchment areas.^ Only five variables were found to have significant differences between the intervention and comparison catchment areas: Age groups 0-4 and 35-64, the percentage of owner-occupied and renter-occupied households, and the percentage of Asian and Pacific Islander residents. All other variables showed no significant differences between the two groups. This study shows that the methodology used to select intervention and comparison catchment areas for the Texas CORD Study was effective and can be used in future studies. The results of this study can be used in future Texas CORD studies to confirm the comparability of the intervention and comparison catchment areas. In addition, this study demonstrates a methodology for describing detailed characteristics about a geographic area that practitioners, researchers, and educators can use.^

Appendix A. Whole-rock major, trace and rare earth element analyses of the Ulubey volcanics, Appendix B. Analytical standards and detection limits for analyses

Collisional and post-collisional volcanic rocks in the Ulubey (Ordu) area at the western edge of the Eastern Pontide Tertiary Volcanic Province (EPTVP) in NE Turkey are divided into four suites; Middle Eocene (49.4-44.6 Ma) aged Andesite-Trachyandesite (AT), Trachyandesite-Trachydacite-Rhyolite (TTR), Trachydacite-Dacite (TD) suites, and Middle Miocene (15.1 Ma) aged Trachybasalt (TB) suite. Local stratigraphy in the Ulubey area starts with shallow marine environment sediments of the Paleocene-Eocene time and then continues extensively with sub-aerial andesitic to rhyolitic and rare basaltic volcanism during Eocene and Miocene time, respectively. Petrographically, the volcanic rocks are composed primarily of andesites/trachyandesites, with minor trachydacites/rhyolites, basalts/trachybasalts and pyroclastics, and show porphyric, hyalo-microlitic porphyric and rarely glomeroporphyric, intersertal, intergranular, fluidal and sieve textures. The Ulubey (Ordu) volcanic rocks indicate magma evolution from tholeiitic-alkaline to calc-alkaline with medium-K contents. Primitive mantle normalized trace element and chondrite normalized rare earth element (REE) patterns show that the volcanic rocks have moderate light rare earth element (LREE)/heavy rare earth element (HREE) ratios relative to E-Type MORB and depletion in Nb, Ta and Ti. High Th/Yb ratios indicate parental magma(s) derived from an enriched source formed by mixing of slab and asthenospheric melts previously modified by fluids and sediments from a subduction zone. All of the volcanic rocks share similar incompatible element ratios (e.g., La/Sm, Zr/Nb, La/Nb) and chondrite-normalized REE patterns, indicating that the basic to acidic rocks originated from the same source. The volcanic rocks were produced by the slab dehydration-induced melting of an existing metasomatized mantle source, and the fluids from the slab dehydration introduced significant large ion lithophile element (LILE) and LREE to the source, masking its inherent HFSE-enriched characteristics. The initial 87Sr/86Sr (0.7044-0.7050) and eNd (-0.3 to +3.4) ratios of the volcanics suggest that they originated from an enriched lithospheric mantle source with low Sm/Nd ratios. Integration of the geochemical, petrological and isotopical with regional and local geological data suggest that the Tertiary volcanic rocks from the Ulubey (Ordu) area were derived from an enriched mantle, which had been previously metasomatized by fluids derived from subducted slab during Eocene to Miocene in collisional and post-collisional extension-related geodynamic setting following Late Mesozoic continental collision between the Eurasian plate and the Tauride-Anatolide platform.

Reconstructed glaciation limits in Eurasia (digitized from map Fig.1)

Based on field investigations in northern Russia and interpretation of offshore seismic data, we have made a preliminary reconstruction of the maximum ice-sheet extent in the Barents and Kara Sea region during the Early/Middle Weichselian and the Late Weichselian. Our investigations indicate that the Barents and Kara ice sheets attained their maximum Weichselian positions in northern Russia prior to 50 000 yr BP, whereas the northeastern flank of the Scandinavian Ice Sheet advanced to a maximum position shortly after 17000 calendar years ago. During the Late Weichselian (25 000-10000 yr BP), much of the Russian Arctic remained ice-free. According to our reconstruction, the extent of the ice sheets in the Barents and Kara Sea region during the Late Weichselian glacial maximum was less than half that of the maximum model which, up to now, has been widely used as a boundary condition for testing and refining General Circulation Models (GCMs). Preliminary numerical-modelling experiments predict Late Weichselian ice sheets which are larger than the ice extent implied for the Kara Sea region from dated geological evidence, suggesting very low precipitation.

Otra Patagonia Austral es posible : proyectos de territorio entre la emergencia y la urgencia

Nuevo paradigma para algunos, o simple eslogan político-mediático para otros, el concepto de desarrollo sustentable levanta reacciones contradictorias en el mundo científico. Existen notables diferencias en el acercamiento al desarrollo sustentable entre los representantes de las ciencias naturales y los de las ciencias humanas. El carácter nómada del concepto (Stengers, 1987) de desarrollo sustentable es percibido por ciertos investigadores en geografía como una verdadera tara genética, cuando otros piensan por el contrario que puede servir de palanca para renovar el acercamiento geográfico a los grandes problemas contemporáneos. ¿Para la investigación en geografía, qué postura es conveniente adoptar? ¿El desarrollo sustentable, como concepto nómada, puede convertirse en una herramienta eficaz e innovadora? ¿O bien su incertidumbre semántica nos conduce de manera inexorable hacia un vagabundeo de las ideas? El objetivo central de esta reflexión es intentar situar el concepto de desarrollo sustentable en la órbita del pensamiento geográfico, en una óptica comparativa con disciplinas vecinas y cuestionando a su vez su interés para la investigación en nuestro campo disciplinario. Para ello, es necesario en primer lugar acercarse sin tabúes a los problemas planteados por este concepto: ¿Debe considerarse el nomadismo conceptual del desarrollo sustentable como una especie de pecado original que lo convertiría en un instrumento inoperante para la geografía? En segundo lugar, desmitificando la novedad aparente del concepto, conviene analizar cuáles son sus filiaciones con la geografía y otras disciplinas. Y finalmente, plantear casos concretos de utilización del concepto en la investigación geográfica (ciudad sustentable; bosques sustentables), subrayando sus aportes, pero también poniendo a la luz sus límites.

Plant distribution and climate data across western North America

Using an extensive network of occurrence records for 293 plant species collected over the past 40 years across a climatically diverse geographic section of western North America, we find that plant species distributions were just as likely to shift upwards (i.e., towards higher elevations) as downward (i.e., towards lower elevations) - despite consistent warming across the study area. Although there was no clear directional response to climate warming across the entire study area, there was significant region-to region- variation in responses (i.e. from as many as 73% to as few as32% of species shifting upward or downward). To understand the factors that might be controlling region-specific distributional shifts, we explored the relationship between the direction of change in distribution limits and the nature of recent climate change. We found that the direction of distribution limit shifts was explained by an interaction between the rate of change in local summer temperatures and seasonal precipitation. Specifically, species shifted upward at their upper elevational limit when snowfall declined at slower rates and minimum temperatures increased. By contrast, species shifted upwards at their lower elevation limit when maximum temperatures increased or both temperature and precipitation decreased. Our results suggest that future species' elevational distribution shifts will be complex, depending on the interaction between seasonal temperature and precipitation change.