Policy analysis of Texas Senate Bill 532 and the regulation of nurse practitioners in the convenience care model

Background. Retail clinics, also called convenience care clinics, have become a rapidly growing trend since their initial development in 2000. These clinics are coupled within a larger retail operation and are generally located in "big-box" discount stores such as Wal-mart or Target, grocery stores such as Publix or H-E-B, or in retail pharmacies such as CVS or Walgreen's (Deloitte Center for Health Solutions, 2008). Care is typically provided by nurse practitioners. Research indicates that this new health care delivery system reduces cost, raises quality, and provides a means of access to the uninsured population (e.g., Deloitte Center for Health Solutions, 2008; Convenient Care Association, 2008a, 2008b, 2008c; Hansen-Turton, Miller, Nash, Ryan, Counts, 2007; Salinsky, 2009; Scott, 2006; Ahmed & Fincham, 2010). Some healthcare analysts even suggest that retail clinics offer a feasible solution to the shortage of primary care physicians facing the nation (AHRQ Health Care Innovations Exchange, 2010). ^ The development and performance of retail clinics is heavily dependent upon individual state policies regulating NPs. Texas currently has one of the most highly regulated practice environments for NPs (Stout & Elton, 2007; Hammonds, 2008). In September 2009, Texas passed Senate Bill 532 addressing the scope of practice of nurse practitioners in the convenience care model. In comparison to other states, this law still heavily regulates nurse practitioners. However, little research has been conducted to evaluate the impact of state laws regulating nurse practitioners on the development and performance of retail clinics. ^ Objectives. (1). To describe the potential impact that SB 532 has on retail clinic performance. (2). To discuss the effectiveness, efficiency, and equity of the convenience care model. (3). To describe possible alternatives to Texas' nurse practitioner scope of practice guidelines as delineated in Texas Senate Bill 532. (4). To describe the type of nurse practitioner state regulation (i.e. independent, light, moderate, or heavy) that best promotes the convenience care model. ^ Methods. State regulations governing nurse practitioners can be characterized as independent, light, moderate, and heavy. Four state NP regulatory types and retail clinic performance were compared and contrasted to that of Texas regulations using Dunn and Aday's theoretical models for conducting policy analysis and evaluating healthcare systems. Criteria for measurement included effectiveness, efficiency, and equity. Comparison states were Arizona (Independent), Minnesota (Light), Massachusetts (Moderate), and Florida (Heavy). ^ Results. A comparative states analysis of Texas SB 532 and alternative NP scope of practice guidelines among the four states: Arizona, Florida, Massachusetts, and Minnesota, indicated that SB 532 has minimal potential to affect the shortage of primary care providers in the state. Although SB 532 may increase the number of NPs a physician may supervise, NPs are still heavily restricted in their scope of practice and limited in their ability to act as primary care providers. Arizona's example of independent NP practice provided the best alternative to affect the shortage of PCPs in Texas as evidenced by a lower uninsured rate and less ED visits per 1,000 population. A survey of comparison states suggests that retail clinics thrive in states that more heavily restrict NP scope of practice as opposed to those that are more permissive, with the exception of Arizona. An analysis of effectiveness, efficiency, and equity of the convenience care model indicates that retail clinics perform well in the areas of effectiveness and efficiency; but, fall short in the area of equity. ^ Conclusion. Texas Senate 532 represents an incremental step towards addressing the problem of a shortage of PCPs in the state. A comparative policy analysis of the other four states with varying degrees of NP scope of practice indicate that a more aggressive policy allowing for independent NP practice will be needed to achieve positive changes in health outcomes. Retail clinics pose a temporary solution to the shortage of PCPs and will need to expand their locations to poorer regions and incorporate some chronic care to obtain measurable health outcomes. ^

The relationship between supermarket nutrient movements and the mortality rates from fat-associated and non-fat-associated cardiovascular disease: Development of an ecologic method for determining community food patterns

Supermarket nutrient movement, a community food consumption measure, aggregated 1,023 high-fat foods, representing 100% of visible fats and approximately 44% of hidden fats in the food supply (FAO, 1980). Fatty acid and cholesterol content of foods shipped from the warehouse to 47 supermarkets located in the Houston area were calculated over a 6 month period. These stores were located in census tracts with over 50% of a given ethnicity: Hispanic, black non-Hispanic, or white non-Hispanic. Categorizing the supermarket census tracts by predominant ethnicity, significant differences were found by ANOVA in the proportion of specific fatty acids and cholesterol content of the foods examined. Using ecological regression, ethnicity, income, and median age predicted supermarket lipid movements while residential stability did not. No associations were found between lipid movements and cardiovascular disease mortality, making further validation necessary for epidemiological application of this method. However, it has been shown to be a non-reactive and cost-effective method appropriate for tracking target foods in populations of groups, and for assessing the impact of mass media nutrition education, legislation, and fortification on community food and nutrient purchase patterns. ^

THE APPLICATION OF PATH ANALYSIS TO ASSESSMENT OF IRON NUTRITIONAL STATUS IN MAN

Path analysis has been applied to components of the iron metabolic system with the intent of suggesting an integrated procedure for better evaluating iron nutritional status at the community level. The primary variables of interest in this study were (1) iron stores, (2) total iron-binding capacity, (3) serum ferritin, (4) serum iron, (5) transferrin saturation, and (6) hemoglobin concentration. Correlation coefficients for relationships among these variables were obtained from published literature and postulated in a series of models using measures of those variables that are feasible to include in a community nutritional survey. Models were built upon known information about the metabolism of iron and were limited by what had been reported in the literature in terms of correlation coefficients or quantitative relationships. Data were pooled from various studies and correlations of the same bivariate relationships were averaged after z- transformations. Correlation matrices were then constructed by transforming the average values back into correlation coefficients. The results of path analysis in this study indicate that hemoglobin is not a good indicator of early iron deficiency. It does not account for variance in iron stores. On the other hand, 91% of the variance in iron stores is explained by serum ferritin and total iron-binding capacity. In addition, the magnitude of the path coefficient (.78) of the serum ferritin-iron stores relationship signifies that serum ferritin is the most important predictor of iron stores in the proposed model. Finally, drawing upon known relations among variables and the amount of variance explained in path models, it is suggested that the following blood measures should be made in assessing community iron deficiency: (1) serum ferritin, (2) total iron-binding capacity, (3) serum iron, (4) transferrin saturation, and (5) hemoglobin concentration. These measures (with acceptable ranges and cut-off points) could make possible the complete evaluation of all three stages of iron deficiency in those persons surveyed at the community level. ^

A study of nutrition promotion in and consumer nutrition environments of hospitals

Dietary intake is a complex, health-related behavior, and although individual-level theoretical models explain some variation in dietary intake, comprehensive theoretical models such as the ecological framework describe the multiple levels which influence diet-related behaviors. Thus, the ecological framework is a preferred model for designing comprehensive nutrition interventions. While ecological-based nutrition interventions have been described, little work has focused on interventions in the hospital setting. Because hospitals are considered the hallmarks of health, it might seem that hospitals would regularly engage in worksite nutrition promotion; however, recent publications and other anecdotal evidence have indicated otherwise. The first paper of this dissertation systematically reviewed the scientific literature between 1996 and 2012 and identified 13 outcome evaluation trials for hospital-based worksite nutrition interventions. Of these 13 interventions, only one intervention targeted three of the four levels of the ecological framework and no intervention targeted all four levels. Only half of the interventions targeted the physical environment of hospitals, thus warranting more investigation into this specific level of the ecological framework in this setting. ^ A critical type of nutrition-related physical environments is the consumer nutrition environment. Although other tools measure the consumer nutrition environments of stores and restaurants, no tool specifically measured the consumer nutrition environments of hospitals until the CDC developed the Healthy Hospital Environment Scan for Cafeterias, Vending Machines, and Gift Shops (HHES-CVG). The HHES-CVG, a tool which measures the consumer nutrition environments of hospital cafeterias, vending machines, and gifts shops, was released in November 2011, and in the second paper of this dissertation, the reliability of this tool was investigated. Two trained raters visited 39 hospitals across Southern California between February and May 2012, and based on analyses of the raters' findings, the HHES-CVG exhibited strong reliability metrics (inter-observer agreement between 74 and 100%, and an intraclass correlation coefficient of 0.961 for the overall nutrition composite score). Because the HHES-CVG was found to be a reliable tool, the third paper of this dissertation presented HHES-CVG results from the 39 hospitals. Overall, hospitals only scored about one-fourth of the total possible points for the nutrition composite score, indicating that most facilities do not have acceptable consumer nutrition environments. Some of the best practices observed in cafeterias were significantly associated with having a large facility and with having a contracted foodservice operation, but overall nutrition composite score was not associated with any specific facility or operation type. ^ The dissertation concluded that much work is needed in order to improve the consumer nutrition environments of hospitals. Practitioners and healthcare administrators should consider starting with ecological-based interventions addressing all levels including the physical environment.^

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.^

Something real: A social marketing approach to smoking prevention among Montevideo youth

Uruguay has some of the strictest tobacco-control laws in Latin America. Despite this, youth smoking rates in Uruguay are amongst the highest in South America. Thus, it is important to identify strategies to prevent youth smoking in Uruguay. The current qualitative research study sought to identify intrapersonal and socioenvironmental factors that are associated with smoking among middle school youth in Uruguay. It also sought to develop potential prevention strategies and media messages that would resonate with youth for a social media campaign. The study was grounded in social cognitive theory and the theory of reasoned action/planned behavior, among other behavioral science theories; anthropological perspectives were also considered. To achieve these goals, 29 group and individual structured interviews were conducted in two private middle schools catering to lower and higher SES youth in Montevideo, Uruguay during the summer of 2012. One hundred and three study participants, including students, parents, and teachers, were interviewed. The structured interviews were recorded, transcribed, translated, back translated, coded and analyzed. The study findings show that positive attitudes towards smoking (i.e. to be seen, to increase status, to ensure women's equality, to looking old, and to service as a rite of passage), delinquent behavior (i.e. transgression/deviant behavior), social norms that support smoking (i.e. peer pressure and modeling, group membership/sense of belonging, parental modeling, and family support), easy access and availability to tobacco (i.e. retails stores) were factors associated with youth smoking. Potential protective factors may include parental support, negative attitudes towards smoking, sports/music, and smoke-free environments. Because study participants are accustomed to government-sponsored strong countermarketing graphic imaging, study participants selected even stronger images and messages as the preferred way to receive tobacco prevention messages. Something Real ("Algo Real") was a theme that resonated with the participants and chosen as the name for the proposed campaign. This campaign was designed as a multiple component intervention that included mass, school base, and family based strategies to prevent tobacco use. Some intervention materials specific to these intervention components were developed to target relevant intrapersonal and socioenvironmental factors identified above. These materials will be tested in future pilot studies and larger scale evaluation with this population, outside the scope of this dissertation. ^

Monitoreo de condiciones de higiene y seguridad del ambiente en entornos industriales usando redes de sensores inalámbricos

Resumen: Las redes de sensores inalámbricos han atraído mucha atención en los últimos años debido a la integración de tecnología inalámbrica, computación y tecnología de sensores. Estas redes consisten en una serie de nodos equipados con capacidades de procesamiento, comunicación y sensado. Utilizan protocolos especiales de radio para transmitir datos en un modo multisalto de operación. En este trabajo se propone utilizar una red de sensores para el monitoreo de las condiciones ambientales de Higiene y Seguridad en entornos industriales. Concretamente se monitorean Temperatura, Humedad, Ruido y Luminosidad. Se propone esta recolección de datos para dar soporte a la inspección anual de un auditor externo, por lo que no se considera esta recolección como crítica dado que no controlan ningún dispositivo. En primera instancia se aborda el problema utilizando una red de sensores con módulos que utilizan el protocolo 802.15 los cuales transmiten a un nodo maestro que sirve como gateway para enviar la información a un servidor que la almacena. La recolección de datos se realiza a través de una plataforma arduino como interface entre el módulo inalámbrico y los sensores. Esta primera propuesta es contrastada con un enfoque de Internet de las Cosas (IoT) utilizando módulos Arduino con WiFi embebido, denominados Wido, que permiten la comunicación de datos directamente al servidor de almacenaje. El trabajo comprende la caracterización del problema, elección del hardware, diseño de la red y la realización de pruebas para evaluar el funcionamiento de ambos enfoques.

Wal-Mart, caballo de Troya de la globalización

Creada en 1962 por Sam Walton, una pequeña empresa de distribución norteamericana se convertirá rápidamente en la primera empresa mundial. Desde Bentonville, Arkansas, hasta el interior de China, Wal-Mart muestra un camino bastante clásico que va desde la sede principal de la empresa hacia una proliferación de sus tiendas en una quincena de países. Con una facturación de 405 mil millones de dólares en 2008, la empresa de distribución número uno en el mundo fue sobrepasada en abril de 2009 por la empresa petrolera Exxon Mobil en la clasificación de las quinientas empresas mundiales más importantes. Pero a diferencia de otras grandes transnacionales como Exxon Mobil o Microsoft, Wal-Mart, la primera empresa mundial de distribución, tiene que adaptarse al medio ambiente local con el fin de atraer a un máximo de consumidores. El artículo propone una aproximación a escala múltiple de las estrategias de desarrollo de esta firma internacional. Así, la aplicación de un análisis espacial es apropiada para esclarecer los vínculos existentes entre los territorios y las estrategias de los actores a diferentes escalas geográficas.

Cambios en la distribución minorista de alimentos y bebidas en Argentina 2001-2003 : Hacia nuevas horizontalidades territoriales

Se presentan en este trabajo los principales cambios en la distribución minorista de alimentos y bebidas en la Argentina iniciados con la crisis económica, política y social del año 2001. El territorio usado por parte de los actores sociales involucrados, como las empresas de diferentes tamaños (desde hipermercados a almacenes), y las personas (consumidores), ya no solo responderá a un orden global y a verticalidades territoriales, sino que muchas de estas nuevas tendencias estarán comandadas por normas locales relacionadas con la horizontalidad territorial. Entre estos cambios, son los más importantes: el consumo orientado a las ofertas; a empaques más chicos; a segundas y terceras marcas; a marcas propias de supermercados; a una nueva frecuencia en la realización de las compras; a la combinación de varios canales de distribución con el fenómeno denominado "vuelta al barrio", y a compras de productos sueltos.

Wal-Mart, caballo de Troya de la globalización

Creada en 1962 por Sam Walton, una pequeña empresa de distribución norteamericana se convertirá rápidamente en la primera empresa mundial. Desde Bentonville, Arkansas, hasta el interior de China, Wal-Mart muestra un camino bastante clásico que va desde la sede principal de la empresa hacia una proliferación de sus tiendas en una quincena de países. Con una facturación de 405 mil millones de dólares en 2008, la empresa de distribución número uno en el mundo fue sobrepasada en abril de 2009 por la empresa petrolera Exxon Mobil en la clasificación de las quinientas empresas mundiales más importantes. Pero a diferencia de otras grandes transnacionales como Exxon Mobil o Microsoft, Wal-Mart, la primera empresa mundial de distribución, tiene que adaptarse al medio ambiente local con el fin de atraer a un máximo de consumidores. El artículo propone una aproximación a escala múltiple de las estrategias de desarrollo de esta firma internacional. Así, la aplicación de un análisis espacial es apropiada para esclarecer los vínculos existentes entre los territorios y las estrategias de los actores a diferentes escalas geográficas.

Cambios en la distribución minorista de alimentos y bebidas en Argentina 2001-2003 : Hacia nuevas horizontalidades territoriales

Se presentan en este trabajo los principales cambios en la distribución minorista de alimentos y bebidas en la Argentina iniciados con la crisis económica, política y social del año 2001. El territorio usado por parte de los actores sociales involucrados, como las empresas de diferentes tamaños (desde hipermercados a almacenes), y las personas (consumidores), ya no solo responderá a un orden global y a verticalidades territoriales, sino que muchas de estas nuevas tendencias estarán comandadas por normas locales relacionadas con la horizontalidad territorial. Entre estos cambios, son los más importantes: el consumo orientado a las ofertas; a empaques más chicos; a segundas y terceras marcas; a marcas propias de supermercados; a una nueva frecuencia en la realización de las compras; a la combinación de varios canales de distribución con el fenómeno denominado "vuelta al barrio", y a compras de productos sueltos.

Wal-Mart, caballo de Troya de la globalización

Creada en 1962 por Sam Walton, una pequeña empresa de distribución norteamericana se convertirá rápidamente en la primera empresa mundial. Desde Bentonville, Arkansas, hasta el interior de China, Wal-Mart muestra un camino bastante clásico que va desde la sede principal de la empresa hacia una proliferación de sus tiendas en una quincena de países. Con una facturación de 405 mil millones de dólares en 2008, la empresa de distribución número uno en el mundo fue sobrepasada en abril de 2009 por la empresa petrolera Exxon Mobil en la clasificación de las quinientas empresas mundiales más importantes. Pero a diferencia de otras grandes transnacionales como Exxon Mobil o Microsoft, Wal-Mart, la primera empresa mundial de distribución, tiene que adaptarse al medio ambiente local con el fin de atraer a un máximo de consumidores. El artículo propone una aproximación a escala múltiple de las estrategias de desarrollo de esta firma internacional. Así, la aplicación de un análisis espacial es apropiada para esclarecer los vínculos existentes entre los territorios y las estrategias de los actores a diferentes escalas geográficas.

Cambios en la distribución minorista de alimentos y bebidas en Argentina 2001-2003 : Hacia nuevas horizontalidades territoriales

Se presentan en este trabajo los principales cambios en la distribución minorista de alimentos y bebidas en la Argentina iniciados con la crisis económica, política y social del año 2001. El territorio usado por parte de los actores sociales involucrados, como las empresas de diferentes tamaños (desde hipermercados a almacenes), y las personas (consumidores), ya no solo responderá a un orden global y a verticalidades territoriales, sino que muchas de estas nuevas tendencias estarán comandadas por normas locales relacionadas con la horizontalidad territorial. Entre estos cambios, son los más importantes: el consumo orientado a las ofertas; a empaques más chicos; a segundas y terceras marcas; a marcas propias de supermercados; a una nueva frecuencia en la realización de las compras; a la combinación de varios canales de distribución con el fenómeno denominado "vuelta al barrio", y a compras de productos sueltos.

Biological traits, and egg and fecal pellet production of Calanus finmarchicus and Calanus glacialis in situ and during experiments

The effects of temperature and food was examined for Calanus finmarchicus and C. glacialis during 3 phases of the phytoplankton spring bloom in Disko Bay, western Greenland. The 2 species were collected during pre-bloom, bloom, and post-bloom and exposed to temperatures from 0 to 10°C, combined with deficient or excess food. Fecal pellet and egg production were measured as indices for grazing and secondary production, respectively. Furthermore, changes in body carbon, nitrogen, and lipid content were measured. C. glacialis sampled before the bloom and incubated with excess food exhibited high specific egg production at temperatures between 0 and 2.5°C. Higher temperatures did not increase egg production considerably, whereas egg production for C. finmarchicus more than tripled between 2.5 and 5°C. Starved C. glacialis produced eggs at all temperatures stimulated by increasing temperatures, whereas starved C. finmarchicus needed temperatures above 5°C to produce eggs fueled by their lipid stores. Few C. finmarchicus had mature gonads at the initiation of the pre-bloom and bloom experiment, and egg production of C. finmarchicus therefore only increased as the ratio of individuals with mature gonads increased. During the bloom, both C. glacialis and C. finmarchicus used the high food availability for egg production, while refueling or exhausting their lipid stores, respectively. Finally, during the post-bloom experiment, production was low by C. finmarchicus, whereas C. glacialis had terminated production. Our results suggest that a future warmer ocean will reduce the advantage of early spawning by C. glacialis and that C. finmarchicus will become increasingly prevalent.

Bone metabolic and hormonal characteristics of Australian Antarctic expeditioners

Summary: Serum 25(OH)D levels decline without sunlight exposure. We studied 120 expeditioners to Antarctica to determine the skeletal and hormonal responses to sunlight deprivation. With emerging vitamin D insufficiency, serum calcium decreased, PTH increased, and bone loss at the proximal femur was observed. Baseline serum 25(OH)D levels >100 nmol/L prevented vitamin D insufficiency. Introduction: Vitamin D stores deplete without adequate sunlight exposure unless supplementation is provided. We studied 120 healthy adults who spent a year in Antarctica as a model for sunlight deprivation to define the timing and magnitude of the skeletal and hormonal responses to emerging vitamin D insufficiency. Methods: Fasting blood samples were assessed at baseline, 6 and 12 months for serum 25-hydroxyvitamin D (25(OH)D), osteocalcin (OC), bone formation (P1NP) and resorption (CTx), PTH and calcium. Lumbar spine and proximal femur BMD was measured using DXA. Differences over time were determined using repeated measures ANOVA. Percent changes were expressed as (Delta value/(value A +value B)/2)x100. Relationships between outcome measures were determined using Spearman's correlations. Results: Vitamin D insufficiency (<50 nmol/L) was observed in 85% of expeditioners by 6 months when serum calcium decreased and PTH increased (p<0.01). By 12 months, OC increased by 7.4±3.0% (p<0.05), and BMD decreased by 1.0±2.0% at the total proximal femur (p<0.05). For those with vitamin D sufficiency at baseline (>50 nmol/L), sunlight deprivation produced vitamin D insufficiency within 4 months unless baseline values were >100 nmol/L. Conclusion: Supplementation may be necessary for expeditioners with limited access to UV light.