Medical Practice and International Networks. A Swiss National Foundation Funded project based ath the University of Bern

Project presentation

Clinical effectiveness of cognitive behavioral therapy for depression in routine care: A propensity score based comparison between randomized controlled trials and clinical practice

Background: The efficacy of cognitive behavioral therapy (CBT) for the treatment of depressive disorders has been demonstrated in many randomized controlled trials (RCTs). This study investigated whether for CBT similar effects can be expected under routine care conditions when the patients are comparable to those examined in RCTs. Method: N=574 CBT patients from an outpatient clinic were stepwise matched to the patients undergoing CBT in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). First, the exclusion criteria of the RCT were applied to the naturalistic sample of the outpatient clinic. Second, propensity score matching (PSM) was used to adjust the remaining naturalistic sample on the basis of baseline covariate distributions. Matched samples were then compared regarding treatment effects using effect sizes, average treatment effect on the treated (ATT) and recovery rates. Results: CBT in the adjusted naturalistic subsample was as effective as in the RCT. However, treatments lasted significantly longer under routine care conditions. Limitations: The samples included only a limited amount of common predictor variables and stemmed from different countries. There might be additional covariates, which could potentially further improve the matching between the samples. Conclusions: CBT for depression in clinical practice might be equally effective as manual-based treatments in RCTs when they are applied to comparable patients. The fact that similar effects under routine conditions were reached with more sessions, however, points to the potential to optimize treatments in clinical practice with respect to their efficiency.

Physician adoption of a practice guideline: Effect on the cost of medical care for adult patients with diabetes

In the demanding environment of healthcare reform, reduction of unwanted physician practice variation is promoted, often through evidence-based guidelines. Guidelines represent innovations that direct change(s) in physician practice; however, compliance has been disappointing. Numerous studies have analyzed guideline development and dissemination, while few have evaluated the consequences of guideline adoption. The primary purpose of this study was to explore and analyze the relationship between physician adoption of the glycated hemoglobin test guideline for management of adult patients with diabetes, and the cost of medical care. The study also examined six personal and organizational characteristics of physicians and their association with innovativeness, or adoption of the guideline. ^ Cost was represented by approved charges from a managed care claims database. Total cost, and diabetes and related complications cost, first were compared for all patients of adopter physicians with those of non-adopter physicians. Then, data were analyzed controlling for disease severity based on insulin dependency, and for high cost cases. There was no statistically significant difference in any of eight cost categories analyzed. This study represented a twelve-month period, and did not reflect cost associated with future complications known to result from inadequate management of glycemia. Guideline compliance did not increase annual cost, which, combined with the future benefit of glycemic control, lends support to the cost effectiveness of the guideline in the long term. Physician adoption of the guideline was recommended to reduce the future personal and economic burden of this chronic disease. ^ Only half of physicians studied had adopted the glycated hemoglobin test guideline for at least 75% of their diabetic patients. No statistically significant relationship was found between any physician characteristic and guideline adoption. Instead, it was likely that the innovation-decision process and guideline dissemination methods were most influential. ^ A multidisciplinary, multi-faceted approach, including interventions for each stage of the innovation-decision process, was proposed to diffuse practice guidelines more effectively. Further, it was recommended that Organized Delivery Systems expand existing administrative databases to include clinical information, decision support systems, and reminder mechanisms, to promote and support physician compliance with this and other evidence-based guidelines. ^

The Continuing Practice and Impact of Discrimination

This chapter provides a detailed discussion of the evidence on housing and mortgage lending discrimination, as well as the potential impacts of such discrimination on minority outcomes like homeownership and neighborhood environment. The paper begins by discussing conceptual issues surrounding empirical analyses of discrimination including explanations for why discrimination takes place, defining different forms of discrimination, and the appropriate interpretation of observed racial and ethnic differences in treatment or outcomes. Next, the paper reviews evidence on housing market discrimination starting with evidence of segregation and price differences in the housing market and followed by direct evidence of discrimination by real estate agents in paired testing studies. Finally, mortgage market discrimination and barriers in access to mortgage credit are discussed. This discussion begins with an assessment of the role credit barriers play in explaining racial and ethnic differences in homeownership and follows with discussions of analyses of underwriting and the price of credit based on administrative and private sector data sources including analyses of the subprime market. The paper concludes that housing discrimination has declined especially in the market for owner-occupied housing and does not appear to play a large role in limiting the neighborhood choices of minority households or the concentration of minorities into central cities. On the other hand, the patterns of racial centralization and lower home ownership rates of African-Americans appear to be related to each other, and lower minority homeownership rates are in part attributable to barriers in the market for mortgage credit. The paper presents considerable evidence of racial and ethnic differences in mortgage underwriting, as well as additional evidence suggesting these differences may be attributable to differential provision of coaching, assistance, and support by loan officers. At this point, innovation in loan products, the shift towards risk based pricing, and growth of the subprime market have not mitigated the role credit barriers play in explaining racial and ethnic differences in homeownership. Further, the growth of the subprime lending industry appears to have segmented the mortgage market in terms of geography leading to increased costs of relying on local/neighborhood sources of mortgage credit and affecting the integrity of many low-income minority neighborhoods through increased foreclosure rates.

A project to improve the information seeking skills and increase the use of evidence-based research in public health practice

The ability of public health practitioners (PHPs) to work efficiently and effectively is negatively impacted by their lack of knowledge of the broad range of evidence-based practice information resources and tools that can be utilized to guide them in their development of health policies and programs. This project, a three-hour continuing education hands-on workshop with supporting resources, was designed to increase knowledge and skills of these resources. The workshop was presented as a pre-conference continuing education program for the Texas Public Health Association (TPHA) 2008 Annual Conference. Topics included: identification of evidence-based practice resources to aid in the development of policies and programs; identification of sources of publicly available data; utilization of data for community assessments; and accessing and searching the literature through a collection of databases available to all citizens of Texas. Supplemental resources included a blog that served as a gateway to the resources explored during the presentation, a community assessment workbook that incorporates both Healthy People 2010 objectives and links to reliable sources of data, and handouts providing additional instruction on the use of the resources covered during the workshop.^ Before- and after-workshop surveys based on Kirkpatrick's 4-level model of evaluation and the Theory of Planned Behavior were administered. Of the questions related to the trainer, the workshop, and the usefulness of the workshop, participants gave "Good" to "Excellent" responses to all one question. Confidence levels overall increased a statistically significant amount; measurements of attitude, social norms, and control showed no significant differences before and after the workshop. Lastly, participants indicated they were likely to use resources shown during the workshop within a one to three month time period on average. ^ The workshop and creation of supplemental resources served as a pilot for a funded project that will be continued with the development and delivery of four 4-week long webinar-based training sessions to be completed by December 2008. ^

Physician's adherence to CDC standards for physical activity counseling of older women in a cardiology practice in Texas---An exploratory study

Physical activity is an important health-promoting behavior to prevent and control chronic disease. Interventions to increase physical activity are vitally needed. Women are not meeting the recommended goals for physical activity - a behavior that has been shown to effectively reduce the incidence of chronic disease and the medical costs associated with treating it. Among many factors predicting physical activity and the different forms of interventions that have been applied, physician counseling is one potentially cost-effective approach that may produce at least modest effects on women's behavior. The Centers for Disease Control and Prevention has published standards for physician counseling of patients regarding physical activity. This study used a short questionnaire to assess the degree to which a group practice of cardiology physicians in Texas queried and discussed physical activity recommendations to older women that they treat and whether they are meeting the physical activity counseling goals of the Centers for Disease Control and Prevention. The majority of this group of physicians counseled patients without benefit of exploring patient behavior. Although these physicians "agreed" that physical activity delayed or prevented disease, the outcome suggests that low self-efficacy hampered efforts to counsel older women on this. Physicians' perceptions that counseling may be ineffective could explain the lower rate of physical activity counseling that does not meet the goals of the Centers for Disease Control and Prevention. ^

Future pandemic influenza control (FPIC) related strategic management plan based on the 2009 H1N1 pandemic influenza review of health policy decisions, their practice and implications

This cross-sectional study is based on the qualitative and quantitative research design to review health policy decisions, their practice and implications during 2009 H1N1 influenza pandemic in the United States and globally. The “Future Pandemic Influenza Control (FPIC) related Strategic Management Plan” was developed based on the incorporation of the “National Strategy for Pandemic Influenza (2005)” for the United States from the U.S. Homeland Security Council and “The Canadian Pandemic Influenza Plan for the Health Sector (2006)” from the Canadian Pandemic Influenza Committee for use by the public health agencies in the United States as well as globally. The “global influenza experts’ survey” was primarily designed and administered via email through the “Survey Monkey” system to the 2009 H1N1 influenza pandemic experts as the study respondents. The effectiveness of this plan was confirmed and the approach of the study questionnaire was validated to be convenient and the excellent quality of the questions provided an efficient opportunity to the study respondents to evaluate the effectiveness of predefined strategies/interventions for future pandemic influenza control.^ The quantitative analysis of the responses to the Likert-scale based questions in the survey about predefined strategies/interventions, addressing five strategic issues to control future pandemic influenza. The effectiveness of strategies defined as pertinent interventions in this plan was evaluated by targeting five strategic issues regarding pandemic influenza control. For the first strategic issue pertaining influenza prevention and pre pandemic planning; the confirmed effectiveness (agreement) for strategy (1a) 87.5%, strategy (1b) 91.7% and strategy (1c) 83.3%. The assessment of the priority level for strategies to address the strategic issue no. (1); (1b (High Priority) > 1a (Medium Priority) > 1c (Low Priority) based on the available resources of the developing and developed countries. For the second Strategic Issue encompassing the preparedness and communication regarding pandemic influenza control; the confirmed effectiveness (agreement) for the strategy (2a) 95.6%, strategy (2b) 82.6%, strategy (2c) 91.3% and Strategy (2d) 87.0%. The assessment of the priority level for these strategies to address the strategic issue no. (2); (2a (highest priority) > 2c (high priority) >2d (medium priority) > 2b (low priority). For the third strategic issue encompassing the surveillance and detection of pandemic influenza; the confirmed effectiveness (agreement) for the strategy (3a) 90.9% and strategy (3b) 77.3%. The assessment of the priority level for theses strategies to address the strategic Issue No. (3) (3a (high priority) > 3b (medium/low priority). For the fourth strategic issue pertaining the response and containment of pandemic influenza; the confirmed effectiveness (agreement) for the strategy (4a) 63.6%, strategy (4b) 81.8%, strategy (4c) 86.3%, and strategy (4d) 86.4%. The assessment of the priority level for these strategies to address the strategic issue no. (4); (4d (highest priority) > 4c (high priority) > 4b (medium priority) > 4a (low priority). The fifth strategic issue about recovery from influenza and post pandemic planning; the confirmed effectiveness (agreement) for the strategy (5a) 68.2%, strategy (5b) 36.3% and strategy (5c) 40.9%. The assessment of the priority level for strategies to address the strategic issue no. (5); (5a (high priority) > 5c (medium priority) > 5b (low priority).^ The qualitative analysis of responses to the open-ended questions in the study questionnaire was performed by means of thematic content analysis. The following recurrent or common “themes” were determined for the future implementation of various predefined strategies to address five strategic issues from the “FPIC related Strategic Management Plan” to control future influenza pandemics. (1) Pre Pandemic Influenza Prevention, (2) Seasonal Influenza Control, (3) Cost Effectiveness of Non Pharmaceutical Interventions (NPI), (4) Raising Global Public Awareness, (5) Global Influenza Vaccination Campaigns, (6)Priority for High Risk Population, (7) Prompt Accessibility and Distribution of Influenza Vaccines and Antiviral Drugs, (8) The Vital Role of Private Sector, (9) School Based Influenza Containment, (10) Efficient Global Risk Communication, (11) Global Research Collaboration, (12) The Critical Role of Global Public Health Organizations, (13) Global Syndromic Surveillance and Surge Capacity and (14) Post Pandemic Recovery and Lessons Learned. The future implementation of these strategies with confirmed effectiveness to primarily “reduce the overall response time’ in the process of ‘early detection’, ‘strategies (interventions) formulation’ and their ‘implementation’ to eventually ensure the following health outcomes: (a) reduced influenza transmission, (b) prompt and effective influenza treatment and control, (c) reduced influenza related morbidity and mortality.^

A Path Forward: Evidence-Based Approaches to Educational Policy and Practice

In the complex landscape of public education, participants at all levels are searching for policy and practice levers that can raise overall performance and close achievement gaps. The collection of articles in this edition of the Journal of Applied Research on Children takes a big step toward providing the tools and tactics needed for an evidence-based approach to educational policy and practice.

Industrial Development and the Innovation System of the Ethanol Sector in Brazil

The purpose of this paper is to analyze innovations and the innovation system and its dynamics in the ethanol sector in the State of Sao Paulo. More specifically, this paper focuses on the development process in the sector, the public policies taken to promote the sector, and the organizations and key players involved in these policies and their responses to unforeseeable changes in economic, social and technological environments. To this end, this paper takes an historical perspective and reviews data on the cultivation of sugar cane, the production of ethanol, and on sugar cane yields as indicators of the innovations achieved in the sector. The geographical distribution of these indicators is also examined. Next, several cases in Piracicaba and Campinas in the State of Sao Paulo are presented; these give us a more concrete idea of the processes involved in innovation and technology transfer. Based on these observations, the ethanol cluster and the innovation system of the State of Sao Paulo are discussed from the viewpoint of the flowchart approach to industrial cluster policy.

Chapter 3 Knowledge Exchanges and Innovation in Connected Firms: Evidence from Upstream-Downstream Relationships

This paper proposes evidences for linking innovation and knowledge exchanges in developing economies towards a comprehensive theory of new economic geography in the knowledge based spatial economy. Firms which dispatched engineers to customers achieved more innovations than firms which did not. Mutual sharing of knowledge also stimulates innovations. A just-in-time relationship is effective for dealing with upgrading production process. But such strong complementarities with partners are not effective for product innovation.. These evidences support the hypothesis that face-to-face communication and complementarities among production linkages have different roles in knowledge creation.

Knowledge pipeline in freight pipeline industry: competence- based model for open innovation

There is growing concern over the challenges for innovation in Freight Pipeline industry. Since the early works of Chesbrough a decade ago, we have learned a lot about the content, context and process of open innovation. However, much more research is needed in Freight Pipeline Industry. The reality is that few corporations have institutionalized open innovation practices in ways that have enabled substantial growth or industry leadership. Based on this, we pursue the following question: How does a firm’s integration into knowledge networks depend on its ability to manage knowledge? A competence-based model for freight pipeline organizations is analysed, this model should be understood by any organization in order to be successful in motivating professionals who carry out innovations and play a main role in collaborative knowledge creation processes. This paper aims to explain how can open innovation achieve its potential in most Freight Pipeline Industries.

Towards a concurrent semantics-based analysis of CC and CLP. principles and practice of constraint programming

Abstract is not available.

Localization and activity detection Based on the fusion of environment And inertial sensors = Localización y detección de actividad Basadas en integración de sensores y dispositivos inerciales

Los sensores inerciales (acelerómetros y giróscopos) se han ido introduciendo poco a poco en dispositivos que usamos en nuestra vida diaria gracias a su minituarización. Hoy en día todos los smartphones contienen como mínimo un acelerómetro y un magnetómetro, siendo complementados en losmás modernos por giróscopos y barómetros. Esto, unido a la proliferación de los smartphones ha hecho viable el diseño de sistemas basados en las medidas de sensores que el usuario lleva colocados en alguna parte del cuerpo (que en un futuro estarán contenidos en tejidos inteligentes) o los integrados en su móvil. El papel de estos sensores se ha convertido en fundamental para el desarrollo de aplicaciones contextuales y de inteligencia ambiental. Algunos ejemplos son el control de los ejercicios de rehabilitación o la oferta de información referente al sitio turístico que se está visitando. El trabajo de esta tesis contribuye a explorar las posibilidades que ofrecen los sensores inerciales para el apoyo a la detección de actividad y la mejora de la precisión de servicios de localización para peatones. En lo referente al reconocimiento de la actividad que desarrolla un usuario, se ha explorado el uso de los sensores integrados en los dispositivos móviles de última generación (luz y proximidad, acelerómetro, giróscopo y magnetómetro). Las actividades objetivo son conocidas como ‘atómicas’ (andar a distintas velocidades, estar de pie, correr, estar sentado), esto es, actividades que constituyen unidades de actividades más complejas como pueden ser lavar los platos o ir al trabajo. De este modo, se usan algoritmos de clasificación sencillos que puedan ser integrados en un móvil como el Naïve Bayes, Tablas y Árboles de Decisión. Además, se pretende igualmente detectar la posición en la que el usuario lleva el móvil, no sólo con el objetivo de utilizar esa información para elegir un clasificador entrenado sólo con datos recogidos en la posición correspondiente (estrategia que mejora los resultados de estimación de la actividad), sino también para la generación de un evento que puede producir la ejecución de una acción. Finalmente, el trabajo incluye un análisis de las prestaciones de la clasificación variando el tipo de parámetros y el número de sensores usados y teniendo en cuenta no sólo la precisión de la clasificación sino también la carga computacional. Por otra parte, se ha propuesto un algoritmo basado en la cuenta de pasos utilizando informaiii ción proveniente de un acelerómetro colocado en el pie del usuario. El objetivo final es detectar la actividad que el usuario está haciendo junto con la estimación aproximada de la distancia recorrida. El algoritmo de cuenta pasos se basa en la detección de máximos y mínimos usando ventanas temporales y umbrales sin requerir información específica del usuario. El ámbito de seguimiento de peatones en interiores es interesante por la falta de un estándar de localización en este tipo de entornos. Se ha diseñado un filtro extendido de Kalman centralizado y ligeramente acoplado para fusionar la información medida por un acelerómetro colocado en el pie del usuario con medidas de posición. Se han aplicado también diferentes técnicas de corrección de errores como las de velocidad cero que se basan en la detección de los instantes en los que el pie está apoyado en el suelo. Los resultados han sido obtenidos en entornos interiores usando las posiciones estimadas por un sistema de triangulación basado en la medida de la potencia recibida (RSS) y GPS en exteriores. Finalmente, se han implementado algunas aplicaciones que prueban la utilidad del trabajo desarrollado. En primer lugar se ha considerado una aplicación de monitorización de actividad que proporciona al usuario información sobre el nivel de actividad que realiza durante un período de tiempo. El objetivo final es favorecer el cambio de comportamientos sedentarios, consiguiendo hábitos saludables. Se han desarrollado dos versiones de esta aplicación. En el primer caso se ha integrado el algoritmo de cuenta pasos en una plataforma OSGi móvil adquiriendo los datos de un acelerómetro Bluetooth colocado en el pie. En el segundo caso se ha creado la misma aplicación utilizando las implementaciones de los clasificadores en un dispositivo Android. Por otro lado, se ha planteado el diseño de una aplicación para la creación automática de un diario de viaje a partir de la detección de eventos importantes. Esta aplicación toma como entrada la información procedente de la estimación de actividad y de localización además de información almacenada en bases de datos abiertas (fotos, información sobre sitios) e información sobre sensores reales y virtuales (agenda, cámara, etc.) del móvil. Abstract Inertial sensors (accelerometers and gyroscopes) have been gradually embedded in the devices that people use in their daily lives thanks to their miniaturization. Nowadays all smartphones have at least one embedded magnetometer and accelerometer, containing the most upto- date ones gyroscopes and barometers. This issue, together with the fact that the penetration of smartphones is growing steadily, has made possible the design of systems that rely on the information gathered by wearable sensors (in the future contained in smart textiles) or inertial sensors embedded in a smartphone. The role of these sensors has become key to the development of context-aware and ambient intelligent applications. Some examples are the performance of rehabilitation exercises, the provision of information related to the place that the user is visiting or the interaction with objects by gesture recognition. The work of this thesis contributes to explore to which extent this kind of sensors can be useful to support activity recognition and pedestrian tracking, which have been proven to be essential for these applications. Regarding the recognition of the activity that a user performs, the use of sensors embedded in a smartphone (proximity and light sensors, gyroscopes, magnetometers and accelerometers) has been explored. The activities that are detected belong to the group of the ones known as ‘atomic’ activities (e.g. walking at different paces, running, standing), that is, activities or movements that are part of more complex activities such as doing the dishes or commuting. Simple, wellknown classifiers that can run embedded in a smartphone have been tested, such as Naïve Bayes, Decision Tables and Trees. In addition to this, another aim is to estimate the on-body position in which the user is carrying the mobile phone. The objective is not only to choose a classifier that has been trained with the corresponding data in order to enhance the classification but also to start actions. Finally, the performance of the different classifiers is analysed, taking into consideration different features and number of sensors. The computational and memory load of the classifiers is also measured. On the other hand, an algorithm based on step counting has been proposed. The acceleration information is provided by an accelerometer placed on the foot. The aim is to detect the activity that the user is performing together with the estimation of the distance covered. The step counting strategy is based on detecting minima and its corresponding maxima. Although the counting strategy is not innovative (it includes time windows and amplitude thresholds to prevent under or overestimation) no user-specific information is required. The field of pedestrian tracking is crucial due to the lack of a localization standard for this kind of environments. A loosely-coupled centralized Extended Kalman Filter has been proposed to perform the fusion of inertial and position measurements. Zero velocity updates have been applied whenever the foot is detected to be placed on the ground. The results have been obtained in indoor environments using a triangulation algorithm based on RSS measurements and GPS outdoors. Finally, some applications have been designed to test the usefulness of the work. The first one is called the ‘Activity Monitor’ whose aim is to prevent sedentary behaviours and to modify habits to achieve desired objectives of activity level. Two different versions of the application have been implemented. The first one uses the activity estimation based on the step counting algorithm, which has been integrated in an OSGi mobile framework acquiring the data from a Bluetooth accelerometer placed on the foot of the individual. The second one uses activity classifiers embedded in an Android smartphone. On the other hand, the design of a ‘Travel Logbook’ has been planned. The input of this application is the information provided by the activity and localization modules, external databases (e.g. pictures, points of interest, weather) and mobile embedded and virtual sensors (agenda, camera, etc.). The aim is to detect important events in the journey and gather the information necessary to store it as a journal page.

HF spectrum activity prediction model based on HMM for cognitive radio applications

Although most of the research on Cognitive Radio is focused on communication bands above the HF upper limit (30 MHz), Cognitive Radio principles can also be applied to HF communications to make use of the extremely scarce spectrum more efficiently. In this work we consider legacy users as primary users since these users transmit without resorting to any smart procedure, and our stations using the HFDVL (HF Data+Voice Link) architecture as secondary users. Our goal is to enhance an efficient use of the HF band by detecting the presence of uncoordinated primary users and avoiding collisions with them while transmitting in different HF channels using our broad-band HF transceiver. A model of the primary user activity dynamics in the HF band is developed in this work to make short-term predictions of the sojourn time of a primary user in the band and avoid collisions. It is based on Hidden Markov Models (HMM) which are a powerful tool for modelling stochastic random processes and are trained with real measurements of the 14 MHz band. By using the proposed HMM based model, the prediction model achieves an average 10.3% prediction error rate with one minute-long channel knowledge but it can be reduced when this knowledge is extended: with the previous 8 min knowledge, an average 5.8% prediction error rate is achieved. These results suggest that the resulting activity model for the HF band could actually be used to predict primary users activity and included in a future HF cognitive radio based station.