FACTORS INFLUENCING THE PATTERNS OF PHYSICIAN VISITS TO NURSING HOME RESIDENTS

This study was designed to identify some of the factors related to patterns of physician visits to nursing home residents. The relationship of ten resident and organizational characteristics to patterns of physician visits was investigated through secondary analysis of data abstracted from the 1973-74 National Nursing Home Survey of the National Center for Health Statistics. The study sample was composed of 11,135 of the 19,013 nursing home residents who participated in the survey.^ The analytic results revealed that all ten variables had a statistically significant relationship to patterns of physician visits, mainly due to the large sample size. The degrees of association between the variables, measured by the Cramer's V statistic, ranged from moderate to very weak.^ Certification status of the nursing home under Medicare and/or Medicaid was shown to be most strongly related to patterns of physician visits, followed by primary source of payment for nursing home care, and residence prior to nursing home admission. Several variables thought to be related to patterns of physician visits were found to have a very weak relationship: age of the resident, marital status, length of stay, primary diagnosis, number of chronic conditions, activities of daily living status, and levels of care.^ In order to get a more precise picture of the relative influence of certification status and primary source of payment when the other variables were statistically controlled, these two variables were combined into a single variable. The results revealed that the combined effects of certification status and primary source of payment were sustained, regardless of differences in the residents' personal, utilization, and health status characteristics, and the levels of care that they received. The results also indicated that the five groups created by combining the two variables differed in patterns of physician visits. For example, private pay residents in intermediate care facilities (ICF's) and non-certified facilities were more likely to receive unscheduled visits than private pay residents in skilled nursing homes (SNH's), residents in SNH's supported by Medicare or Medicaid, and residents in ICF's supported by Medicaid. ^

Practice and attitude differences in physician cigarette use: A study of prevalence, physicians' role, and smoking policy awareness in Dubai, UAE

The use of tobacco products ruins the health of millions of people around the world. On average, tobacco users die nearly seven years earlier than non-tobacco users. n1 Cigarette smoking is a particular concern in the developing countries of the Middle East and Gulf Cooperation Council (GCC) region where smoking prevalence is expected to increase. This is due to the tobacco industry's vigorous commercial and marketing activities. n3 Smoking prevalence among physicians is considered to be an effective indicator of a society's readiness to identify the smoking epidemic and its related health diseases. n4 There is a lack of detailed data on the smoking prevalence among healthcare professionals, particularly physicians, in the United Arab Emirates (UAE). This cross sectional study is the first to address smoking practices among physicians working at the Department of Health and Medical Services (DOHMS); in Dubai, UAE. ^ This study describes the cigarette smoking prevalence among DOHMS Physicians, physician attitudes towards tobacco use and tobacco bans; physician attitudes towards smoking cessation techniques (among smokers and non-smokers); and physician awareness of official anti-smoking policies. Data for the study was collected through the use of an adapted WHO standardized questionnaire, the Global Health Professionals Survey. The questionnaire was administered by the researcher to physicians (n=288) at their work place. Date was analyzed using the SPSS analytic software program. ^ Twelve percent of DOHMS physicians smoked cigarettes. Regardless of smoking status, the majority supported a tobacco ban in hospitals and public places, and a ban on tobacco advertising. There is a significant relationship between physician smoking status and discussing risks of tobacco use (p < 0.05). Non-smoking physicians reported spending more time with patients discussing hazards of smoking (p < 0.01). Non-smokers reported providing more counseling than their smoking colleagues. The majority of DOHMS physicians (63%) reported a lack of knowledge about 5As/ 5Rs. The majority of physicians also reported they are aware of hospital smoking policies that restrict smoking. Regardless of physician smoking status, DOHMS physicians are not very actively involved in smoking cessation activities. This cross sectional study is the first to address smoking programs, policies, and practices among physicians in Dubai, UAE. Findings support the need for increased physical smoking cessation training as well as the development of smoking cessation programs for tobacco control, and programs with a focus on physician participation in reducing tobacco and cigarette use among the general population.^

Errors in the administration of medication in inpatient hospitals: A systematic review of the research literature on commercial computerized physician order entry systems

Errors in the administration of medication represent a significant loss of medical resources and pose life altering or life threatening risks to patients. This paper considered the question, what impact do Computerized Physician Order Entry (CPOE) systems have on medication errors in the hospital inpatient environment? Previous reviews have examined evidence of the impact of CPOE on medication errors, but have come to ambiguous conclusions as to the impact of CPOE and decision support systems (DSS). Forty-three papers were identified. Thirty-one demonstrated a significant reduction in prescribing error rates for all or some drug types; decreases in minor errors were most often reported. Several studies reported increases in the rate of duplicate orders and failures to remove contraindicated drugs, often attributed to inappropriate design or to an inability to operate the system properly. The evidence on the effectiveness of CPOE to reduce errors in medication administration is compelling though it is limited by modest study sample sizes and designs. ^

"I understood what she meant when she said '21st century medicine'": A qualitative analysis of patient responses for plans for colorectal cancer screening following a recommendation from their physician

Although physician recommendation has been significantly associated with colorectal cancer screening (CRCS), it still does not motivate all patients to get CRCS. Although improved physician recommendation for CRCS has been shown to increase patient CRCS screening, questions remain about what elements of that discussion may lead to screening. The objective of this study is to describe patients' perceptions and interpretations about their physician's recommendation for CRCS during their annual wellness exam. A subset of patients (n=51) participating in a supplement study of a behavioral intervention trial designed to increase CRCS completed a follow-up, open-ended interview two to four weeks after their annual wellness visit. Using qualitative methods, transcripts of these interviews were analyzed. Findings suggest that most patients would follow their physician's recommendation for CRCS despite not engaging in much discussion. Patients may refrain from CRCS discussion because of a commitment to CRCS, awareness of screening guidelines, and trust in physician's honesty and beneficence. Yet many patients left their wellness exams with questions, refraining because of future plans to consult with their physicians, perceived time constraints or a lack of a patient-physician relationship. If patients are leaving their wellness exams with unanswered questions, interventions should prepare physicians for patient reticence, teaching physicians how to assure patients that CRCS is a primary care activity where all questions and concerns, including cost and scheduling, may be resolved.^

Physician attitudes on the HPV vaccine

The quadrivalent HPV vaccine was developed primarily for the prevention of cervical cancer. The vaccine, originally approved for females, was recently approved by the American Committee for Immunization Practices to be administered to males, allowing federal programs to pay for the vaccination for both males and females. However, uptake for this vaccination has been low. Studies show that physicians have great influence over whether or not parents decide to vaccinate their children. In this study, a survey was mailed out asking physicians about their attitude towards the HPV vaccination and what they believed to be the barriers to the vaccination of their patients. The analysis of the data included descriptive statistics and chi-square analysis in order to compare the differences in responses between male and female patients. The vast majority of physicians supported the vaccination of both females and males. However, the perceived barriers to vaccinating females differed from males, with physicians believing that parents' concern about sexual promiscuity was a greater barrier to vaccination in girls than boys (p=0.007). The other major significant difference in perceived barriers among physicians is the belief that physicians in general are less likely to promote the vaccination in males compared to females (p=0.01). Despite evidence to the contrary, it seems more patient education is needed regarding sexual promiscuity and its association with the HPV vaccine. There may also be a need for increased physician education regarding the use of the HPV vaccine for male patients.^

A comparative analysis of hospital -based physician monitoring systems

The purpose of the multiple case-study was to determine how hospital subsystems (such as physician monitoring and credentialing; quality assurance; risk management; and peer review) were supporting the monitoring of physicians? Three large metropolitan hospitals in Texas were studied and designated as hospitals #1, #2, and #3. Realizing that hospital subsystems are a unique entity and part of a larger system, conclusions were made on the premises of a quality control system, in relation to the tools of government (particularly the Health Care Quality Improvement Act (HCQIA)), and in relation to itself as a tool of a hospital.^ Three major analytical assessments were performed. First, the subsystems were analyzed as to their "completeness"; secondly, the subsystems were analyzed for "performance"; and thirdly, the subsystems were analyzed in reference to the interaction of completeness and performance.^ The physician credentialing and monitoring and the peer review subsystems as quality control systems were most complete, efficient, and effective in hospitals #1 and #3. The HCQIA did not seem to be an influencing factor in the completeness of the subsystem in hospital #1. The quality assurance and risk management subsystem in hospital #2 was not representative of completeness and performance and the HCQIA was not an influencing factor in the completeness of the Q.A. or R.M. systems in any hospital. The efficiency (computerization) of the physician credentialing, quality assurance and peer review subsystems in hospitals #1 and #3 seemed to contribute to their effectiveness (system-wide effect).^ The results indicated that the more complete, effective, and efficient subsystems were characterized by (1) all defined activities being met, (2) the HCQIA being an influencing factor, (3) a decentralized administrative structure, (4) computerization an important element, and (5) staff was sophisticated in subsystem operations. However, other variables were identified which deserve further research as to their effect on completeness and performance of subsystems. They include (1) medical staff affiliations, (2) system funding levels, (3) the system's administrative structure, and (4) the physician staff "cultural" characteristics. Perhaps by understanding other influencing factors, health care administrators may plan subsystems that will be compatible with legislative requirements and administrative objectives. ^

Estimates of hospital and physician costs of epilepsy in the United States for 1995 comparing the provider -based survey method and a patient -based medical charts and billing method

This investigation compares two different methodologies for calculating the national cost of epilepsy: provider-based survey method (PBSM) and the patient-based medical charts and billing method (PBMC&BM). The PBSM uses the National Hospital Discharge Survey (NHDS), the National Hospital Ambulatory Medical Care Survey (NHAMCS) and the National Ambulatory Medical Care Survey (NAMCS) as the sources of utilization. The PBMC&BM uses patient data, charts and billings, to determine utilization rates for specific components of hospital, physician and drug prescriptions. ^ The 1995 hospital and physician cost of epilepsy is estimated to be $722 million using the PBSM and $1,058 million using the PBMC&BM. The difference of $336 million results from $136 million difference in utilization and $200 million difference in unit cost. ^ Utilization. The utilization difference of $136 million is composed of an inpatient variation of $129 million, $100 million hospital and $29 million physician, and an ambulatory variation of $7 million. The $100 million hospital variance is attributed to inclusion of febrile seizures in the PBSM, $−79 million, and the exclusion of admissions attributed to epilepsy, $179 million. The former suggests that the diagnostic codes used in the NHDS may not properly match the current definition of epilepsy as used in the PBMC&BM. The latter suggests NHDS errors in the attribution of an admission to the principal diagnosis. ^ The $29 million variance in inpatient physician utilization is the result of different per-day-of-care physician visit rates, 1.3 for the PBMC&BM versus 1.0 for the PBSM. The absence of visit frequency measures in the NHDS affects the internal validity of the PBSM estimate and requires the investigator to make conservative assumptions. ^ The remaining ambulatory resource utilization variance is $7 million. Of this amount, $22 million is the result of an underestimate of ancillaries in the NHAMCS and NAMCS extrapolations using the patient visit weight. ^ Unit cost. The resource cost variation is $200 million, inpatient is $22 million and ambulatory is $178 million. The inpatient variation of $22 million is composed of $19 million in hospital per day rates, due to a higher cost per day in the PBMC&BM, and $3 million in physician visit rates, due to a higher cost per visit in the PBMC&BM. ^ The ambulatory cost variance is $178 million, composed of higher per-physician-visit costs of $97 million and higher per-ancillary costs of $81 million. Both are attributed to the PBMC&BM's precise identification of resource utilization that permits accurate valuation. ^ Conclusion. Both methods have specific limitations. The PBSM strengths are its sample designs that lead to nationally representative estimates and permit statistical point and confidence interval estimation for the nation for certain variables under investigation. However, the findings of this investigation suggest the internal validity of the estimates derived is questionable and important additional information required to precisely estimate the cost of an illness is absent. ^ The PBMC&BM is a superior method in identifying resources utilized in the physician encounter with the patient permitting more accurate valuation. However, the PBMC&BM does not have the statistical reliability of the PBSM; it relies on synthesized national prevalence estimates to extrapolate a national cost estimate. While precision is important, the ability to generalize to the nation may be limited due to the small number of patients that are followed. ^

Enfermedad de Creutzfeld Jakob, desafío diagnóstico : reporte de dos casos en la ciudad de Mendoza

La enfermedad de Creutzfeldt-Jakob (ECJ) es una afección neurodege-nerativa rápidamente progresiva y mortal producida por priones. Es la más común de las encefalopatías espongiformes. La hipótesis prevalente sugiere que se inicia y propaga por conversión de una proteína priónica normal (PrP) en una isoforma conformacional anormal (PrPreS), que se acumula en el cerebro causando destrucción neuronal. Se reporta el caso de dos pacientes asistido en el Servicio de Neurología del Hospital Lagomaggiore de la ciudad de Mendoza en el período de 2 años: mujer de 49 años con cuadro de deterioro cognitivo rápidamente progresivo asociado a trastorno de la marcha y ataxia de 2 meses de evolución; y varón de 54 años con conductas inapropiadas y desorientación temporo-espacial de 20 días de evolución. Ambos con EEG compatible y proteína 14.3.3 positiva, falleciendo semanas después del diagnóstico. Se discute ambos casos, los cuales representaron un desafío diagnóstico dada la baja frecuencia y escaso reconocimiento de esta entidad en nuestro medio, debiendo debe ser considerado en pacientes que evolucionan a una demencia rápidamente progresiva.

Arsenic speciation in edible alga samples by microwave-assisted extraction and high performance liquid chromatography coupled to atomic fluorescence spectrometry

Twelve commercially available edible marine algae from France, Japan and Spain and the certified reference material (CRM) NIES No. 9 Sargassum fulvellum were analyzed for total arsenic and arsenic species. Total arsenic concentrations were determined by inductively coupled plasma atomic emission spectrometry (ICP-AES) after microwave digestion and ranged from 23 to 126 μg g−1. Arsenic species in alga samples were extracted with deionized water by microwave-assisted extraction and showed extraction efficiencies from 49 to 98%, in terms of total arsenic. The presence of eleven arsenic species was studied by high performance liquid chromatography–ultraviolet photo-oxidation–hydride generation atomic–fluorescence spectrometry (HPLC–(UV)–HG–AFS) developed methods, using both anion and cation exchange chromatography. Glycerol and phosphate sugars were found in all alga samples analyzed, at concentrations between 0.11 and 22 μg g−1, whereas sulfonate and sulfate sugars were only detected in three of them (0.6-7.2 μg g−1). Regarding arsenic toxic species, low concentration levels of dimethylarsinic acid (DMA) (<0.9 μg g−1) and generally high arsenate (As(V)) concentrations (up to 77 μg g−1) were found in most of the algae studied. The results obtained are of interest to highlight the need to perform speciation analysis and to introduce appropriate legislation to limit toxic arsenic species content in these food products.

Internal quantum efficiency of III-nitride quantum dot superlattices grown by plasma-assisted molecular-beam epitaxy

We present a study of the optical properties of GaN/AlN and InGaN/GaN quantum dot (QD) superlattices grown via plasma-assisted molecular-beam epitaxy, as compared to their quantum well (QW) counterparts. The three-dimensional/two-dimensional nature of the structures has been verified using atomic force microscopy and transmission electron microscopy. The QD superlattices present higher internal quantum efficiency as compared to the respective QWs as a result of the three-dimensional carrier localization in the islands. In the QW samples, photoluminescence (PL) measurements point out a certain degree of carrier localization due to structural defects or thickness fluctuations, which is more pronounced in InGaN/GaN QWs due to alloy inhomogeneity. In the case of the QD stacks, carrier localization on potential fluctuations with a spatial extension smaller than the QD size is observed only for the InGaN QD-sample with the highest In content (peak emission around 2.76 eV). These results confirm the efficiency of the QD three-dimensional confinement in circumventing the potential fluctuations related to structural defects or alloy inhomogeneity. PL excitation measurements demonstrate efficient carrier transfer from the wetting layer to the QDs in the GaN/AlN system, even for low QD densities (~1010 cm-3). In the case of InGaN/GaN QDs, transport losses in the GaN barriers cannot be discarded, but an upper limit to these losses of 15% is deduced from PL measurements as a function of the excitation wavelength.

Modulation-mode assignment in SVD-assisted multiuser MIMO-OFDM systems

In order to comply with the demand on increasing available data rates in particular in wireless technologies, systems with multiple transmit and receive antennas, also called MIMO (multiple-input multiple-output) systems, have become indispensable for future generations of wireless systems. Due to the strongly increasing demand in high-data rate transmission systems, frequency non-selective MIMO links have reached a state of maturity and frequency selective MIMO links are in the focus of interest. In this field, the combination of MIMO transmission and OFDM (orthogonal frequency division multiplexing) can be considered as an essential part of fulfilling the requirements of future generations of wireless systems. However, single-user scenarios have reached a state of maturity. By contrast multiple users’ scenarios require substantial further research, where in comparison to ZF (zero-forcing) multiuser transmission techniques, the individual user’s channel characteristics are taken into consideration in this contribution. The performed joint optimization of the number of activated MIMO layers and the number of transmitted bits per subcarrier along with the appropriate allocation of the transmit power shows that not necessarily all user-specific MIMO layers per subcarrier have to be activated in order to minimize the overall BER under the constraint of a given fixed data throughput.

Control of the morphology on selective area growth of GaN nanocolumns by rf-plasma-assisted

Selective area growth (SAG) of GaN nanocolumns (NCs), making use of patterned or masked (nanoholes) substrates, yields a periodic, homogeneous distribution of nanostructures, that makes their processing much easier compared with self-assembled ones. In addition, the control on the diameter and density of NCs avoids dispersion in the electrooptical characteristics of the heterostructures based on this type of material (embedded InGaN/GaN quantum disks for example). Selective area growth using a mask with nanohole arrays has been demonstrated by rf-plasma-assisted MBE [1, 2].

Modulation-mode Assignment for SVD-assisted Multiuser MIMO Systems with Correlation.

Multiuser multiple-input multiple-output (MIMO) downlink (DL) transmission schemes experience both multiuser interference as well as inter-antenna interference. The singular value decomposition provides an appropriate mean to process channel information and allows us to take the individual user’s channel characteristics into account rather than treating all users channels jointly as in zero-forcing (ZF) multiuser transmission techniques. However, uncorrelated MIMO channels has attracted a lot of attention and reached a state of maturity. By contrast, the performance analysis in the presence of antenna fading correlation, which decreases the channel capacity, requires substantial further research. The joint optimization of the number of activated MIMO layers and the number of bits per symbol along with the appropriate allocation of the transmit power shows that not necessarily all user-specific MIMO layers has to be activated in order to minimize the overall BER under the constraint of a given fixed data throughput.

Modulation-mode Assignment in SVD-assisted Multiuser MIMO-OFDM Systems

In order to comply with the demand on increasing available data rates in particular in wireless technologies, systems with multiple transmit and receive antennas, also called MIMO (multiple-input multiple-output) systems, have become indispensable for future generations of wireless systems. Due to the strongly increasing demand in high-data rate transmission systems, frequency non-selective MIMO links have reached a state of maturity and frequency selective MIMO links are in the focus of interest. In this field, the combination of MIMO transmission and OFDM (orthogonal frequency division multiplexing) can be considered as an essential part of fulfilling the requirements of future generations of wireless systems. However, single-user scenarios have reached a state of maturity. By contrast multiple users’ scenarios require substantial further research, where in comparison to ZF (zero-forcing) multiuser transmission techniques, the individual user’s channel characteristics are taken into consideration in this contribution. The performed joint optimization of the number of activated MIMO layers and the number of transmitted bits per subcarrier along with the appropriate allocation of the transmit power shows that not necessarily all user-specific MIMO layers per subcarrier have to be activated in order to minimize the overall BER under the constraint of a given fixed data throughput

Serial or Parallel Linear-Assisted Switching Converter as Envelope Amplifier: Optimization and Comparison

This paper presents a theoretical analysis and an optimization method for envelope amplifier. Highly efficient envelope amplifiers based on a switching converter in parallel or series with a linear regulator have been analyzed and optimized. The results of the optimization process have been shown and these two architectures are compared regarding their complexity and efficiency. The optimization method that is proposed is based on the previous knowledge about the transmitted signal type (OFDM, WCDMA...) and it can be applied to any signal type as long as the envelope probability distribution is known. Finally, it is shown that the analyzed architectures have an inherent efficiency limit.