Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis

BackgroundHealth services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends.Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators.ConclusionsThe study found that extending access was associated with a reduction in emergency department visits in the first 12 months. The results of the research have already informed the decision by National Health Service England to extend primary care access across Greater Manchester from 2016. However, further evidence is needed to understand whether extending primary care access is cost-effective and sustainable.     

Influence of Royal College of Radiologists' guidelines on referral from general practice. Royal College of Radiologists Working Party.

OBJECTIVE--To measure the effect on general practitioner referrals for radiography of introducing guidelines of good practice together with monitoring and peer review. DESIGN--Collection of referral data during 1 January 1989 to 31 December 1990. Guidelines were introduced on 1 January 1990. SETTING--Open access radiology services provided by one non-teaching district in England. SUBJECTS--144614 registered patients from 22 practices. MAIN OUTCOME MEASURES--Number of referrals per 1000 registered patients for radiography of the chest, skull, spine, abdomen, limbs, and joints and for barium investigation and excretion urography. RESULTS--Overall referrals fell from 88.4/1000 registered patients to 77.2/1000 after the guidelines were introduced. The commonest reasons for referral were for examination of the chest, spine, and limbs and joints and referrals for these fell by 9.4%, 17.5%, and 13.5% respectively. Referrals for skull radiography fell by 30% (from 241 to 168). CONCLUSIONS--By helping general practitioners to be more selective in their use of diagnostic radiology, the guidelines reduced the rate of referral and thus patients'' exposure to radiation.     

BioWAP, mobile Internet service for bioinformatics

We have developed a new Internet service, which provides mobile access to bioinformatics databases and software tools. The BioWAP service facilitates access to basic bioinformatics databases and analysis tools from everywhere without a PC or a laptop computer. Both open source bioinformatics program suites and Internet services, which are not designed for mobile Internet access, were utilized in the BioWAP service. AVAILABILITY: The BioWAP service starting page can be browsed with any WAP terminal from http://bioinf.uta.fi/wml/welcome.wml.     

OECD guidelines on open access: commercialization in disguise?

The Organisation for Economic Co-operation and Development (OECD) has published a new set of principles and guidelines to promote open access to datasets and results from publicly funded research. However, there is reason to think twice about the implications of making demands for transparency and open access for publicly funded research only. How will such demands affect incentives and research agendas? Might this new regulation of publicly funded research have undesirable effects on the quality and value of research? Placing the OECD guidelines in a broader context of research regulation, we argue that they might provide a further push toward collaboration with commercially sponsored research and reinforce incentive structures that favour the creation of commercial value.     

Preprinting is positively associated with early career researcher status in ecology and evolution

The usage of preprint servers in ecology and evolution is increasing, allowing research to be rapidly disseminated and available through open access at no cost. Early Career Researchers (ECRs) often have limited experience with the peer review process, which can be challenging when trying to build publication records and demonstrate research ability for funding opportunities, scholarships, grants, or faculty positions. ECRs face different challenges relative to researchers with permanent positions and established research programs. These challenges might also vary according to institution size and country, which are factors associated with the availability of funding for open access journals. We predicted that the career stage and institution size impact the relative usage of preprint servers among researchers in ecology and evolution. Using data collected from 500 articles (100 from each of two open access journals, two closed access journals, and a preprint server), we showed that ECRs generated more preprints relative to non‐ECRs, for both first and last authors. We speculate that this pattern is reflective of the advantages of quick and open access research that is disproportionately beneficial to ECRs. There is also a marginal association between first author, institution size, and preprint usage, whereby the number of preprints tends to increase with institution size for ECRs. The United States and United Kingdom contributed the greatest number of preprints by ECRs, whereas non‐Western countries contributed relatively fewer preprints. This empirical evidence that preprint usage varies with the career stage, institution size, and country helps to identify barriers surrounding large‐scale adoption of preprinting in ecology and evolution.     

Factors affecting localized abundance and distribution of lesser mealworm in earth-floor broiler houses in subtropical Australia

Factors that influence the localized abundance and distribution of lesser mealworm, Alphitobius diaperinus (Panzer), in litter of two compacted earth-floor broiler houses in subtropical Australia were studied using various experimental manipulations. Numbers of lesser mealworms substantially increased inside caged areas and under uncaged empty feed pans placed in open areas of the houses. These populations were found to be localized and independent of chicken-feed, manure, and high beetle populations that normally occur under existing feed pans. Substantial horizontal movement of larvae to under feed pans was recorded. Placing metal barriers around these pans significantly restricted this movement. In almost all treatments, lesser mealworms typically peaked in numbers during the middle of the flock time. This temporal pattern of abundance also was observed under pans within barriers, where relatively low insect numbers occurred, but it was not observed in uncaged open areas (where chickens had complete access). It is likely that larvae do not establish in open areas, but fluctuate in numbers as they either move to refuges away from chickens or suffer high rates of mortality. In these refuges, larvae peak in numbers and then leave the litter environment to pupate in the earth floor before the end of the flock time. This behavior might be exploited for management of lesser mealworm by targeting applications of control agents.     

The Changing Regulation of Coastal Shipping in Australia

Market access to coastal shipping services is often severely restricted. Most countries impose national flag requirements as a minimum. However, Australia's coastal shipping market has been more open than many other markets, allowing foreign flag access to domestic shipping through a unique permit and licensing scheme. This article assesses Australia's regulation of cabotage by examining the nature of the permits issued to foreign flag companies for domestic shipments and evaluates the changes currently being proposed against a database of permits issued in 2009 and 2010.     

Childhood stunting and cognitive effects of water and sanitation in Indonesia

Close to 100 million Indonesians lack access to improved sanitation, while 33 million live without improved drinking water. Indonesia is home to the second largest number of open defecators in the world, behind India. Repeated exposure to fecal pathogens, especially common in areas where open defecation is practiced, can cause poor absorption and nutrient loss through diarrhea and poor gut function, leading to undernutrition, growth stunting and irreversible impairment of health, development, learning and earnings – the effects of which outlast a lifetime. Using data from a sample of over six thousand children in the Indonesia Family Life Survey (IFLS), a household socioeconomic panel representative of over 80 percent of the Indonesian population, we examine the relationship between poor household and community water and sanitation services and childhood stunting and cognitive development. We find that children living in households that have access to improved sanitation when they are under 2 years of age are approximately 5 percentage points less likely to end up being stunted. Community rates of sanitation are also important. Children living in open defecation free communities during this critical development window are more than 10 percentage points less likely to be stunted, than children in communities where all other households defecate in the open. Further, cognitive test scores are adversely affected by open defecation. These findings suggest that owning a toilet and living in a community where most of one’s neighbors own a toilet are important drivers of child growth and development.     

The eStation,an Earth Observation processing service in support to ecological monitoring

The eStation is a collecting and processing system designed to automatically deal with the reception, processing, analysis and dissemination of key environmental parameters derived from remotely sensed data. Developed mainly at the Joint Research Centre of the European Commission, the eStation has been distributed to 47 sub-Saharan countries in the frame of the AMESD (Africa n Monitoring of Environment for Sustainable Development) project to provide local institutions with the capacity to easily access a large range of remote sensing products on vegetation, precipitation, fires and oceans. These products, derived from the processing of images coming from various instruments including SPOT-Vegetation, MSG-SEVIRI and MODIS are developed to allow end-users to make local and regional assessments of the state of marine and terrestrial ecosystems. The products, dispatched to the users through the EUMETSAT data broadcasting system (EUMETCast) or provided by other Earth Observation (EO) data agencies (e.g. NASA), are further processed by the eStation to allow end-users to generate their own environmental, whether terrestrial or marine, assessments and reports. Initially designed as a stand-alone system using an open source development framework, the eStation has recently been further developed as a web processing service to allow a broader range of end-users to access the data and services over the Internet. It is the purpose of this paper to introduce the readers to the eStation and its products, to share the lessons learnt in deploying these services as well as to discuss its more recent use in chained environmental web based modeling services.     

Spatial Access to Emergency Services in Low- and Middle-Income Countries: A GIS-Based Analysis

Injury is a leading cause of the global disease burden, accounting for 10 percent of all deaths worldwide. Despite 90 percent of these deaths occurring in low and middle-income countries (LMICs), the majority of trauma research and infrastructure development has taken place in high-income settings. Furthermore, although accessible services are of central importance to a mature trauma system, there remains a paucity of literature describing the spatial accessibility of emergency services in LMICs. Using data from the Service Provision Assessment component of the Demographic and Health Surveys of Namibia and Haiti we defined the capabilities of healthcare facilities in each country in terms of their preparedness to provide emergency services. A Geographic Information System-based network analysis method was used to define 5- 10- and 50-kilometer catchment areas for all facilities capable of providing 24-hour care, higher-level resuscitative services or tertiary care. The proportion of a country’s population with access to each level of service was obtained by amalgamating the catchment areas with a population layer. A significant proportion of the population of both countries had poor spatial access to lower level services with 25% of the population of Haiti and 51% of the population of Namibia living further than 50 kilometers from a facility capable of providing 24-hour care. Spatial access to tertiary care was considerably lower with 51% of Haitians and 72% of Namibians having no access to these higher-level services within 50 kilometers. These results demonstrate a significant disparity in potential spatial access to emergency services in two LMICs compared to analogous estimates from high-income settings, and suggest that strengthening the capabilities of existing facilities may improve the equity of emergency services in these countries. Routine collection of georeferenced patient and facility data in LMICs will be important to understanding how spatial access to services influences outcomes.     

Revenue management for outpatient appointments: joint capacity control and overbooking with class-dependent no-shows

Outpatient appointment scheduling balances efficiency with access to healthcare services, yet appointment no-shows, cancellations, and delay are significant barriers to effective healthcare delivery. Patients with longer appointment delay often waste appointments more frequently, prompting a need for greater flexibility in appointment allocation. We present a joint capacity control and overbooking model where a clinic maximizes profits by controlling bookings from two sequential patient classes with different no-show rates. When booking advance requests, the clinic must balance high no-show probability with the probability of subsequent requests at lower waste rates. We show the optimal policy is computationally intensive to derive; therefore, we develop bounds and approximations which we compare via numerical study with the optimal policy as well as policies from practice and previous literature. We find the optimal policy increases profits 17.8% over first-come-first-serve allocation. We develop a simple policy which performs 0.3% below optimal on average. While pure open access can achieve optimality, it performs 23.0% below optimal on average.     

Witness response at acute onset of stroke: a qualitative theory-guided study

Background

Delay in calling emergency medical services following stroke limits access to early treatment that can reduce disability. Emergency medical services contact is mostly initiated by stroke witnesses (often relatives), rather than stroke patients. This study explored appraisal and behavioural factors that are potentially important in influencing witness behaviour in response to stroke.

Methods and Findings

Semi-structured interviews with 26 stroke witnesses were transcribed and theory-guided content analysed was undertaken based on the Common Sense Self-Regulation Model (appraisal processes) and Theory Domains Framework (behavioural determinants). Response behaviours were often influenced by heuristics-guided appraisal (i.e. mental rules of thumb). Some witnesses described their responses to the situation as ‘automatic’ and ‘instinctive’, rather than products of deliberation. Potential behavioural influences included: environmental context and resources (e.g. time of day), social influence (e.g. prompts from patients) and beliefs about consequences (e.g. 999 accesses rapid help). Findings are based on retrospective accounts and need further verification in prospective studies.

Conclusions

Witnesses play a key role in patient access to emergency medical services. Factors that potentially influence witnesses’ responses to stroke were identified and could inform behavioural interventions and future research. Interventions might benefit from linking automatic/instinctive threat perceptions with deliberate appraisal of stroke symptoms, prompting action to call emergency medical services.     

Lessons from the genomes of extremely acidophilic bacteria and archaea with special emphasis on bioleaching microorganisms

This mini-review describes the current status of recent genome sequencing projects of extremely acidophilic microorganisms and highlights the most current scientific advances emerging from their analysis. There are now at least 56 draft or completely sequenced genomes of acidophiles including 30 bacteria and 26 archaea. There are also complete sequences for 38 plasmids, 29 viruses, and additional DNA sequence information of acidic environments is available from eight metagenomic projects. A special focus is provided on the genomics of acidophiles from industrial bioleaching operations. It is shown how this initial information provides a rich intellectual resource for microbiologists that has potential to open innovative and efficient research avenues. Examples presented illustrate the use of genomic information to construct preliminary models of metabolism of individual microorganisms. Most importantly, access to multiple genomes allows the prediction of metabolic and genetic interactions between members of the bioleaching microbial community (ecophysiology) and the investigation of major evolutionary trends that shape genome architecture and evolution. Despite these promising beginnings, a major conclusion is that the genome projects help focus attention on the tremendous effort still required to understand the biological principles that support life in extremely acidic environments, including those that might allow engineers to take appropriate action designed to improve the efficiency and rate of bioleaching and to protect the environment.     

Biphenyls as potential mimetics of protein alpha-helix

Based on theoretical arguments, 2,6,3',5'-substituted biphenyl analogues are proposed as protein alpha-helix mimetics superimposing the side chains of the residues i, i+1, i+3 and i+4. Knowing that many protein-protein interactions of therapeutical relevance involve alpha-helix contacts, the communication outlines how this novel category of scaffolds might potentially open access to such targets.     

Ethnic elders.

The numbers of elderly people from ethnic groups within Britain is rising rapidly as postwar immigrants age. Ethnic elders face problems owing to age-associated increased risks of common chronic diseases, racial discrimination, and poor access to many health services and social services. This disadvantage will be alleviated through increased understanding of health beliefs held by ethnic elders and ensuring better access to services through mechanisms such as employment of more staff from ethnic minority groups in senior positions, better training of staff, and more appropriate and sensitive environments. The myths that family care is sufficient, that no use of services implies no need, and that assimilation into the majority population will occur must be discounted.     

The Importance of Biodiversity E-infrastructures for Megadiverse Countries

Addressing the challenges of biodiversity conservation and sustainable development requires global cooperation, support structures, and new governance models to integrate diverse initiatives and achieve massive, open exchange of data, tools, and technology. The traditional paradigm of sharing scientific knowledge through publications is not sufficient to meet contemporary demands that require not only the results but also data, knowledge, and skills to analyze the data. E-infrastructures are key in facilitating access to data and providing the framework for collaboration. Here we discuss the importance of e-infrastructures of public interest and the lack of long-term funding policies. We present the example of Brazil’s speciesLink network, an e-infrastructure that provides free and open access to biodiversity primary data and associated tools. SpeciesLink currently integrates 382 datasets from 135 national institutions and 13 institutions from abroad, openly sharing ~7.4 million records, 94% of which are associated to voucher specimens. Just as important as the data is the network of data providers and users. In 2014, more than 95% of its users were from Brazil, demonstrating the importance of local e-infrastructures in enabling and promoting local use of biodiversity data and knowledge. From the outset, speciesLink has been sustained through project-based funding, normally public grants for 2–4-year periods. In between projects, there are short-term crises in trying to keep the system operational, a fact that has also been observed in global biodiversity portals, as well as in social and physical sciences platforms and even in computing services portals. In the last decade, the open access movement propelled the development of many web platforms for sharing data. Adequate policies unfortunately did not follow the same tempo, and now many initiatives may perish.     

Radiology services for remote communities: cost minimisation study of telemedicine.

OBJECTIVES--To determine the social costs of providing a rural population with radiology services under three different systems: the existing system (a small x ray unit at the remote site and all other examinations at the nearest radiology department (the host site)); a teleradiology system (most examinations at the remote site and more advanced examinations at the host site); and all examinations at the host site. DESIGN--Cost minimisation study. SETTING--Primary health care in a remote community in Norway. SUBJECTS--A randomly selected sample (n = 597) of all patients (n = 1793) having radiological examinations in 1993. MAIN OUTCOME MEASURES--Annual direct medical costs, direct non-medical (travel) costs, and indirect costs (lost production) of the three options. RESULTS--After exclusion of costs common to the three systems the direct medical, direct non-medical, and indirect costs of the three options were, respectively, 9000 pounds, 51,000 pounds, and 31,500 pounds (total 91,500 pounds) for the existing system; 108,000 pounds, 2,000 pounds, and 13,500 pounds (total 123,500 pounds) for the teleradiology option; and 0 pounds, 75,000 pounds, and 42,000 pounds (117,000 pounds in total) for the "all at host" option. Sensitivity analyses indicated that the existing system is the least costly option except when lost leisure is valued as highly as lost production. CONCLUSION--The teleradiology option did not seem to be cost saving in the study community. Such systems, however, may be justified on the grounds of equity of access and quality of care.