Essays on the Evaluation of Environmental Programs

This dissertation comprises four chapters. The unifying theme is the evaluation of environmental programs. Specifically, each chapter examines some facet of the impacts of protected areas. The first chapter examines the heterogeneous environmental and economic impacts of protected areas in Costa Rica. Previous studies suggest that Costa Rica\u27s protected area system induced both reduced deforestation and alleviated poverty. We demonstrate that these environmental and social impacts were spatially heterogeneous. Importantly, the characteristics associated with the most avoided deforestation are the characteristics associated with the least poverty alleviation. In other words, the same characteristics that have limited the conservation effectiveness of protected areas may have improved the social welfare impacts of these areas. These results suggest that `win-win\u27 efforts to protect ecosystems and alleviate poverty may be possible when policymakers are satisfied with low levels of each outcome, but tradeoffs exist when more of either outcome is desired. The second chapter explores in more detail the heterogeneous impacts of protected areas in Costa Rica and Thailand. In particular we investigate the potential for protected areas to act as a mechanism for poverty traps and use semiparametric models to identify the spatial congruence of environmental and economic outcomes. We find no evidence that protected areas trap historically poorer areas in poverty. In fact, we find that poorer areas at baseline appear to have the greatest levels of poverty reduction as a result of protection. However, we do find that the spatial characteristics associated with the most poverty alleviation are not necessarily the characteristics associated with the most avoided deforestation. We demonstrate how an understanding of these spatially heterogeneous responses to protection can be used to generate suitability maps that identify locations in which both environmental and poverty alleviation goals are most likely to be achieved. In the third chapter we address the mechanisms through which protected areas affect economic outcomes. Using recently developed quasi-experimental methods and rich biophysical and demographic data, we quantify the causal post-treatment mechanism impacts of tourism, infrastructure development and ecosystem services on poverty, due to the establishment of protected areas in Costa Rica prior to 1980. We find that nearly 50% of the poverty reduction estimated in a previous study can be attributed to tourism. In addition, although the mechanism estimates for the infrastructure and ecosystem services proxies are negligible, we argue that the results provide evidence that enhanced ecosystem services from the establishment of protected areas has likely helped to reduce poverty. The results provide additional information to policy makers that wish to enhance the future establishment of protected areas with complementary policy. The final chapter studies the economic impacts of protected areas in Bolivia. We find that municipalities with at least 10% of their area occupied by a protected area between 1992 and 2000 exhibited differentially greater levels of poverty reduction between 1992 and 2001 compared to similar municipalities unaffected by protected areas. We find that the results are robust to a number of econometric specifications, spillover analyses and a placebo study. Although the overarching results that Bolivia\u27s protected areas were associated with poverty reduction are similar to previous studies , the underlying results are subtly, but significantly, different. In previous studies it was found that controlling for key observable covariates lead to fundamentally antithetical results compared to naive estimates. Conversely, these results indicate that naive estimates lead to an over-estimation of the poverty reducing impacts of protected areas. The results expose the heterogeneity of protected area impacts across countries and, therefore, underscore the importance of country-level impact evaluations in order to build the global knowledge base regarding the socioeconomic impacts of protected areas

PubMed QUEST: The PubMed Query Search Tool. An informatics tool to aid cancer centers and cancer investigators in searching the PubMed databases

Searching PubMed for citations related to a specific cancer center or group of authors can be labor-intensive. We have created a tool, PubMed QUEST, to aid in the rapid searching of PubMed for publications of interest. It was designed by taking into account the needs of entire cancer centers as well as individual investigators. The experience of using the tool by our institution’s cancer center administration and investigators has been favorable and we believe it could easily be adapted to other institutions. Use of the tool has identified limitations of automated searches for publications based on an author’s name, especially for common names. These limitations could likely be solved if the PubMed database assigned a unique identifier to each author

Estimating the Impacts of Bolivia\u27s Protected Areas on Poverty

Protected areas represent a powerful policy tool for the preservation of ecosystems and their services. The rapid proliferation of protected areas in Bolivia over the past several decades has prompted interest in understanding their impacts on surrounding populations. Recent studies from other developing countries show that protected areas have had positive impacts on poverty. Using rich biophysical and socioeconomic data from Bolivia we and that municipalities with at least 10% of their area occupied by a protected area established between 1992 and 2000 exhibited differentially greater levels of poverty reduction between 1992 and 2001 compared to similar municipalities indicted by protected areas. We and that our results are robust to a number of econometric specifications, spillover analyses and a placebo study. Although our overarching results that Bolivia\u27s protected areas were associated with poverty reduction are similar to previous studies, our underlying results di are subtly, but significantly. Previous studies found that controlling for key observable covariates led to fundamentally antithetical results compared to na+ye (uncontrolled) estimates. Conversely, our results indicate that na+ve estimates lead to an over estimation of the poverty reducing impacts of protected areas. Our results expose the heterogeneity of protected area impacts across countries and, therefore, underscore the importance of country-level impact evaluations in order to build the global knowledge base regarding the socioeconomic impacts of protected areas

Computerized Automated Reminder Diabetes System (CARDS): E-Mail and SMS Cell Phone Text Messaging Reminders to Support Diabetes Management

Abstract Background: Cell phone text messaging, via the Short Messaging Service (SMS), offers the promise of a highly portable, well-accepted, and inexpensive modality for engaging youth and young adults in the management of their diabetes. This pilot and feasibility study compared two-way SMS cell phone messaging with e-mail reminders that were directed at encouraging blood glucose (BG) monitoring. Methods: Forty insulin-treated adolescents and young adults with diabetes were randomized to receive electronic reminders to check their BG levels via cell phone text messaging or e-mail reminders for a 3-month pilot study. Electronic messages were automatically generated, and participant replies with BG results were processed by the locally developed Computerized Automated Reminder Diabetes System (CARDS). Participants set their schedule for reminders on the secure CARDS website where they could also enter and review BG data. Results: Of the 40 participants, 22 were randomized to receive cell phone text message reminders and 18 to receive e-mail reminders; 18 in the cell phone group and 11 in the e-mail group used the system. Compared to the e-mail group, users in the cell phone group received more reminders (180.4 vs. 106.6 per user) and responded with BG results significantly more often (30.0 vs. 6.9 per user, P = 0.04). During the first month cell phone users submitted twice as many BGs as e-mail users (27.2 vs. 13.8 per user); by month 3, usage waned. Conclusions: Cell phone text messaging to promote BG monitoring is a viable and acceptable option in adolescents and young adults with diabetes. However, maintaining interest levels for prolonged intervals remains a challenge.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78128/1/dia.2008.0022.pd

Pre-operative localization of solitary pulmonary nodules with computed tomography-guided hook wire: report of 181 patients.

BACKGROUND: Video-assisted thoracic surgery (VATS) is currently performed to diagnose and treat solitary pulmonary nodules (SPN). However, the intra-operative identification of deep nodules can be challenging with VATS as the lung is difficult to palpate. The aim of the study was to report the utility and the results of pre-operative computed tomography (CT)-guided hook wire localization of SPN. METHODS: All records of the patients undergoing CT-guided hook wire localization prior to VATS resection for SPN between 2002 and 2013 were reviewed. The efficacy in localizing the nodule, hook wire complications, necessity to convert VATS to thoracotomy and the histology of SPN are reported. RESULTS: One hundred eighty-one patients (90 females, mean age 63 y, range 28-82 y) underwent 187 pulmonary resections after CT-guided hook wire localization. The mean SPN diameter was 10.3 mm (range: 4-29 mm). The mean distance of the lesion from the pleural surface was 11.6 mm (range: 0-45 mm). The mean time interval from hook wire insertion to VATS resection was 224 min (range 54-622 min). Hook wire complications included pneumothorax requiring chest tube drainage in 4 patients (2.1%) and mild parenchymal haemorrhage in 11 (5.9%) patients. Migration of the hook wire occurred in 7 patients (3.7%) although it did not affect the success of VATS resection (nodule location guided by the lung puncture site). Three patients underwent additional wedge resection by VATS during the same procedure because no lesion was identified in the surgical specimen. Conversion thoracotomy was required in 13 patients (7 %) for centrally localized lesions (6 patients) and pleural adhesions (7 patients). The mean operative time was 60 min (range 18-135 min). Pathological examination revealed a malignant lesion in 107 patients (59 %). The diagnostic yield was 98.3 %. CONCLUSION: VATS resection for SPN after CT-guided hook wire localization for SPN is safe and allows for proper diagnosis with a low thoracotomy conversion rate

Impacts of forests on children’s diet in rural areas across 27 developing countries

Micronutrient deficiency affects about a third of the world’s population. Children in developing countries are particularly vulnerable. Consequences include impaired cognitive and physical development and increased childhood morbidity and mortality. Recent studies suggest that forests help alleviate micronutrient deficiency by increasing dietary diversity. However, evidence is mostly based on weakly designed local case studies of limited relevance to global policies. Furthermore, impacts of forests on diet vary among communities, and understanding this variation can help target actions to enhance impact. We compile data on children’s diets in over 43,000 households across 27 developing countries to examine the impacts of forests on dietary diversity. We use empirical designs that are attentive to assumptions necessary for causal interpretations and that adequately account for confounding factors that could mask or mimic the impact. We find that high exposure to forests causes children to have at least 25% greater dietary diversity compared to lack of exposure, a result comparable to the impacts of some nutrition-sensitive agricultural programs. A closer look at a subset of African countries indicates that impacts are generally higher for less developed communities, but highest with certain access to markets, roads, and education. Our results also indicate that forests could help reduce vitamin A and iron deficiencies. Our study establishes the causal relationship between forests and diet and thus strengthens the evidence for integrating forest conservation and management into nutrition interventions. Our results also suggest that providing households some access to capital can increase the impact of forest-related interventions on nutrition

Changing trends in residents-as-teachers across graduate medical education

BACKGROUND: Teaching residents how to teach is a critical part of residents' training in graduate medical education (GME). The purpose of this study was to assess the change in resident-as-teacher (RaT) instruction in GME over the past 15 years in the US. METHODS: We used a quantitative and qualitative survey of all program directors (PDs) across specialties. We compared our findings with a previous work from 2000-2001 that studied the same matter. Finally, we qualitatively analyzed PDs' responses regarding the reasons for implementing and not implementing RaT instruction. RESULTS: Two hundred and twenty-one PDs completed the survey, which yields a response rate of 12.6%. Over 80% of PDs implement RaT, an increase of 26.34% compared to 2000-2001. RaT instruction uses multiple methods with didactic lectures reported as the most common, followed by role playing in simulated environments, then observing and giving feedback. Residents giving feedback, clinical supervision, and bedside teaching were the top three targeted skills. Through our qualitative analysis we identified five main reasons for implementing RaT: teaching is part of the residents' role; learners desire formal RaT training; regulatory bodies require RaT training; RaT improves residents' education; and RaT prepares residents for their current and future roles. CONCLUSION: The use of RaT instruction has increased significantly in GME. More and more PDs are realizing its importance in the residents' formative training experience. Future studies should examine the effectiveness of each method for RaT instruction

Vedolizumab for Treating Moderately to Severely Active Crohn’s Disease After Prior Therapy: An Evidence Review Group Perspective of a NICE Single Technology Appraisal

As part of its single technology appraisal process, the National Institute for Health and Care Excellence (NICE) invited the manufacturer of vedolizumab (Takeda UK) to submit evidence of the clinical effectiveness and cost effectiveness of vedolizumab for the treatment of patients with moderate-to-severe, active Crohn’s disease. The School of Health and Related Research (ScHARR) at the University of Sheffield was commissioned as the Evidence Review Group (ERG) and produced a critical review of the evidence of the clinical effectiveness and cost effectiveness of the technology, based upon the company’s submission to NICE. The GEMINI II and III trials formed the main supporting evidence for the intervention. Both studies were phase III, randomised, double-blind, placebo-controlled, multicentre trials designed to evaluate the efficacy and safety of vedolizumab. They included patients who were naïve to tumour necrosis factor alpha antagonist (anti-TNF-α) therapy and patients who had an inadequate response to, loss of response to or intolerance of immunomodulators or anti-TNF-α agents. GEMINI II was designed to evaluate the efficacy and safety of vedolizumab as an induction treatment (dosing at weeks 0 and 2, with assessment at week 6) and maintenance treatment (during weeks 6–52). In contrast, GEMINI III was designed to evaluate the efficacy and safety of vedolizumab as an induction treatment only, with doses at weeks 0, 2 and 6, and assessment at weeks 6 and 10. In the absence of any direct head-to-head, randomised, controlled trials comparing vedolizumab with other relevant biologic therapies (adalimumab and infliximab) for the treatment of moderate-to-severe Crohn’s disease, the company conducted a network meta-analysis, which compared vedolizumab, adalimumab, infliximab and placebo for the outcomes of clinical response, enhanced clinical response, clinical remission and discontinuation due to adverse events. The company model estimated the incremental cost-effectiveness ratio (ICER) for vedolizumab compared with the standard of care (consisting of 5-aminosalicylic acids, corticosteroids and immunosuppressants) to be £21,620 per quality-adjusted life-year (QALY) gained within the anti-TNF-α-failure population (which included a confidential patient access scheme for vedolizumab). The ICERs were above £30,000 per QALY gained for the mixed intention-to-treat population (including both anti-TNF-α-naïve and anti-TNF-α-failure populations) and in patients who were anti-TNF-α naïve only. The ERG identified a number of limitations that were believed to limit the robustness of the results presented by the company. These limitations could not be addressed by the ERG without major restructuring of the economic model. Therefore, the ERG concluded that the results from the company’s model needed to be interpreted with caution and that it was unclear whether the ICERs would increase or decrease following amendment of the identified structural issues

Hemiarthroplasty of the Hip in a 52-Year-old Patient with Osteogenesis Imperfecta-Related Femoral Neck Fracture: A Case Report.

Osteogenesis imperfecta (OI)-related femoral neck fractures are rare. This is rarely described in the literature. This article presents a way to surgically treat such a fracture. We describe the case of a 52-year-old patient with OI Type III with a displaced femoral neck fracture with varus deformity. We performed a hemiarthroplasty of the hip with valgus and shortening osteotomy of the proximal femoral shaft. The incidence of OI is 1 in 10,000-,000 births. People suffering from OI are known to be at more risk of fractures. Due to the bone deformity and weakness, treatment of fractures in patients with OI is a big challenge for orthopedic surgeons. Combined osteotomy and hemiarthroplasty is a reliable technique to treat a femoral neck fracture in a patient with typical OI-related varus deformity of the femora