Nonprice Barriers to Ambulatory Care After an Emergency Department Visit

Study objective: Availability of timely follow-up care is essential in emergency medicine. We describe nonprice barriers to care experienced by callers reporting to be emergency department (ED) patients in need of follow-up care. Methods: This was a secondary analysis of data collected during a survey of ambulatory clinics in 9 US cities. Research assistants called a random sample of 603 ambulatory clinics, generated from actual ED referral lists. Callers identified themselves as new patients referred by the local ED. Outcome measures were the percentage of callers experiencing failed appointment attempts for a variety of reasons and inconvenience factors associated with the appointment process: number and amount of time spent on hold, voicemail, repeated calls, and total telephone time. Results: Only 242 (23%) of 1065 total calls resulted in an appointment within one week, for an ultimate caller success rate of 40% (242/603 pseudopatient scenarios). Independent of insurance status, 43% of 603 initial calls to ED referral numbers were unsuccessful: 27% of initial call failures were due to clinic closures, busy signals, voicemail, or personnel too busy to take the call; 6% wrong numbers; 4% disconnected or extended holds; and 6% out of practice scope. If they reached clinic personnel, 55% of callers were placed on hold; average hold time was 2.43 minutes (median 1.35 minutes). Answering system time averaged 1.17 minutes (median 0.68 minutes; range 0.02 to 13.90 minutes). On average, it required 1.7 calls to reach appointment staff and 8% of clinic contacts required 4 or more attempts. Total telephone time averaged 11.1 minutes for successful appointments. Conclusion: There are important nonprice barriers to obtaining follow-up appointments for urgent conditions, independent of insurance status

Exploring barriers to 'Respondent driven sampling' in sex worker and drug-injecting sex worker populations in Eastern Europe

Respondent driven sampling (RDS) has been used in several counties to sample injecting drug users, sex workers (SWs) and men who have sex with men and as a means of collecting behavioural and biological health data. We report on the use of RDS in three separate studies conducted among SWs between 2004 and 2005 in the Russian Federation, Serbia, and Montenegro. Findings suggest that there are limitations associated with the use of RDS in SW populations in these regions. Findings highlight three main factors that merit further investigation as a means of assessing the feasibility and appropriateness of RDS in this high risk population: the network characteristics of SWs; the appropriate level of participant incentives; and lack of service contact. The highly controlled and hidden nature of SW organizations and weak SW social networks in the region can combine to undermine assumptions underpinning the feasibility of RDS approaches and potentially severely limit recruitment. We discuss the implications of these findings for recruitment and the use of monetary and non-monetary incentives in future RDS studies of SW populations in Eastern Europe

Southwest Missouri's changing farm supply picture

March, 1990"This study was partially funded by the Agricultural Cooperative Service, USDA, under cooperative agreement 58-3J321-50018"Includes bibliographical references (page 21)

Departmental savings and loss characteristics for 12 locally owned farmer cooperatives, 1985

New 10/87/550--Cover

Changes in financial performance, Missouri local form supply cooperatives, 1983-1985

Title from JPEG cover page (University of Missouri Digital Library, viewed Mar. 24, 2010)

Single-grain post-IR IRSL signals of K-feldspars from alluvial fan deposits in Baja California Sur, Mexico

Single grains of K-feldspar from alluvial fan units are dated using a more time-stable signal, the post-infrared infrared stimulated luminescence, or, ‘post-IR IRSL’. A quick measurement protocol is discussed, ‘fast post-IR IRSL,’ that stimulates first with the IR diodes at the lower temperature and then measures grain-by grain at the higher temperature. A criterion is offered for rejecting outlying grains based on hierarchical clustering. Single-grain fading rates are found to diverge from single aliquot fading values, and the fading rates from the brightest subset of grains correspond well with an infinite age cobble and independent age control. Age comparison with a cosmogenic depth-profile age shows agreement at 1σ. The depositional chronology suggests that the climate responsible for regionally-extensive, upper-regime floods which aggraded the older units, transitioned into a climate producing weaker channelized floods around the Late Pleistocene–Holocene transition

HIV Epidemics in the European Region: Vulnerability and Response

This report provides a systematic review of the evidence on HIV vulnerability and response in all 53 countries of the WHO European Region, stretching from Iceland to the borders of China. It focuses on key populations most at risk of HIV infection: people who inject drugs, sex workers and men who have sex with men. It confirms that these populations are disproportionately affected by the growing HIV epidemic in Europe. Twenty-five percent of HIV diagnoses in Europe are associated with injecting drug use, with much higher proportions in Eastern Europe (33%) than in Western Europe (5%) and Central Europe (7%). Sex between men accounted for 10% of all HIV diagnoses, with higher rates reported in Western Europe (36%), followed by Central Europe (22%) and Eastern Europe (0.5%). HIV remains relatively low among female sex workers who do not inject drugs, (less than 1%), but higher among those who inject drugs (over 10%) as well as among male and transgender sex workers. The analysis highlights the pivotal role of social and structural factors in shaping HIV epidemics and HIV prevention responses. Poverty, marginalization and stigma contribute to the HIV epidemic in Europe and Central Asia. Economic volatility and recession risks are increasing vulnerability to HIV and infections. Barriers to successful HIV responses include the criminalization of sex work, of sex between men, and of drug use combined with social stigmatization, violence and rights violations. HIV prevention requires social and environmental change. The report calls for policymakers and HIV program implementers to target the right policies and programs to maximize the health and social impacts of Europe’s HIV responses and get higher returns on HIV-related investments. The report is a product of a collaboration between the World Bank, the London School of Hygiene and Tropical Medicine, the WHO Regional Office for Europe and UNAIDS

Pre-freezing of multifractal exponents in Random Energy Models with logarithmically correlated potential

Boltzmann-Gibbs measures generated by logarithmically correlated random potentials are multifractal. We investigate the abrupt change ("pre-freezing") of multifractality exponents extracted from the averaged moments of the measure - the so-called inverse participation ratios. The pre-freezing can be identified with termination of the disorder-averaged multifractality spectrum. Naive replica limit employed to study a one-dimensional variant of the model is shown to break down at the pre-freezing point. Further insights are possible when employing zero-dimensional and infinite-dimensional versions of the problem. In particular, the latter version allows one to identify the pattern of the replica symmetry breaking responsible for the pre-freezing phenomenon.Comment: This is published version, 11 pages, 1 figur

Controlled Irradiative Formation of Penitentes

Spike-shaped structures are produced by light-driven ablation in very different contexts. Penitentes 1-4 m high are common on Andean glaciers, where their formation changes glacier dynamics and hydrology. Laser ablation can produce cones 10-100 microns high with a variety of proposed applications in materials science. We report the first laboratory generation of centimeter-scale snow and ice penitentes. Systematically varying conditions allows identification of the essential parameters controlling the formation of ablation structures. We demonstrate that penitente initiation and coarsening requires cold temperatures, so that ablation leads to sublimation rather than melting. Once penitentes have formed, further growth of height can occur by melting. The penitentes intially appear as small structures (3 mm high) and grow by coarsening to 1-5 cm high. Our results are an important step towards understanding and controlling ablation morphologies.Comment: Accepted for publication in Physical Review Letter