Background: In the treatment of hypertension, physicians’ attitudes and practice patterns are receiving increased attention as contributors to poor blood pressure (BP) control. Thus, current use of antihypertensive drugs in primary care was analyzed and the association with selected physician and patient characteristics was assessed. Methods: The Hypertension and Diabetes Risk Screening and Awareness (HYDRA) study is a cross-sectional point prevalence study of 45,125 primary care attendees recruited from a representative nationwide sample of 1912 primary care practices in Germany. Prescription frequencies of the various antihypertensive drugs in the individual patients were recorded by the physicians using standardized questionnaires. We assessed the association of patient variables [age, gender; co-morbidities such as diabetes, nephropathy or coronary heart disease (CHD)] and physician variables (general practitioner vs internist, guideline adherence, etc.) with drug treatment intensity and prescription patterns. Results: Of all 43,549 patients for whom a physician diagnosis on hypertension or diabetes was available, 17,485 (40.1%) had hypertension. Of these hypertensive patients, 1647 (9.4%) received no treatment at all, 1191 (6.8%) received non-pharmacological measures only, and 14,647 (83.8%) were given one or more antihypertensive drugs. Drug treatment rates were lower in young patients (16–40 years: 57.4%). BP control was poor: 70.6% of all patients were not normalized, i.e., had BP ≥140/90 mmHg. Antihypertensive treatment was generally intensified with increasing age, or if complications or comorbidities were present. The use of the different drug classes was rather uniform across the various patient subgroups (e.g., by age and gender). Individualized treatment with regard to co-morbidities as recommended in guidelines was not the rule. Adherence to guidelines as self-reported by physicians as well as other physician characteristics (region, training etc.) did not result in more differentiated prescription pattern. Conclusions: Despite the broad armamentarium of drug treatment options, physicians in primary care did not treat hypertension aggressively enough. Treatment was only intensified at a late stage, after complications had occurred. Treatment should be more differentiated in terms of coexisting morbidities such as diabetes, nephropathy, or CHD.

Denna uppsats har haft examensarbetet “MPLS kontra traditionell IP-routing - enjämförelse av resursåtgång” av Sebastian Viking och Anton Öhlin som stöd. Derasarbete jämförde processoranvändning vid routing med, respektive utan, MPLS.Resultatet påvisade att MPLS gav högre processorbelastning gentemot traditionell IProuting,tvärtemot vad teorin för MPLS säger. På grund av uppenbara motsägelsermellan teori och praktik ämnade detta arbete skapa en hypotes som undersöks deduktivtmed målet att bekräfta dess utsaga: På grund av MPLS, respektive IP:s implementation iunderliggande hårdvaruarkitektur, kommer ingen märkbar skillnad iprocessorbelastning att uppvisas vid tester där en routers uppgift är att förmedla paket.Vi har därför återskapat deras tester för att verifiera äktheten i deras resultat. Resultetfrån våra egna tester visade ingen uppenbar olikhet mellan routingteknikerna IP medCEF, respektive MPLS. Presenterat resultat visar därmed på att hypotesen, som stöds avteknikernas teori, bevisats i praktiken från denna undersökning. / This paper was based on the thesis "MPLS kontra traditionell IP routing - enjämnförelse av resursåtgång" by Sebastian Viking and Anton Öhlin. Their workcompared the CPU usage when performing routing with, and without, MPLS. Theresults demonstrates that MPLS provides higher processor load over traditional IProuting, contrary to the theory of MPLS. Due to the apparent contradictions betweentheory and practice has this work intended to create a hypothesis examined deductivelywith the aim to confirm its statement: Because of MPLS, and IP's, implementation ofthe underlying hardware architecture should no noticeable difference in processor usagebe presentated at tests where a router's job is to convey the package. Therefore, we recreatedtheir tests to confirm the authenticity of their results. The results from the testsin this paper showed no significant difference between IP routing technologies withCEF, and MPLS. Presented results thus confirm the hypothesis supported by thetheories behind the techniques used.

This dissertation is composed of two essays that examine the role of public and private health insurance on healthcare access, use, and cost containment. In Chapter 1, Dugan, Virani, and Ho examine the impact of Medicare eligibility on healthcare utilization and access. Although Medicare eligibility has been shown to generally increase health care utilization, few studies have examined these relationships among the chronically ill. We use a regression-discontinuity framework to compare physician utilization and financial access to care among people before and after the Medicare eligibility threshold at age 65. Specifically, we focus on coronary heart disease and stroke (CHDS) patients. We find that Medicare eligibility improves health care access and physician utilization for many adults with CHDS, but it may not promote appropriate levels of physician use among blacks with CHDS. My second chapter examines the extent to which the managed care backlash affected managed care's ability to contain hospital costs among short-term, non-federal hospitals between 1998 and 2008. My analysis focuses on health maintenance organizations (HMOs), the most aggressive managed care model. Unlike previous studies that use cross-sectional or fixed effects estimators to address the endogeneity of HMO penetration with respect to hospital costs, this study uses a fixed effects instrumental variable approach. The results suggest two conclusions. First, I find the impact of increased HMO penetration on costs declined over the study period, suggesting regulation adversely impacted managed care's ability to contain hospital costs. Second, when costs are decomposed into unit costs by hospital service, I find the impact of increased HMO penetration on inpatient costs reversed over the study period, but HMOs were still effective at containing outpatient costs.

Background: Most treatment for people with arthritis occurs at the primary care level yet many studies have documented the need for improved arthritis management in this environment. The dissemination of clinical practice guidelines (CPGs) has been suggested as one method for improving care delivery. Getting a Grip on Arthritis, a theory and evidence-based educational program was developed to disseminate arthritis best practices based on published CPGs for the management of osteoarthritis (OA) and rheumatoid arthritis (RA). Primary care organizations were invited to enroll providers in an inter-professional workshop. Six months of reinforcement activities were offered following the workshop to support the delivery of arthritis care in their communities. Purpose: This study was designed to determine which organizational and individual level characteristics contributed to improved provider use of arthritis best practices six months following the workshops. Methods: The ACREU Primary Care Survey was completed by workshop participants at baseline and six months following the workshops in order to evaluate their use of arthritis best practices. This survey measured providers’ responses to open-ended questions that asked how they would manage the individual patients described in three hypothetical case scenarios. One point was given for each recorded best practice and totaled for each case scenario, with the highest possible score being eight for the late RA case and moderate knee OA case, and seven for the early RA case. Requests for reinforcement activities were tracked by study staff during the six months following the workshops. A practice profile was also completed by each organization. Analysis: Two models of knowledge utilization (KU) were constructed for testing. For Model 1, two-level hierarchical linear modeling (HLM) was used to determine the direct effects of provider and organizational level variables on intended use of arthritis best practices six months post-workshops, while controlling for clustering within organizations. In model 2, logistic regression was used to determine the influence of organization level factors on one specific best practice, that is, dissemination of patient educational materials during the six months following the workshop. Results: 275 providers from 131 organizations completed both baseline and six month follow-up surveys. For Model 1, total best practice scores for all three case scenarios were predicted by the discipline of the provider, the model of care in which they worked and baseline best practice scores (P<0.05). Controlling for these variables, baseline confidence in managing arthritis also predicted the six month follow-up scores for moderate knee OA (P=0.05) and baseline satisfaction with ability to manage arthritis predicted the follow-up scores for late RA (P=0.04). For Model 2, the estimated probability of disseminating patient educational materials was >82% for community health centres, primary care networks and regionally funded models of care compared to 30% for the federally funded model of care (P<0.01), and was 88% for organizations that sent multidisciplinary team members to the workshops, compared to 70% for those that did not send such a team (P=0.07). Conclusions: Use of arthritis best practices may be influenced by provider characteristics (discipline, satisfaction and confidence in managing arthritis), the model of care in which they work and the team learning experience. These results have implications for the training and education of health professionals and the design of models of care to enhance arthritis care delivery.

In the first chapter, we develop a dynamic model of collusion in city-pair routes for selected US airlines and specify the first order conditions using a state-space representation that is estimated by Kalman-filtering techniques using the Databank 1A (DB1A) Department of Transportation (DOT) data during the period 1979I-1988IV. We consider two airlines, American (AA) and United (UA) and four city pairs. Our measure of market power is based on the shadow value of long-run profits in a two person strategic dynamic game and we find evidence of relative market power of UA in three of the four city pairs we analyze. The second chapter explores three models of forecasting airline energy demand: Trend line, ARIMA and Structural Model based on results from Chapter 1 and find that none of them is a dominant winner in American (AA) and United (UA) between Chicago and Salt Lake City. In the third chapter, we use Model Averaging and Forecast Combination Techniques to provide a decisive conclusion focusing on discussing Equal Weighted Averaging, Mean Square Weighted Averaging and Optimized Weighted Averaging on UA and AA in City-Pairs Chicago -Seattle and Chicago-San Diego.

AbstractDifferent approaches for implementing a complex multiplier in pipelined FFT are considered andimplemented to find an efficient one in this project. The implemented design is synthesized on Cyclone IIand Stratix III to know the performance. The design is implemented with a focus of reducing the resourcesused. Some approaches resulted in the reduced number of DSP blocks and others resulted in reducednumber of LUTs. Analysis of Synthesis results is performed for different widths (bit lengths) of complexmultiplier approaches.

This paper presents the feasibility study of setting up the new potting tray production line based on the two alternatives: partly outsource a process in the production line or wholly make all processes in-house. Both the qualitative and quantitative approaches have been exploited to analyze and compare between the make or buy decision. Also the nature of business, particularly SMEs, in Thailand has been presented, in which it has certain characteristics that influence the business doing and decision, especially to the supply chain management. The literature relating to the forecasting techniques, outsourcing decision framework, inventory management, and investment analysis have been reviewed and applied with the empirical findings. As this production line has not yet been in place, monthly sales volumes are forecasted within the five years time frame. Based on the forecasted sales volume, simulations are implemented to distribute the probability and project a certain demand required for each month. The projected demand is used as a baseline to determine required safety stock of materials, inventory cost, time between production runs and resources utilization for each option. Finally, in the quantitative analysis, the five years forecasted sales volume is used as a framework and several decision making-techniques such as break-even analysis, cash flow and decision trees are employed to come up with the results in financial aspects.

Background: Most treatment for people with arthritis occurs at the primary care level yet many studies have documented the need for improved arthritis management in this environment. The dissemination of clinical practice guidelines (CPGs) has been suggested as one method for improving care delivery. Getting a Grip on Arthritis, a theory and evidence-based educational program was developed to disseminate arthritis best practices based on published CPGs for the management of osteoarthritis (OA) and rheumatoid arthritis (RA). Primary care organizations were invited to enroll providers in an inter-professional workshop. Six months of reinforcement activities were offered following the workshop to support the delivery of arthritis care in their communities. Purpose: This study was designed to determine which organizational and individual level characteristics contributed to improved provider use of arthritis best practices six months following the workshops. Methods: The ACREU Primary Care Survey was completed by workshop participants at baseline and six months following the workshops in order to evaluate their use of arthritis best practices. This survey measured providers’ responses to open-ended questions that asked how they would manage the individual patients described in three hypothetical case scenarios. One point was given for each recorded best practice and totaled for each case scenario, with the highest possible score being eight for the late RA case and moderate knee OA case, and seven for the early RA case. Requests for reinforcement activities were tracked by study staff during the six months following the workshops. A practice profile was also completed by each organization. Analysis: Two models of knowledge utilization (KU) were constructed for testing. For Model 1, two-level hierarchical linear modeling (HLM) was used to determine the direct effects of provider and organizational level variables on intended use of arthritis best practices six months post-workshops, while controlling for clustering within organizations. In model 2, logistic regression was used to determine the influence of organization level factors on one specific best practice, that is, dissemination of patient educational materials during the six months following the workshop. Results: 275 providers from 131 organizations completed both baseline and six month follow-up surveys. For Model 1, total best practice scores for all three case scenarios were predicted by the discipline of the provider, the model of care in which they worked and baseline best practice scores (P<0.05). Controlling for these variables, baseline confidence in managing arthritis also predicted the six month follow-up scores for moderate knee OA (P=0.05) and baseline satisfaction with ability to manage arthritis predicted the follow-up scores for late RA (P=0.04). For Model 2, the estimated probability of disseminating patient educational materials was >82% for community health centres, primary care networks and regionally funded models of care compared to 30% for the federally funded model of care (P<0.01), and was 88% for organizations that sent multidisciplinary team members to the workshops, compared to 70% for those that did not send such a team (P=0.07). Conclusions: Use of arthritis best practices may be influenced by provider characteristics (discipline, satisfaction and confidence in managing arthritis), the model of care in which they work and the team learning experience. These results have implications for the training and education of health professionals and the design of models of care to enhance arthritis care delivery.

Alcohol abuse during pregnancy has been associated with Fetal Alcohol Spectrum Disorder (FASD). Research to date has focused on the role played by ethanol in the development of this disorder. In addition to ethanol, alcoholic drinks also contain methanol. Hence, consumption of alcohol can also lead to methanol accumulation. Methanol is metabolized to formaldehyde, which is then rapidly metabolized to formate, a toxic metabolite. Folate, a B-vitamin and antoxidant, is a cofactor in the metabolism of formate. This study assessed the relationship between formate and folate, formate kinetics in folate deficiency and, changes in antioxidant capacity during formate insult in folate deficiency. The findings of this study would lead to a better understanding of the role of formate in the development of the etiology of FASD and form the basis of future research. The relationship between formate and folate was investigated in intoxicated human female subjects, sober drug rehabilitating females and, pregnant women. A negative (inverse) relationship was observed between plasma formate and folate in pregnant sober women (correlation coefficient = -0.4989). Such a relationship, however, was not observed in whole blood in alcohol intoxicated (correlation coefficient = 0.0899) and detox women (correlation coefficient = 0.2382). Because of the health promoting ingredients in grain and fruit based alcoholic drinks, antioxidant B-vitamins were higher during intoxication while homocysteine levels were lower.<p>Formate kinetics during folate deficiency and changes in the body antioxidant capacity was investigated in folate deficient young swine. Folate deficiency altered formate kinetics leading to decreased systemic clearance (by approximately 2.3 fold), increased half-life (by 2.5 fold) and, consequently increased exposure (by 2.7 fold). Folate deficiency alone compromised antioxidant capacity. However, the combination of folate deficiency and formate insult further compromised antioxidant capacity.<p>In conclusion, methanol accumulates after alcohol intoxication, which can lead to formate build up in the body. During folate deficiency formate kinetics is altered leading to reduced formate clearance and increased exposure. Exposure to formate coupled to folate deficiency compromises antioxidant capacity, which can have deleterious effects on the fetus.

Chronic diseases place a substantial economic burden on the health care system. Physical inactivity, poor diet and smoking are considered to be the main causes of high rates of chronic disease. Evidence clearly supports the positive influence of physical activity on health determinants, other health outcomes and quality of life. This implies that an increase in physical activity improves general health status and has the potential to reduce utilization of expensive healthcare services and disability days. Earlier studies show that physical activity programs would be an effective way of providing preventive care for people with chronic conditions. However studies that relate physical activity programs to health care utilization are limited in economics literature.<p>The aim of this paper is to examine the impact of physical activity programs on healthcare utilization. From 2002 to 2003, adults over the age of 50 years, in a mid-size Canadian city, presenting with excess weight, type 2 diabetes, hypertension, hyperlipidemia or osteoarthritis were recruited. Following a screening process, eligible participants were randomly assigned to one of two programs: a class-based structured program or a home-based unstructured program. Validated questionnaires related to health status and quality of life were completed and physical tests were carried out at baseline, 3, 6, 12 months and 24 months after the program initiation. In addition participants use of physician and hospital services and pharmaceutical expenditures were accessed through their administrative data files for three years, one year before and two years after the intervention. Using administrative data from Sask Health and individual level survey data the effects of physical activity programs on health care utilization were estimated. The results showed that structured physical activity program can reduce annual physician costs significantly. The exponential effect of aging was found to be significant on hospital utilization, and the number of comorbidities was found to be significant on prescription drug utilization.