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1.  Using GIS to establish a public library consumer health collection 
Background
Learning the exact demographic characteristics of a neighborhood in which a public library serves, assists the collection development librarian in building an appropriate collection. Gathering that demographic information can be a lengthy process, and then formatting the information for the neighborhood in question becomes arduous.
As society ages and the methods for health care evolve, people may take charge of their own health. With this prospectus, public libraries should consider creating a consumer health collection to assist the public in their health care needs. Using neighborhood demographic information can inform the collection development librarians as to the dominant age groups, sex, and races within the neighborhood. With this information, appropriate consumer health materials may be assembled in the public library.
Methods
In order to visualize the demographics of a neighborhood, the computer program ArcView GIS (geographic information systems) was used to create maps for specified areas. The neighborhood data was taken from the U.S. Census Department's annual census and library addresses were accumulated through a free database. After downloading the census block information from the data was manipulated with ArcView GIS and queried to produce maps displaying the requested neighborhood demographics to view in respect to libraries.
Results
ArcView GIS produced maps displaying public libraries and requested demographics. After viewing the maps the collection development librarian can see exactly what populations are served by the library and adjust the library's collection accordingly.
Conclusions
ArcView GIS can be used to produce maps displaying the communities that libraries serve, spot boundaries, be it "man-made or natural," that exist prohibiting customer service, and assist collection development librarians in justifying their purchases for a dedicated consumer health collection or resources in general.
doi:10.1186/1742-5581-1-3
PMCID: PMC535547  PMID: 15550171
2.  Public library consumer health information pilot project: results of a National Library of Medicine evaluation 
In October 1998, the National Library of Medicine (NLM) launched a pilot project to learn about the role of public libraries in providing health information to the public and to generate information that would assist NLM and the National Network of Libraries of Medicine (NN/LM) in learning how best to work with public libraries in the future. Three regional medical libraries (RMLs), eight resource libraries, and forty-one public libraries or library systems from nine states and the District of Columbia were selected for participation. The pilot project included an evaluation component that was carried out in parallel with project implementation. The evaluation ran through September 1999. The results of the evaluation indicated that participating public librarians were enthusiastic about the training and information materials provided as part of the project and that many public libraries used the materials and conducted their own outreach to local communities and groups. Most libraries applied the modest funds to purchase additional Internet-accessible computers and/or upgrade their health-reference materials. However, few of the participating public libraries had health information centers (although health information was perceived as a top-ten or top-five topic of interest to patrons). Also, the project generated only minimal usage of NLM's consumer health database, known as MEDLINEplus, from the premises of the monitored libraries (patron usage from home or office locations was not tracked). The evaluation results suggested a balanced follow-up by NLM and the NN/LM, with a few carefully selected national activities, complemented by a package of targeted activities that, as of January 2000, are being planned, developed, or implemented. The results also highlighted the importance of building an evaluation component into projects like this one from the outset, to assure that objectives were met and that evaluative information was available on a timely basis, as was the case here.
PMCID: PMC35252  PMID: 11055298
3.  Expanding the DOCLINE network to include nonmedical libraries in the state of Nevada. 
Most libraries cannot meet patron demands for biomedical information using only their in-house collections. Consequently, many types of libraries request biomedical information through interlibrary loan, and these include not only academic health sciences libraries, hospital and special libraries, but also general libraries. In Nevada, with its small population spread over a large geographic area, it has become critical to develop a statewide network for sharing biomedical information. As the state resource library, the Savitt Medical Library launched an effort to establish a network, via DOCLINE, of all Nevada libraries that have health-related collections. The process of convincing academic and community college libraries to join DOCLINE and the resulting benefits of improved resource sharing and cooperative collection development are discussed.
PMCID: PMC225730  PMID: 8428190
4.  Design and implementation of an institutional case report form library 
Background
Case report forms (CRFs) are used to collect data in clinical research. Case report form development represents a significant part of the clinical trial process and can impact study success. Libraries of CRFs can preserve the organizational knowledge and expertise invested in CRF development and expedite the sharing of such knowledge. Although CRF libraries have been advocated, there have been no published accounts reporting institutional experiences with creating and using them.
Purpose
We sought to enhance an existing institutional CRF library by improving information indexing and accessibility. We describe this CRF library and discuss challenges encountered in its development and implementation, as well as future directions for continued work in this area.
Methods
We transformed an existing but underused and poorly accessible CRF library into a resource capable of supporting and expediting clinical and translational investigation at our institution by (1) expanding access to the entire institution; (2) adding more form attributes for improved information retrieval; and (3) creating a formal information curation and maintenance process. An open-source content management system, Plone (Plone.org), served as the platform for our CRF library.
Results
We report results from these three processes. Over the course of this project, the size of the CRF library increased from 160 CRFs comprising an estimated total of 17,000 pages, to 177 CRFs totaling 1.5 gigabytes. Eighty-two of these CRFs are now available to researchers across our institution; 95 CRFs remain within a contractual confidentiality window (usually 5 years from database lock) and are not available to users outside of the Duke Clinical Research Institute (DCRI). Conservative estimates suggest that the library supports an average of 37 investigators per month. The resources needed to curate and maintain the CRF library require less than 10% of the effort of one full-time equivalent employee.
Limitations
Although we succeeded in expanding use of the CRF library, creating awareness of such institutional resources among investigators and research teams remains challenging, and requires additional efforts to overcome. Institutions that have not achieved a critical mass of attractive research resources or effective dissemination mechanisms may encounter persistent difficulty attracting researchers to use institutional resources. Further, a useful CRF library requires both an initial investment of resources for development, as well as ongoing maintenance once it is established.
Conclusions
CRF libraries can be established and made broadly available to institutional researchers. Curation—i.e., indexing newly added forms—is required. Such a resource provides knowledge management capacity for institutions until standards and software are available to support widespread exchange of data and form definitions.
doi:10.1177/1740774510391916
PMCID: PMC3494996  PMID: 21163853
Data collection; Clinical research; Clinical trial; Case report form; Knowledge management
5.  Hyper Text Mark-up Language and Dublin Core metadata element set usage in websites of Iranian State Universities’ libraries 
Introduction:
Recent progress in providing innovative solutions in the organization of electronic resources and research in this area shows a global trend in the use of new strategies such as metadata to facilitate description, place for, organization and retrieval of resources in the web environment. In this context, library metadata standards have a special place; therefore, the purpose of the present study has been a comparative study on the Central Libraries’ Websites of Iran State Universities for Hyper Text Mark-up Language (HTML) and Dublin Core metadata elements usage in 2011.
Materials and Methods:
The method of this study is applied-descriptive and data collection tool is the check lists created by the researchers. Statistical community includes 98 websites of the Iranian State Universities of the Ministry of Health and Medical Education and Ministry of Science, Research and Technology and method of sampling is the census. Information was collected through observation and direct visits to websites and data analysis was prepared by Microsoft Excel software, 2011.
Results:
The results of this study indicate that none of the websites use Dublin Core (DC) metadata and that only a few of them have used overlaps elements between HTML meta tags and Dublin Core (DC) elements. The percentage of overlaps of DC elements centralization in the Ministry of Health were 56% for both description and keywords and, in the Ministry of Science, were 45% for the keywords and 39% for the description. But, HTML meta tags have moderate presence in both Ministries, as the most-used elements were keywords and description (56%) and the least-used elements were date and formatter (0%).
Conclusion:
It was observed that the Ministry of Health and Ministry of Science follows the same path for using Dublin Core standard on their websites in the future. Because Central Library Websites are an example of scientific web pages, special attention in designing them can help the researchers to achieve faster and more accurate information resources. Therefore, the influence of librarians’ ideas on the awareness of web designers and developers will be important for using metadata elements as general, and specifically for applying such standards.
doi:10.4103/2277-9531.127554
PMCID: PMC3977404  PMID: 24741646
Dublin Core metadata standard; Hyper Text Mark-up Language meta tags; Iran State University; metadata elements; websites
6.  The Global Health Network and globalization of higher education 
The year 2001 and the next millennium will soon be upon us. The major gains in health in the 20th century were primarily the result of improvements in public health including sanitation and immunization. Global health improvements will occur in the 21st century through improvements in information (in particular health training). We will describe a new paradigm for transnational training, the supercourse. In the next century global lecture-shareware training will take place, with Deming based quality control systems on the Internet. Faculty will thus share their best, most passionate lectures on the internet.
During the past 100 years there has been a 25-year increase in life expectancy. It has been estimated that 24 of the 25 years were the result of prevention. Most prevention activity is sharing of information. We are working with leaders from WHO, the World Bank, IBM, NASA, PAHO to create a discipline called telepreventive medicine. This is the application of low band with information systems (the Internet) to large numbers of well people to prevent disease. One of the most important aspect of this work is the establishment globalisation of prevention education; the Supercourse.
Question: What is the best way to improve health training/research?
Answer: Improve the lectures.
Question: How do we improve health training/research lectures:
Answer: Have academic faculty worldwide share their lectures:
Question: Will faculty share lectures?
Answer: Yes, The Supercourse has 1107 faculty from 101 countries who created a Library of Lectures with 110 lectures on the Internet with quality control, and cutting edge cognitive design. This is being shared worldwide.
We are developing a "Library of Lectures" with passionate lectures in public health from across the world such as seen here from South Africa. We propose to expand this to all areas of research in health. Our program consists of:
Shareware: A Global faculty is developing and sharing their best, most passionate lectures. This benefits all. The experienced faculty member can beef up their lectures that are not cutting edge. New instructors reduce preparation time and improve their lectures, as they can employ state of the art lectures from others. Faculty in developing countries have access to current public health information for the first time. The concept is that of a library of lectures for all to use is in many ways similar to that of "shareware" on the computer.
Statistical Quality Assurance: We have established a Deming Model of statistical quality control to monitor lectures over time
Supporting the teachers: The Library of Lectures consists of exciting lectures by public health experts in the field. The classroom teacher "takes" them out for free like a library book. There is no direct teaching of students from a distance, rather the concept of the system is to provide cutting edge material for all faculty to present.
Hypertext comic book: The lectures are icon driven, and the students can go deep into the Internet for more information through hyperlinks. It is based upon PowerPoint for ease of usage
Presentation Speed: We have discovered technologies to speed access to lectures world wide
Text books: The British Medical Association has put 2 current text books on line for us
Multilingual: For global use, this must be multilingual, the first lecture is in 8 languages
Voice-Sound Video: We are using state of the art Internet voice-video systems. We soon will be using "clickable" voice video
We have published over 68 papers in leading medical journals including the Lancet, British Medical Journal, Nature Medicine among others. We are working with PAHO to put mirrored servers into every medical school in the Americas this year, with 5 years we should reach globally all medical schools. WHO has developed a Supercourse.
Initial pilot studies reveal that 2500 individuals will see each lecture each year, which is 50 times that of our classroom teaching. We have beta tested lectures in 2 centers in Japan and one in South Africa with very positive results. We are now developing a Chinese Heritage course.
doi:10.2196/jmir.1.suppl1.e5
PMCID: PMC1761712
7.  Transnational Tobacco Company Interests in Smokeless Tobacco in Europe: Analysis of Internal Industry Documents and Contemporary Industry Materials 
PLoS Medicine  2013;10(9):e1001506.
In light lobbying by transnational tobacco companies to remove the European Union ban on the sale of snus (a smokeless tobacco product), Silvy Peeters and Anna Gilmore explore the motivation behind tobacco companies' interests in smokeless tobacco products in Europe.
Please see later in the article for the Editors' Summary
Background
European Union (EU) legislation bans the sale of snus, a smokeless tobacco (SLT) which is considerably less harmful than smoking, in all EU countries other than Sweden. To inform the current review of this legislation, this paper aims to explore transnational tobacco company (TTC) interests in SLT and pure nicotine in Europe from the 1970s to the present, comparing them with TTCs' public claims of support for harm reduction.
Methods and Results
Internal tobacco industry documents (in total 416 documents dating from 1971 to 2009), obtained via searching the online Legacy Tobacco Documents Library, were analysed using a hermeneutic approach. This library comprises documents obtained via litigation in the US and does not include documents from Imperial Tobacco, Japan Tobacco International, or Swedish Match. To help overcome this limitation and provide more recent data, we triangulated our documentary findings with contemporary documentation including TTC investor presentations. The analysis demonstrates that British American Tobacco explored SLT opportunities in Europe from 1971 driven by regulatory threats and health concerns, both likely to impact cigarette sales negatively, and the potential to create a new form of tobacco use among those no longer interested in taking up smoking. Young people were a key target. TTCs did not, however, make SLT investments until 2002, a time when EU cigarette volumes started declining, smoke-free legislation was being introduced, and public health became interested in harm reduction. All TTCs have now invested in snus (and recently in pure nicotine), yet both early and recent snus test markets appear to have failed, and little evidence was found in TTCs' corporate materials that snus is central to their business strategy.
Conclusions
There is clear evidence that BAT's early interest in introducing SLT in Europe was based on the potential for creating an alternative form of tobacco use in light of declining cigarette sales and social restrictions on smoking, with young people a key target. We conclude that by investing in snus, and recently nicotine, TTCs have eliminated competition between cigarettes and lower-risk products, thus helping maintain the current market balance in favour of (highly profitable) cigarettes while ensuring TTCs' long-term future should cigarette sales decline further and profit margins be eroded.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Every year, about 5 million people die from cancer, heart disease, and other tobacco-related diseases. In recent years, to reduce this growing loss of life, international and national bodies have drawn up various tobacco control conventions and directives. For example, the European Union (EU) Directives on tobacco control call for member states to ban tobacco advertising, promotion, and sponsorship and to adopt taxation policies aimed at reducing tobacco consumption. The 2001 EU Tobacco Products Directive also bans the sale of snus, a form of smokeless tobacco (SLT), in all EU countries except Sweden. Snus, which originated in Sweden in the early 19th century, is a moist tobacco product that is placed under the upper lip. Although snus is considerably less harmful than smoking, the sale of snus was banned in the EU in 1992 because of fears that it might cause cancer and was being marketed to young people. When Sweden joined the EU in 1994, exemption from the ban was made a condition of the membership treaty.
Why Was This Study Done?
Transnational tobacco companies (TTCs) have been investing in European snus manufacturers since 2002 and more recently in pure nicotine products, and it has been suggested that, faced with declining cigarette markets in Europe and elsewhere, TTCs are preparing for a “post-cigarette era”. Since 2008, TTCs have been lobbying EU member states and the European Commission to remove the ban on snus sales, arguing that public health would be improved if governments allowed potentially reduced-harm products like snus onto the market. At the end of 2012, however, the European Commission proposed that the ban on snus sales should be continued. Here, to help inform this controversial policy debate, the researchers explore the interest of TTCs in SLT and pure nicotine in Europe from the 1970s to the present by examining internal tobacco documents and compare these interests with public claims of support for harm reduction made by TTCs.
What Did the Researchers Do and Find?
By searching the Legacy Tobacco Documents Library (internal tobacco industry documents released following US litigation cases), the researchers identified 416 documents that detail the historical interest of TTCs in SLT and pure nicotine and their efforts to enter European markets, and to influence national and EU public-health policy. The researchers analyzed these documents using a “hermeneutic” approach—methodical reading and re-reading of the documents to identify themes and sub-themes. Finally, they used TTC investor presentations and other documents to confirm these themes and to provide recent data on TTC investment in SLT. British American Tobacco (BAT) explored the opportunities for marketing SLT products in Europe from 1971 onwards. This exploration was driven by regulatory threats and health concerns, both of which were likely to impact tobacco sales, and by the potential to create a new form of tobacco use among people no longer interested in taking up smoking. TTCs did not begin to invest in SLT, however, until 2002, a time when EU cigarette sale volumes started to decline, smoke-free legislation was being introduced, and tobacco harm reduction first became a major public-health issue. All the TTCs have now invested in snus even though snus test markets appear to have failed and even though there is little evidence in corporate materials that snus is central to the business strategy of TTCs.
What Do These Findings Mean?
These findings suggest that BAT's early interest in SLT in Europe was driven by business concerns and was based on the potential for creating an alternative form of tobacco use among people—particularly young people—who would no longer take up smoking because of health concerns. They also suggest that TTC investments in snus were defensive—by buying up snus manufacturers and more recently nicotine producers, TTCs have eliminated competition between cigarettes and lower-risk products, thereby helping to maintain the current market balance in favor of cigarettes while ensuring the long-term future of TTCs should cigarette sales decline further. Although these findings are limited by the possibility that some relevant documents may have been omitted from this analysis, they nevertheless raise the concern that, if TTC investment in SLT continues, competition between cigarettes and SLT will reduce the potential for harm reduction to benefit public health. Legalization of snus sales in the European Union may therefore have considerably less benefit than envisaged.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001506.
The World Health Organization provides information about the dangers of tobacco (in several languages) and about the Framework Convention on Tobacco Control, an international treaty for tobacco control; for information about the tobacco industry's influence on policy, see the 2009 World Health Organization report Tobacco interference with tobacco control
Details of European Union legislation on the manufacture, presentation, and sale of tobacco products is available (in several languages)
Wikipedia has pages on tobacco harm reduction and on snus (note: Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
The Legacy Tobacco Documents Library is a searchable public database of tobacco company internal documents detailing their advertising, manufacturing, marketing, sales, and scientific activities
The UK Centre for Tobacco Control Studies is a network of UK universities that undertakes original research, policy development, advocacy, and teaching and training in the field of tobacco control
SmokeFree, a website provided by the UK National Health Service, offers advice on quitting smoking and includes personal stories from people who have stopped smoking
Smokefree.gov, from the US National Cancer Institute, offers online tools and resources to help people quit smoking
TobaccoTactics.org, an online resource managed by the University of Bath, provides up-to-date information on the tobacco industry and their tactics to influence tobacco regulation
doi:10.1371/journal.pmed.1001506
PMCID: PMC3769209  PMID: 24058299
8.  Hospital Performance, the Local Economy, and the Local Workforce: Findings from a US National Longitudinal Study 
PLoS Medicine  2010;7(6):e1000297.
Blustein and colleagues examine the associations between changes in hospital performance and their local economic resources. Locationally disadvantaged hospitals perform poorly on key indicators, raising concerns that pay-for-performance models may not reduce inequality.
Background
Pay-for-performance is an increasingly popular approach to improving health care quality, and the US government will soon implement pay-for-performance in hospitals nationwide. Yet hospital capacity to perform (and improve performance) likely depends on local resources. In this study, we quantify the association between hospital performance and local economic and human resources, and describe possible implications of pay-for-performance for socioeconomic equity.
Methods and Findings
We applied county-level measures of local economic and workforce resources to a national sample of US hospitals (n = 2,705), during the period 2004–2007. We analyzed performance for two common cardiac conditions (acute myocardial infarction [AMI] and heart failure [HF]), using process-of-care measures from the Hospital Quality Alliance [HQA], and isolated temporal trends and the contributions of individual resource dimensions on performance, using multivariable mixed models. Performance scores were translated into net scores for hospitals using the Performance Assessment Model, which has been suggested as a basis for reimbursement under Medicare's “Value-Based Purchasing” program. Our analyses showed that hospital performance is substantially associated with local economic and workforce resources. For example, for HF in 2004, hospitals located in counties with longstanding poverty had mean HQA composite scores of 73.0, compared with a mean of 84.1 for hospitals in counties without longstanding poverty (p<0.001). Hospitals located in counties in the lowest quartile with respect to college graduates in the workforce had mean HQA composite scores of 76.7, compared with a mean of 86.2 for hospitals in the highest quartile (p<0.001). Performance on AMI measures showed similar patterns. Performance improved generally over the study period. Nevertheless, by 2007—4 years after public reporting began—hospitals in locationally disadvantaged areas still lagged behind their locationally advantaged counterparts. This lag translated into substantially lower net scores under the Performance Assessment Model for hospital reimbursement.
Conclusions
Hospital performance on clinical process measures is associated with the quantity and quality of local economic and human resources. Medicare's hospital pay-for-performance program may exacerbate inequalities across regions, if implemented as currently proposed. Policymakers in the US and beyond may need to take into consideration the balance between greater efficiency through pay-for-performance and socioeconomic equity.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
These days, many people are rewarded for working hard and efficiently by being given bonuses when they reach preset performance targets. With a rapidly aging population and rising health care costs, policy makers in many developed countries are considering ways of maximizing value for money, including rewarding health care providers when they meet targets, under “pay-for-performance.” In the UK, for example, a major pay-for-performance initiative—the Quality and Outcomes Framework—began in 2004. All the country's general practices (primary health care facilities that deal with all medical ailments) now detail their achievements in terms of numerous clinical quality indicators for common chronic conditions (for example, the regularity of blood sugar checks for people with diabetes). They are then rewarded on the basis of these results.
Why Was This Study Done?
In the US, the government is poised to implement a nationwide pay-for-performance program in hospitals within Medicare, the government program that provides health insurance to Americans aged 65 years or older, as well as people with disabilities. However, some observers are concerned about the effect that the proposed pay-for-performance program might have on the distribution of health care resources in the US. Pay-for-performance assumes that health care providers have the economic and human resources that they need to perform or to improve their performance. But, if a hospital's capacity to perform depends on local resources, payment based on performance might worsen existing health care inequalities because hospitals in under-resourced areas might lose funds to hospitals in more affluent regions. In other words, the government might act as a reverse Robin Hood, taking from the poor and giving to the rich. In this study, the researchers examine the association between hospital performance and local economic and human resources, to explore whether this scenario is a plausible result of the pending change in US hospital reimbursement.
What Did the Researchers Do and Find?
US hospitals have voluntarily reported their performance on indicators of clinical care (“process-of-care measures”) for acute myocardial infarction (AMI, heart attack), heart failure (HF), and pneumonia under the Hospital Quality Alliance (HQA) program since 2004. The researchers identified 2,705 hospitals that had fully reported process-of-care measures for AMI and HF in both 2004 and 2007. They then used the “Performance Assessment Model” (a methodology developed by the US Centers for Medicare and Medicaid Services to score hospital performance) to calculate scores for each hospital. Finally, they looked for associations between these scores and measures of the hospital's local economic and human resources such as population poverty levels and the percentage of college graduates in the workforce. Hospital performance was associated with local and economic workforce capacity, they report. Thus, hospitals in counties with longstanding poverty had lower average performance scores for HF and AMI than hospitals in affluent counties. Similarly, hospitals in counties with a low percentage of college graduates in the workforce had lower average performance scores than hospitals in counties where more of the workforce had been to college. Finally, although performance improved generally over the study period, hospitals in disadvantaged areas still lagged behind hospitals in advantaged areas in 2007.
What Do These Findings Mean?
These findings indicate that hospital performance (as measured by the clinical process measures considered here) is associated with the quantity and quality of local human and economic resources. Thus, the proposed Medicare hospital pay-for-performance program may exacerbate existing US health care inequalities by leading to the transfer of funds from hospitals in disadvantaged locations to those in advantaged locations. Although further studies are needed to confirm this conclusion, these findings have important implications for pay-for-performance programs in health care. They suggest that US policy makers may need to modify how they measure performance improvement—the current Performance Assessment Model gives hospitals that start from a low baseline less credit for improvements than those that start from a high baseline. This works against hospitals in disadvantaged locations, which start at a low baseline. Second and more generally, they suggest that there may be a tension between the efficiency goals of pay-for-performance and other equity goals of health care systems. In a world where resources vary across regions, the expectation that regions can perform equally may not be realistic.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000297.
KaiserEDU.org is an online resource for learning about the US health care system. It includes educational modules on such topics as the Medicare program and efforts to improve the quality of care
The Hospital Quality Alliance provides information on the quality of care in US hospitals
Information about the UK National Health Service Quality and Outcomes Framework pay-for-performance initiative for general practice surgeries is available
doi:10.1371/journal.pmed.1000297
PMCID: PMC2893955  PMID: 20613863
9.  Community perceptions and utilization of a consumer health center* 
The purpose of this study was to understand factors that may affect the usage of a consumer health center located in a public library. More specifically, the authors wanted to know what health resources are of interest to the community, what patrons' perceptions of their experience at the center are, and finally, how staff can increase utilization of the center. In general, perceptions of the center were positive. The findings support that participants appreciate efforts to provide health information in the public library setting and that utilization could be improved through marketing and outreach.
doi:10.3163/1536-5050.103.1.007
PMCID: PMC4279932  PMID: 25552943
10.  Using Medicaid claims to construct dental service market areas. 
Health Services Research  1999;34(5 Pt 1):1047-1062.
OBJECTIVE: To use Medicaid claims data to construct patient origin-based market areas for dental services and compare constructed market areas with those based on the practice county. DATA SOURCES: North Carolina Medicaid claims, eligibility, and provider files, the Cooperative Health Information Systems' dentist licensure files, and the Log Into North Carolina data. STUDY DESIGN: A visit-level file was created from the Medicaid claims data and aggregated by provider practice county and patient county of residence. Using the aggregated file and an algorithm based on the Elzinga-Hogarty approach, patient travel patterns were used to construct mutually exclusive patient origin market areas. DATA ANALYSIS: Market area characteristics were compared across definitions using Pearson correlation coefficients. In addition, estimations of provider participation were performed using market area characteristics as control variables. The beta coefficients associated with market area characteristics were compared across market area definitions. PRINCIPAL FINDINGS: Medicaid claims data, when combined with provider licensure files, can be used to construct market areas based on patient origin data. However, measures of market area characteristics are correlated highly between the two types of market areas studied. Furthermore, beta coefficients on market area variables in models of provider participation are similar in sign, significance, and magnitude across market definitions. CONCLUSIONS: Compared with market areas constructed using patient origin data, county-based market areas adequately proxy for dental markets. Using the county as the market area also avoids the time and computational costs associated with using a patient origin-based approach and facilitates the use of widely available data.
Images
PMCID: PMC1089072  PMID: 10591272
11.  Using a journal availability study to improve access 
Purpose: Identify journal collection access and use factors.
Setting and Subjects: University of North Carolina at Chapel Hill's Health Sciences Library patrons.
Methodology: Survey forms and user interactions were monitored once a week for twelve weeks during the fall 1997 semester. The project was based on a 1989 New Mexico State University study and used Kantor's Branching Analysis to measure responses.
Result: 80% of reported sought journal articles were found successfully. Along with journal usage data, the library obtained demographic and behavioral information.
Discussion and Conclusions: Journals are the library's most used resource and, even as more electronic journals are offered, print journals continue to make up the majority of the collection. Several factors highlighted the need to study journal availability. User groups indicated that finding journals was problematic, and internal statistics showed people requesting interlibrary loans for owned items. The study looked at success rates, time, and ease of finding journals. A variety of reasons contributed to not finding journals. While overall user reports indicated relatively high success rate and satisfaction, there were problems to be addressed. As the library proceeds in redesigning both the physical space and electronic presence, the collected data have provided valuable direction.
PMCID: PMC31700  PMID: 11209797
12.  Sexual Networks, Surveillance, and Geographical Space during Syphilis Outbreaks in Rural North Carolina 
Epidemiology (Cambridge, Mass.)  2012;23(6):845-851.
Background
Sexually transmitted infections (STIs) spread along sexual networks whose structural characteristics promote transmission that routine surveillance may not capture. Cases who have partners from multiple localities may operate as spatial network bridges, thereby facilitating geographical dissemination. We investigated the relationships between surveillance, sexual networks, and spatial bridges for syphilis outbreaks in rural counties of North Carolina.
Methods
We selected from the state health department’s surveillance database cases diagnosed with primary, secondary, or early latent syphilis during October 1998 - December 2002 residing in central and southeastern North Carolina, along with their sex partners, and their social contacts irrespective of infection status. We applied matching algorithms to eliminate duplicate names and create a unique roster of partnerships from which networks were compiled and graphed. Network members were differentiated by disease status and county of residence.
Results
In the county most affected by the outbreak, densely connected networks indicative of STI outbreaks were consistent with elevated incidence and a large case load. In other counties, the case loads were low with fluctuating incidence, but network structures suggested the presence of outbreaks. In a county with stable, low incidence and a high number of cases, the networks were sparse and dendritic, indicative of endemic spread. Outbreak counties exhibited densely connected networks within well-defined geographic boundaries and low connectivity between counties; spatial bridges did not seem to facilitate transmission.
Conclusions
Simple visualization of sexual networks can provide key information to identify communities most in need of resources for outbreak investigation and disease control.
doi:10.1097/EDE.0b013e31826c2b7e
PMCID: PMC4074028  PMID: 23007041
13.  Neighborhood-Level Hot Spot Maps to Inform Delivery of Primary Care and Allocation of Social Resources 
The Permanente Journal  2013;17(1):4-9.
Challenges to health care access in the US are forcing local policymakers and service delivery systems to find novel ways to address the shortage of primary care clinicians. The uninsured and underinsured face the greatest obstacles in accessing services. Geographic information systems mapping software was used to illustrate health disparities in Alachua County, FL; galvanize a community response; and direct reallocation of resources.
The University of Florida Family Data Center created “hot spot” density maps of important health and social indicators to highlight the location of disparities at the neighborhood level. Maps were produced for Medicaid births, teen births, low birth weight, domestic violence incidents, child maltreatment reports, unexcused school absences, and juvenile justice referrals. Maps were widely shared with community partners, including local elected officials, law enforcement, educators, child welfare agencies, health care providers, and service organizations. This data sharing resulted in advocacy efforts to bring resources to the greatest-need neighborhoods in the county. Novel public-private partnerships were forged between the local library district, children and family service providers, and university administrators. Two major changes are detailed: a family resource center built in the neighborhood of greatest need and a mobile clinic staffed by physicians, nurses, physician assistants, health educators, and student and faculty volunteers.
Density maps have several advantages. They require minimal explanation. Anyone familiar with local geographic features can quickly identify locations displaying health disparities. Personalizing health disparities by locating them geographically allows a community to translate data to action to improve health care access.
doi:10.7812/TPP/12-090
PMCID: PMC3627788  PMID: 23596361
14.  Comparison of Iranian National Medical Library with digital libraries of selected countries 
Introduction:
The important role of information and communication technologies and their influence on methods of storing, retrieving information in digital libraries, has not only changed the meanings behind classic library activates but has also created great changes in their services. However, it seems that not all digital libraries provide their users with similar services and only some of them are successful in fulfilling their role in digital environment. The Iranian National Medical library is among those that appear to come short compared to other digital libraries around the world. By knowing the different services provided by digital libraries worldwide, one can evaluate the services provided by Iranian National Medical library. The goal of this study is a comparison between Iranian National Medical library and digital libraries of selected countries.
Materials and Methods:
This is an applied study and uses descriptive – survey method. The statistical population is the digital libraries around the world which were actively providing library services between October and December 2011 and were selected by using the key word “Digital Library” in Google search engine. The data-gathering tool was direct access to the websites of these digital libraries. The statistical study is descriptive and Excel software was used for data analysis and plotting of the charts.
Results:
The findings showed that among the 33 digital libraries investigated worldwide, most of them provided Browse (87.87%), Search (84.84%), and Electronic information retrieval (57.57%) services. The “Help” in public services (48/48%) and “Interlibrary Loan” in traditional services (27/27%) had the highest frequency. The Iranian National Medical library provides more digital services compared to other libraries but has less classic and public services and has less than half of possible public services. Other than Iranian National Medical library, among the 33 libraries investigated, the leaders in providing different services are Library of University of California in classic services, Count Way Library of Medicine in digital services, and Library of Finland in public services.
Results and Discussion:
The results of this study show that among the digital libraries investigated, most provided similar public, digital, and classic services and The Iranian National Medical library has been somewhat successful in providing these services compared to other digital libraries. One can also conclude that the difference in services is at least in part due to difference in environments, information needs, and users.
Conclusion:
Iranian National Medical Library has been somewhat successful in providing library services in digital environment and needs to identify the services which are valuable to its users by identifying the users’ needs and special characteristics of its environment
doi:10.4103/2277-9531.145897
PMCID: PMC4275611  PMID: 25540782
Digital library; Iranian National Medical Library; services
15.  The Reversal of Fortunes: Trends in County Mortality and Cross-County Mortality Disparities in the United States  
PLoS Medicine  2008;5(4):e66.
Background
Counties are the smallest unit for which mortality data are routinely available, allowing consistent and comparable long-term analysis of trends in health disparities. Average life expectancy has steadily increased in the United States but there is limited information on long-term mortality trends in the US counties This study aimed to investigate trends in county mortality and cross-county mortality disparities, including the contributions of specific diseases to county level mortality trends.
Methods and Findings
We used mortality statistics (from the National Center for Health Statistics [NCHS]) and population (from the US Census) to estimate sex-specific life expectancy for US counties for every year between 1961 and 1999. Data for analyses in subsequent years were not provided to us by the NCHS. We calculated different metrics of cross-county mortality disparity, and also grouped counties on the basis of whether their mortality changed favorably or unfavorably relative to the national average. We estimated the probability of death from specific diseases for counties with above- or below-average mortality performance. We simulated the effect of cross-county migration on each county's life expectancy using a time-based simulation model. Between 1961 and 1999, the standard deviation (SD) of life expectancy across US counties was at its lowest in 1983, at 1.9 and 1.4 y for men and women, respectively. Cross-county life expectancy SD increased to 2.3 and 1.7 y in 1999. Between 1961 and 1983 no counties had a statistically significant increase in mortality; the major cause of mortality decline for both sexes was reduction in cardiovascular mortality. From 1983 to 1999, life expectancy declined significantly in 11 counties for men (by 1.3 y) and in 180 counties for women (by 1.3 y); another 48 (men) and 783 (women) counties had nonsignificant life expectancy decline. Life expectancy decline in both sexes was caused by increased mortality from lung cancer, chronic obstructive pulmonary disease (COPD), diabetes, and a range of other noncommunicable diseases, which were no longer compensated for by the decline in cardiovascular mortality. Higher HIV/AIDS and homicide deaths also contributed substantially to life expectancy decline for men, but not for women. Alternative specifications of the effects of migration showed that the rise in cross-county life expectancy SD was unlikely to be caused by migration.
Conclusions
There was a steady increase in mortality inequality across the US counties between 1983 and 1999, resulting from stagnation or increase in mortality among the worst-off segment of the population. Female mortality increased in a large number of counties, primarily because of chronic diseases related to smoking, overweight and obesity, and high blood pressure.
Majid Ezzati and colleagues analyze US county-level mortality data for 1961 to 1999, and find a steady increase in mortality inequality across counties between 1983 and 1999.
Editors' Summary
Background.
It has long been recognized that the number of years that distinct groups of people in the United States would be expected to live based on their current mortality patterns (“life expectancy”) varies enormously. For example, white Americans tend to live longer than black Americans, the poor tend to have shorter life expectancies than the wealthy, and women tend to outlive men. Where one lives might also be a factor that determines his or her life expectancy, because of social conditions and health programs in different parts of the country.
Why Was the Study Done?
While life expectancies have generally been rising across the United States over time, there is little information, especially over the long term, on the differences in life expectancies across different counties. The researchers therefore set out to examine whether there were different life expectancies across different US counties over the last four decades. The researchers chose to look at counties—the smallest geographic units for which data on death rates are collected in the US—because it allowed them to make comparisons between small subgroups of people that share the same administrative structure.
What Did the Researchers Do and Find?
The researchers looked at differences in death rates between all counties in US states plus the District of Columbia over four decades, from 1961 to 1999. They obtained the data on number of deaths from the National Center for Health Statistics, and they obtained data on the number of people living in each county from the US Census. The NCHS did not provide death data after 2001. They broke the death rates down by sex and by disease to assess trends over time for women and men, and for different causes of death.
Over these four decades, the researchers found that the overall US life expectancy increased from 67 to 74 years of age for men and from 74 to 80 years for women. Between 1961 and 1983 the death rate fell in both men and women, largely due to reductions in deaths from cardiovascular disease (heart disease and stroke). During this same period, 1961–1983, the differences in death rates among/across different counties fell. However, beginning in the early 1980s the differences in death rates among/across different counties began to increase. The worst-off counties no longer experienced a fall in death rates, and in a substantial number of counties, mortality actually increased, especially for women, a shift that the researchers call “the reversal of fortunes.” This stagnation in the worst-off counties was primarily caused by a slowdown or halt in the reduction of deaths from cardiovascular disease coupled with a moderate rise in a number of other diseases, such as lung cancer, chronic lung disease, and diabetes, in both men and women, and a rise in HIV/AIDS and homicide in men. The researchers' key finding, therefore, was that the differences in life expectancy across different counties initially narrowed and then widened.
What Do these Findings Mean?
The findings suggest that beginning in the early 1980s and continuing through 1999 those who were already disadvantaged did not benefit from the gains in life expectancy experienced by the advantaged, and some became even worse off. The study emphasizes how important it is to monitor health inequalities between different groups, in order to ensure that everyone—and not just the well-off—can experience gains in life expectancy. Although the “reversal of fortune” that the researchers found applied to only a minority of the population, the authors argue that their study results are troubling because an oft-stated aim of the US health system is the improvement of the health of “all people, and especially those at greater risk of health disparities” (see, for example http://www.cdc.gov/osi/goals/SIHPGPostcard.pdf).
Additional Information.
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.0050066.
A study by Nancy Krieger and colleagues, published in PLoS Medicine in February 2008, documented a similar “fall and rise” in health inequities. Krieger and colleagues reported that the difference in health between rich and poor and between different racial/ethnic groups, as measured by rates of dying young and of infant deaths, shrank in the US from 1966 to 1980 then widened from 1980 to 2002
Murray and colleagues, in a 2006 PLoS Medicine article, calculated US mortality rates according to “race-county” units and divided into the “eight Americas,” and found disparities in life expectancy across them
The US Centers for Disease Control has an Office of Minority Health and Health Disparities. The office “aims to accelerate CDC's health impact in the US population and to eliminate health disparities for vulnerable populations as defined by race/ethnicity, socioeconomic status, geography, gender, age, disability status, risk status related to sex and gender, and among other populations identified to be at-risk for health disparities”
Wikipedia has a chapter on health disparities (note that Wikipedia is a free online encyclopedia that anyone can edit; available in several languages)
In 2001 the US Agency for Healthcare Research and Quality sponsored a workshop on “strategies to reduce health disparities”
doi:10.1371/journal.pmed.0050066
PMCID: PMC2323303  PMID: 18433290
16.  A self-supporting library service in a rural region: a new look at hospital consortia. 
To meet the informational needs of health care practitioners and trainees in a four-county rural area of northwestern North Carolina, the eleven-member UNIFOUR Consortium was founded as a two-year experimental project from 1978 to 1980. The consortium has several unique features: (1) it is an organization of institutions, not libraries; (2) it employs its own professional librarian who manages a central library, coordinates consortium programs, and makes regular circuit visits to all affiliated institutions; (3) the central library, where the circuit is based, is a developing community hospital library, not an established academic medical center library; and (4) it is ultimately tied to the Northwest Area Health Education Center and that organization's emerging learning resources network, which includes the Bowman Gray School of Medicine, Library, two other subregional libraries, and the libraries of all member institutions. At the end of the experimental period in 1980, member institutions voted unanimously to continue the program and assume their share of the costs.
PMCID: PMC226687  PMID: 7039744
17.  Use of focus groups in a library's strategic planning process 
The use of focus groups to determine patron satisfaction with library resources and services is extensive and well established. This article demonstrates how focus groups can also be used to help shape the future direction of a library as part of the strategic planning process. By responding to questions about their long-term library and information needs, focus group participants at the University of Texas Southwestern Medical Center at Dallas Library contributed an abundance of qualitative patron data that was previously lacking from this process. The selection and recruitment of these patrons is discussed along with the line of questioning used in the various focus group sessions. Of special interest is the way the authors utilized these sessions to mobilize and involve the staff in creating the library's strategic plan. This was accomplished not only by having staff members participate in one of the sessions but also by sharing the project's major findings with them and instructing them in how these findings related to the library's future. The authors' experience demonstrates that focus groups are an effective strategic planning tool for libraries and emphasizes the need to share information broadly, if active involvement of the staff is desired in both the development and implementation of the library's strategic plan.
PMCID: PMC64762  PMID: 11838465
18.  Providing consumer health information via health professionals. 
The Health Education Center in Pittsburgh, a community-based health promotion agency which provides library services to health professionals, students, and the lay public, received a resource grant in 1981 from the National Library of Medicine to study professionals' awareness of consumer health information (CHI) materials for their patients and clients. A survey of telephone patrons and on-site library patrons provided details on health professionals' use of the CHI resource center: their areas of interest, the material formats they preferred, and the intended use of the materials. Health professionals' demand for information about consumer-oriented materials and their satisfaction with the HEC library suggest that such a resource can be a valuable asset to a community.
PMCID: PMC227836  PMID: 3742114
19.  The use of free resources in a subscription-based digital library: a case study of the North Carolina AHEC Digital Library 
Background
The North Carolina (NC) Area Health Education Center's (AHEC) Digital Library (ADL) is a web portal designed to meet the information needs of health professionals across the state by pulling together a set of resources from numerous different sources and linking a pool of users to only the resources for which they have eligibility. Although the ADL was designed with the primary purpose of linking health care professionals to a set of licensed resources, the ADL also contains a significant number of links to free resources. These resources are available to any ADL member logging into their ADL account and to guest visitors to the ADL. While there are regular assessments of the subscription resources in the ADL as to utility and frequency of use, up until this point there has been no systematic analysis of the use of the overall set of free resources. It was decided to undertake an examination of the usage of ADL free resources over a 6-month period to analyze the utility of these resources to both ADL members and guests.
Methods
Each time a resource is accessed through the ADL, it is logged in a table. This study used a SQL query to pull every free resource accessed between November 1, 2005 and April 30, 2006. An additional query also pulled the user information for each free resource accessed. Once the queries of the database were complete, the results were imported into an Excel spreadsheet and analyzed using basic descriptive statistics.
Results
The vast majority of resource use through the ADL is to licensed resources. There are 2056 free resource URLs in the ADL, to which 1351 were linked out, meaning there was at least one link out to 65% of the free resources. The single most popular free resource was PubMed with 4803 link outs or nearly 20% of the total link outs to free resources. The breakdown of free resource use by different use groups indicates that the highest percentage of use of free resources was by guests followed by institutional affiliates and AHEC Faculty/Staff. The next 3 highest user groups accessing free resources are: paid members, preceptors, and residents.
Conclusion
The only free resource capturing a significant number of link outs is the free link to PubMed. This reflects the importance placed on traditional medical literature searching by the ADL clinical user base. Institutional affiliates access free resources through the ADL with the second highest frequency of all the user groups. Finally, in analyzing use of free resources, it is important to note the overall limitations of this survey. While link outs are excellent indicators of frequency of use they do not provide any information about the ultimate usefulness of the resource being accessed. Further studies would need to examine not only the quantitative use of resources, but also their qualitative importance to the user.
doi:10.1186/1742-5581-3-9
PMCID: PMC1570362  PMID: 16956409
20.  Realizing what's essential: a case study on integrating electronic journal management into a print-centric technicalservices department 
Objective: To support migration from print to electronic resources, the Cushing/Whitney Medical Library at Yale University reorganized its Technical Services Department to focus on managing electronic resources.
Methods: The library hired consultants to help plan the changes and to present recommendations for integrating electronic resource management into every position. The library task force decided to focus initial efforts on the periodical collection. To free staff time to devote to electronic journals, most of the print subscriptions were switched to online only and new workflows were developed for e-journals.
Results: Staff learned new responsibilities such as activating e-journals, maintaining accurate holdings information in the online public access catalog and e-journals database (“electronic shelf reading”), updating the link resolver knowledgebase, and troubleshooting. All of the serials team members now spend significant amounts of time managing e-journals.
Conclusions: The serials staff now spends its time managing the materials most important to the library's clientele (e-journals and databases). The team's proactive approach to maintenance work and rapid response to reported problems should improve patrons' experiences using e-journals. The library is taking advantage of new technologies such as an electronic resource management system, and library workflows and procedures will continue to evolve as technology changes.
doi:10.3163/1536-5050.95.2.147
PMCID: PMC1852630  PMID: 17443247
21.  Using GIS and Secondary Data to Target Diabetes-Related Public Health Efforts 
Public Health Reports  2013;128(3):212-220.
Objectives
To efficiently help communities prevent and manage diabetes, health departments need to be able to target populations with high risk but low resources. To aid in this process, we mapped county-level diabetes-related rates and resources/use using publicly available secondary data to identify Michigan counties with high diabetes prevalence and low or no medical and/or community resources.
Methods
We collected county-level diabetes-related rates and resources from Web-based sources and mapped them using geographic information systems (GIS) software. Data included age-adjusted county diabetes rates, diabetes-related medical resource and resource use (i.e., the number of endocrinologists and percentage of Medicare patients with diabetes who received hemoglobin A1c testing in the past year), community resources (i.e., the number of certified diabetes self-management education and diabetes support groups), as well as population estimates and demographics (e.g., rural residence, education, poverty, and race/ethnicity). We created GIS maps highlighting areas that had higher-than-median rates of disease and lower-than-median resources. We also conducted linear, logistic, and Poisson regression analyses to confirm GIS findings.
Results
There were clear regional trends in resource distribution across Michigan. The 15 counties in the Upper Peninsula were lacking in medical resources but higher in community resources compared with the 68 counties in the Lower Peninsula. There was little apparent association between need (diabetes prevalence) and diabetes-related resources/use. Specific counties with high diabetes prevalence and low resources were easily identified using GIS mapping.
Conclusion
Using public data and mapping tools identified diabetes health-service shortage areas for targeted public health programming.
PMCID: PMC3610073  PMID: 23633736
22.  Use of Internet Audience Measurement Data to Gauge Market Share for Online Health Information Services 
Background
The transition to a largely Internet and Web-based environment for dissemination of health information has changed the health information landscape and the framework for evaluation of such activities. A multidimensional evaluative approach is needed.
Objective
This paper discusses one important dimension of Web evaluation—usage data. In particular, we discuss the collection and analysis of external data on website usage in order to develop a better understanding of the health information (and related US government information) market space, and to estimate the market share or relative levels of usage for National Library of Medicine (NLM) and National Institutes of Health (NIH) websites compared to other health information providers.
Methods
The primary method presented is Internet audience measurement based on Web usage by external panels of users and assembled by private vendors—in this case, comScore. A secondary method discussed is Web usage based on Web log software data. The principle metrics for both methods are unique visitors and total pages downloaded per month.
Results
NLM websites (primarily MedlinePlus and PubMed) account for 55% to 80% of total NIH website usage depending on the metric used. In turn, NIH.gov top-level domain usage (inclusive of NLM) ranks second only behind WebMD in the US domestic home health information market and ranks first on a global basis. NIH.gov consistently ranks among the top three or four US government top-level domains based on global Web usage. On a site-specific basis, the top health information websites in terms of global usage appear to be WebMD, MSN Health, PubMed, Yahoo! Health, AOL Health, and MedlinePlus. Based on MedlinePlus Web log data and external Internet audience measurement data, the three most heavily used cancer-centric websites appear to be www.cancer.gov (National Cancer Institute), www.cancer.org (American Cancer Society), and www.breastcancer.org (non-profit organization).
Conclusions
Internet audience measurement has proven useful to NLM, with significant advantages compared to sole reliance on usage data from Web log software. Internet audience data has helped NLM better understand the relative usage of NLM and NIH websites in the intersection of the health information and US government information market sectors, which is the primary market intersector for NLM and NIH. However important, Web usage is only one dimension of a complete Web evaluation framework, and other primary research methods, such as online user surveys, usability tests, and focus groups, are also important for comprehensive evaluation that includes qualitative elements, such as user satisfaction and user friendliness, as well as quantitative indicators of website usage.
doi:10.2196/jmir.7.3.e31
PMCID: PMC1550664  PMID: 15998622
Internet; World Wide Web; information services; information dissemination; audience research; evaluation studies
23.  Evaluating a Social Network Analytic Tool to Support Outbreak Management and Contact Tracing in an Outbreak of Pertussis 
Objective
To determine the feasibility and value of a social network analysis tool to support pertussis outbreak management and contact tracing in the state of Utah.
Introduction
Pertussis (i.e., whooping cough) is on the rise in the US. To implement effective prevention and treatment strategies, it is critical to conduct timely contact tracing and evaluate people who may have come into contact with an infected person. We describe a collaborative effort between epidemiologists and public health informaticists at the Utah Department of Health (UDOH) to determine the feasibility and value of a network-analytic approach to pertussis outbreak management and contact tracing.
Methods
The partnership: In early 2012, epidemiologists from UDOH’s Vaccine Preventable Disease Program and UDOH’s public health informaticists formed a partnership to determine the feasibility and value of the Organizational Risk Analyzer (ORA) in pertussis outbreak management and contact tracing (1). Both entities have a longstanding partnership. A characteristic that has made the collaboration particularly strong and mutually beneficial is that both partners have expertise in disease surveillance and outbreak management. In addition, the informaticists have expertise in devising systems that help frontline healthcare providers.
The Organizational Risk Analyzer (ORA): ORA is a computational tool that extends network analysis by using a meta-matrix model. A meta-matrix is defined as a network of connecting entities. The tool uses one or more matrices in an organization’s meta-matrix as input. From this input the tool calculates measures that describe the relationships and ties among the entities. ORA contains over 50 network and node level measures which are categorized by the type of risk they detect (1).
Procedures: Following approval from UDOH’s Institutional Review Board, we analyzed records from 629 deidentified pertussis patients from the UT-NEDSS database from January 2011 to December 2011. The test data included demographics and epidemiological information. We used Excel to create .csv data files, uploaded the data into ORA, and displayed the data in meta-matrices consisting of nodes (cases/contacts) and edges (relationships). We used ORA’s visualizer to check for data-entry errors before performing the network analysis.
Data Analysis: ORA’s centrality measures (degree, closeness, betweenness, hub, and eigenvector) were used to identify geographic locations with high infection rates and the patients who were central to sustaining the outbreak. Next, we applied a concor algorithm to find groups in the meta-network that might be hard to spot visually. Visualizations were used to supplement the metrics.
Results
The ORA analysis identified 5 individuals who were central to perpetuating the outbreak in that their centrality measures were higher than other patients in the network. The index patient (Fig 1) was traced back to Utah County and was linked to 6 direct contacts in the same county and several indirect ties in adjacent counties. The individual was highly connected to others within the network (hub centrality = 1.41 and eigenvector centrality = 1.00). Salt Lake County had the highest number of cases, followed by Utah County and Weber County. The concor analysis revealed hidden networks, including a cluster of patients grouped by age group and case status (Fig 2).
Conclusions
The ORA was found to be a valuable tool for supporting pertussis outbreak management and contact tracing. Although network analysis is relatively new to public health, it can increase public health’s understanding of how patterns of social relationships can aid or inhibit the spread of communicable diseases and provide the information needed to target intervention efforts effectively.
PMCID: PMC3692920
Surveillance; Informatics; Social Network Analysis
24.  Arsenic in North Carolina: Public Health Implications 
Environment international  2011;38(1):10-16.
Arsenic is a known human carcinogen and relevant environmental contaminant in drinking water systems. We set out to comprehensively examine statewide arsenic trends and identify areas of public health concern. Specifically, arsenic trends in North Carolina private wells were evaluated over an eleven-year period using the North Carolina Department of Health and Human Services (NCDHHS) database for private domestic well waters. We geocoded over 63,000 domestic well measurements by applying a novel geocoding algorithm and error validation scheme. Arsenic measurements and geographical coordinates for database entries were mapped using Geographic Information System (GIS) techniques. Furthermore, we employed a Bayesian Maximum Entropy (BME) geostatistical framework, which accounts for geocoding error to better estimate arsenic values across the state and identify trends for unmonitored locations. Of the approximately 63,000 monitored wells, 7,712 showed detectable arsenic concentrations that ranged between 1 and 806 μg/L. Additionally, 1,436 well samples exceeded the EPA drinking water standard. We reveal counties of concern and demonstrate a historical pattern of elevated arsenic in some counties, particularly those located along the Carolina terrane (Carolina slate belt). We analyzed these data in the context of populations using private well water and identify counties for targeted monitoring, such as Stanly and Union Counties. By spatiotemporally mapping these data, our BME estimate revealed arsenic trends at unmonitored locations within counties and better predicted well concentrations when compared to the classical kriging method. This study reveals relevant information on the location of arsenic-contaminated private domestic wells in North Carolina and indicates potential areas at increased risk for adverse health outcomes.
doi:10.1016/j.envint.2011.08.005
PMCID: PMC3539775  PMID: 21982028
Arsenic; drinking water; groundwater monitoring; well water; GIS; spatial analysis; North Carolina; Carolina slate belt
25.  Diabetes and the socioeconomic and built environment: geovisualization of disease prevalence and potential contextual associations using ring maps 
Background
Efforts to stem the diabetes epidemic in the United States and other countries must take into account a complex array of individual, social, economic, and built environmental factors. Increasingly, scientists use information visualization tools to "make sense" of large multivariate data sets. Recently, ring map visualization has been explored as a means of depicting spatially referenced, multivariate data in a single information graphic. A ring map shows multiple attribute data sets as separate rings of information surrounding a base map of a particular geographic region of interest. In this study, ring maps were used to evaluate diabetes prevalence among adult South Carolina Medicaid recipients. In particular, county-level ring maps were used to evaluate disparities in diabetes prevalence among adult African Americans and Whites and to explore potential county-level associations between diabetes prevalence among adult African Americans and five measures of the socioeconomic and built environment—persistent poverty, unemployment, rurality, number of fast food restaurants per capita, and number of convenience stores per capita. Although Medicaid pays for the health care of approximately 15 percent of all diabetics, few studies have examined diabetes in adult Medicaid recipients at the county level. The present study thus addresses a critical information gap, while illustrating the utility of ring maps in multivariate investigations of population health and environmental context.
Results
Ring maps showed substantial racial disparity in diabetes prevalence among adult Medicaid recipients and suggested an association between adult African American diabetes prevalence and rurality. Rurality was significantly positively associated with diabetes prevalence among adult African American Medicaid recipients in a multivariate statistical model.
Conclusions
Efforts to reduce diabetes among adult African American Medicaid recipients must extend to rural African Americans. Ring maps can be used to integrate diverse data sets, explore attribute associations, and achieve insights critical to the promotion of population health.
doi:10.1186/1476-072X-10-18
PMCID: PMC3066107  PMID: 21362176

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