The gender gap in physician pay is often attributed in part to women working fewer hours than men, but evidence to date is limited by self-report and a lack of detail regarding clinical revenue and ...gender differences in practice style.
Using national all-payer claims and data from electronic health records, we conducted a cross-sectional analysis of 24.4 million primary care office visits in 2017 and performed comparisons between female and male physicians in the same practices. Our primary independent variable was physician gender; outcomes included visit revenue, visit counts, days worked, and observed visit time (interval between the initiation and the termination of a visit). We created multivariable regression models at the year, day, and visit level after adjustment for characteristics of the primary care physicians (PCPs), patients, and types of visit and for practice fixed effects.
In 2017, female PCPs generated 10.9% less revenue from office visits than their male counterparts (-$39,143.2; 95% confidence interval CI, -53,523.0 to -24,763.4) and conducted 10.8% fewer visits (-330.5 visits; 95% CI, -406.6 to -254.3) over 2.6% fewer clinical days (-5.3 days; 95% CI, -7.7 to -3.0), after adjustment for age, academic degree, specialty, and number of sessions worked per week, yet spent 2.6% more observed time in visits that year than their male counterparts (1201.3 minutes; 95% CI, 184.7 to 2218.0). Per visit, after adjustment for PCP, patient, and visit characteristics, female PCPs generated equal revenue but spent 15.7% more time with a patient (2.4 minutes; 95% CI, 2.1 to 2.6). These results were consistent in subgroup analyses according to the gender and health status of the patients and the type and complexity of the visits.
Female PCPs generated less visit revenue than male colleagues in the same practices owing to a lower volume of visits, yet spent more time in direct patient care per visit, per day, and per year. (Funded in part by the Robert Wood Johnson Foundation.).
Environmental DNA (eDNA) can be used for early detection, population estimations, and assessment of potential spread of invasive species, but questions remain about factors that influence eDNA ...detection results. Efforts are being made to understand how physical, chemical, and biological factors-settling, resuspension, dispersion, eDNA stability/decay-influence eDNA estimations and potentially population abundance. In a series of field and controlled mesocosm experiments, we examined the detection and accumulation of eDNA in sediment and water and the transport of eDNA in a small stream in the Lake Michigan watershed, using the invasive round goby fish (Neogobius melanostomus) as a DNA source. Experiment 1: caged fish (average n = 44) were placed in a stream devoid of round goby; water was collected over 24 hours along 120-m of stream, including a simultaneous sampling event at 7 distances from DNA source; stream monitoring continued for 24 hours after fish were removed. Experiment 2: round goby were placed in laboratory tanks; water and sediment were collected over 14 days and for another 150 days post-fish removal to calculate eDNA shedding and decay rates for water and sediment. For samples from both experiments, DNA was extracted, and qPCR targeted a cytochrome oxidase I gene (COI) fragment specific to round goby. Results indicated that eDNA accumulated and decayed more slowly in sediment than water. In the stream, DNA shedding was markedly lower than calculated in the laboratory, but models indicate eDNA could potentially travel long distances (up to 50 km) under certain circumstances. Collectively, these findings show that the interactive effects of ambient conditions (e.g., eDNA stability and decay, hydrology, settling-resuspension) are important to consider when developing comprehensive models. Results of this study can help resource managers target representative sites downstream of potential invasion sites, thereby maximizing resource use.
More than 40 medical specialties have identified "Choosing Wisely" lists of five overused or low-value services. But these services vary widely in potential impact on care and spending, and specialty ...societies often name other specialties' services as low value.
Environmental DNA (eDNA) is revolutionizing biodiversity monitoring, occupancy estimates, and real-time detections of invasive species. In the Great Lakes, the round goby (Neogobius melanostomus), an ...invasive benthic fish from the Black Sea, has spread to encompass all five lakes and many tributaries, outcompeting or consuming native species; however, estimates of round goby abundance are confounded by behavior and habitat preference, which impact reliable methods for estimating their population. By integrating eDNA into round goby monitoring, improved estimates of biomass may be obtainable. We conducted mesocosm experiments to estimate rates of goby DNA shedding and decay. Further, we compared eDNA with several methods of traditional field sampling to compare its use as an alternative/complementary monitoring method. Environmental DNA decay was comparable to other fish species, and first-order decay was lower at 12°C (k = 0.043) than at 19°C (k = 0.058). Round goby eDNA was routinely detected in known invaded sites of Lake Michigan and its tributaries (range log10 4.8-6.2 CN/L), but not upstream of an artificial fish barrier. Traditional techniques (mark-recapture, seining, trapping) in Lakes Michigan and Huron resulted in fewer, more variable detections than eDNA, but trapping and eDNA were correlated (Pearson R = 0.87). Additional field testing will help correlate round goby abundance with eDNA, providing insight on its role as a prey fish and its impact on food webs.
Summary The preceding papers in this Series have outlined how underuse and overuse of health-care services occur within a complex system of health-care production, with a multiplicity of causes. ...Because poor care is ubiquitous and has considerable consequences for the health and wellbeing of billions of people around the world, remedying this problem is a morally and politically urgent task. Universal health coverage is a key step towards achieving the right care. Therefore, full consideration of potential levers of change must include an upstream perspective—ie, an understanding of the system-level factors that drive overuse and underuse, as well as the various incentives at work during a clinical encounter. One example of a system-level factor is the allocation of resources (eg, hospital beds and clinicians) to meet the needs of a local population to minimise underuse or overuse. Another example is priority setting using tools such as health technology assessment to guide the optimum diffusion of safe, effective, and cost-effective health-care services. In this Series paper we investigate a range of levers for eliminating medical underuse and overuse. Some levers could operate effectively (and be politically viable) across many different health and political systems (eg, increase patient activation with decision support) whereas other levers must be tailored to local contexts (eg, basing coverage decisions on a particular cost-effectiveness ratio). Ideally, policies must move beyond the purely incremental; that is, policies that merely tinker at the policy edges after underuse or overuse arises. In this regard, efforts to increase public awareness, mobilisation, and empowerment hold promise as universal methods to reset all other contexts and thereby enhance all other efforts to promote the right care.
The number of beach closings caused by bacterial contamination has continued to rise in recent years, putting beachgoers at risk of exposure to contaminated water. Current approaches predict levels ...of indicator bacteria using regression models containing a number of explanatory variables. Data-based modeling approaches can supplement routine monitoring data and provide highly accurate short-term forecasts of beach water quality. In this paper, we apply the nonlinear autoregressive network with exogenous inputs (NARX) method with explanatory variables to predict Escherichia coli concentrations at four Lake Michigan beach sites. We also apply the nonlinear input–output network (NIO) and nonlinear autoregressive neural network (NAR) methods in addition to a hybrid wavelet-NAR (WA-NAR) model and demonstrate their application. All models were tested using 3 months of observed data. Results revealed that the NARX models provided the best performance and that the WA-NAR model, which requires no explanatory variables, outperformed the NIO and NAR models; therefore, the WA-NAR model is suitable for application to data scarce regions. The models proposed in this paper were evaluated using multiple performance metrics, including sensitivity and specificity measures, and produced results comparable or superior to those of previous mechanistic and statistical models developed for the same beach sites. The relatively high R 2 values between data and the NARX models (R 2 values of ∼0.8 for the beach sites and ∼0.9 for the river site) indicate that the new class of models shows promise for beach management.
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