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Objectives: To assess the early impact of implementation of the electronic consults (e-consults) initiative by the Veterans Health Administration (VHA), designed to improve specialty care access., Study Design: Observational cohort study exploiting a natural experiment begun in May 2011 at 12 VHA medical centers and expanded to 122 medical centers by December 2013., Methods: The following were assessed: 1) growth of e-consults by VHA regional networks, medical centers, and specialty; 2) location of patient's primary care provider (medical center vs community-based outpatient clinic [CBOC]); 3) potential patient miles needed to travel for a specialty care face-to-face consult in place of the observed e-consults using estimated geodesic distance; 4) use of specialty care subsequent to the e-consult., Results: Of 11,270,638 consults completed in 13 clinics of interest, 217,014 were e-consults (adjusted rate, 1.93 e-consults per 100 consults). The e-consult rate was highest in endocrinology (5.0 per 100), hematology (3.0 per 100), and gastroenterology (3.0 per 100). The percentage of e-consult patients with CBOC-based primary care grew from 28.5% to 44.4% in the first year of implementation and to 45.6% at year 3. Of those e-consult patients from community clinics, the average potential miles needed to travel was 72.1 miles per patient (SD = 72.6; median = 54.6; interquartile range = 17.1-108), translating to a potential savings of 6,875,631 total miles and travel reimbursement costs of $2,853,387., Conclusions: E-consult volume increased significantly since inception within many medical and surgical specialties. For patients receiving primary care at one of more than 800 CBOCs, e-consults may decrease travel burden and direct travel costs for patients.

Background: Disease management programs (DMPs) for cardiovascular risk (CVR) and chronic obstructive pulmonary disease (COPD) are increasingly implemented in The Netherlands to improve care and patient's health behavior., Objective: The aim of this study was to provide evidence about the (cost-) effectiveness of Dutch DMPs as implemented in daily practice., Methods: We compared the physical activity, smoking status, quality-adjusted life-years, and yearly costs per patient between the most and the least comprehensive DMPs in four disease categories: primary CVR prevention, secondary CVR prevention, both types of CVR prevention, and COPD (N = 1034). Propensity score matching increased comparability between DMPs. A 2-year cost-utility analysis was performed from the health care and societal perspectives. Sensitivity analysis was performed to estimate the impact of DMP development and implementation costs on cost-effectiveness., Results: Patients in the most comprehensive DMPs increased their physical activity more (except for primary CVR prevention) and had higher smoking cessation rates. The incremental QALYs ranged from -0.032 to 0.038 across all diseases. From a societal perspective, the most comprehensive DMPs decreased costs in primary CVR prevention (certainty 57%), secondary CVR prevention (certainty 88%), and both types of CVR prevention (certainty 98%). Moreover, the implementation of comprehensive DMPs led to QALY gains in secondary CVR prevention (certainty 92%) and COPD (certainty 69%)., Conclusions: The most comprehensive DMPs for CVR and COPD have the potential to be cost saving, effective, or cost-effective compared with the least comprehensive DMPs. The challenge for Dutch stakeholders is to find the optimal mixture of interventions that is most suited for each target group., (Copyright © 2015 International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Published by Elsevier Inc. All rights reserved.)

Background: Decentralization of ART services scaled up significantly with the country wide roll out of option B plus in Uganda. Little work has been undertaken to examine population level access to HIV care particularly in hard to reach areas in rural Africa. Most work on ART scale up has been done at health facility level which omits people not accessing healthcare in the community. This study describes health service usage, particularly HIV testing and care in 2/6 parishes of Lapono sub-county of northern Uganda, prior to introduction of ART services in Lira Kato Health Centre (a local lower-level health centre III), as part of ART decentralization., Methods: Household and individual questionnaires were administered to household members (aged 15-59 years). Logit random effects models were used to test for differences in proportions (allowing for clustering within villages)., Results: 2124 adults from 1351 households were interviewed (755 [36%] males, 1369 [64 %] females). 2051 (97%) participants reported seeking care locally for fever, most on foot and over half at Lira Kato Health Centre. 574 (76%) men and 1156 (84%) women reported ever-testing for HIV (P < 0.001 for difference); 34/574 (6%) men and 102/1156 (9%) women reported testing positive (P = 0.04). 818/850 (96%) women who had given birth in the last 5 years had attended antenatal care in their last pregnancy: 7 women were already diagnosed with HIV (3 on ART) and 790 (97%) reported being tested for HIV (34 tested newly positive). 124/136 (91%) HIV-positive adults were in HIV-care, 123/136 (90 %) were taking cotrimoxazole and 74/136 (54%) were on ART. Of adults in HIV-care, most were seen at Kalongo hospital (n = 87), Patongo Health Centre (n = 7) or Lira Kato Health Centre (n = 23; no ART services). 58/87, 5/7 and 20/23 individuals walked to Kalongo hospital (56 km round-trip, District Health Office information), Patongo Health Centre (76 km round-trip, District Health Office information) and Lira Kato Health Centre (local) respectively. 8 HIV-infected children were reported; only 2 were diagnosed aged <24 months: 7/8 were in HIV-care including 3 on ART., Conclusions: Higher proportions of women compared to men reported ever-testing for HIV and testing HIV-positive, similar to other surveys. HIV-infected men and women travelled considerable distances for ART services. Children appeared to be under-accessing testing and referral for treatment. Decentralization of ART services to a local health facility would decrease travel time and transport costs, making care and treatment more easily accessible.

This paper reports the impact of oil spills and tar-ball pollution on the coastal ecosystem of Goa. The factors responsible for degrading the marine ecosystem of the Goan coastline are analyzed. Uncontrolled activities were found to degrade the marine and coastal biodiversity, in turn polluting all beaches. This had a direct impact on the Goan economy through a decline in tourism. The government must adopt the necessary control measures to restore Goan beaches and the surrounding coastal areas., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

A network approach, which simplifies geographic settings as a form of nodes and links, emphasizes the connectivity and relationships of spatial features. Topological networks of spatial features are used to explore geographical connectivity and structures. The PageRank algorithm, a network metric, is often used to help identify important locations where people or automobiles concentrate in the geographical literature. However, geographic considerations, including proximity and location attractiveness, are ignored in most network metrics. The objective of the present study is to propose two geographically modified PageRank algorithms-Distance-Decay PageRank (DDPR) and Geographical PageRank (GPR)-that incorporate geographic considerations into PageRank algorithms to identify the spatial concentration of human movement in a geospatial network. Our findings indicate that in both intercity and within-city settings the proposed algorithms more effectively capture the spatial locations where people reside than traditional commonly-used network metrics. In comparing location attractiveness and distance decay, we conclude that the concentration of human movement is largely determined by the distance decay. This implies that geographic proximity remains a key factor in human mobility.

Objective: Smoke-free policies aiming to improve quality of indoor air and significantly reduce exposure to secondhand smoke in the hospitality industry are faced with strong opposition from the tobacco industry and hospitality venue owners claiming that they lead to reductions of revenues. The objective of our study was to examine the impact of a recently introduced smoke-free legislation on the revenues of the hospitality industry in Cyprus., Methods: Anonymous information on revenues was obtained from the Cyprus government value added tax office for the entire hospitality industry in Cyprus including hotels, bars, restaurants and cafeterias between 2005 and 2011. Panel data methodology was used to examine the effect of a smoke-free legislation, on tourism, businesses' revenues adjusting for gross domestic product, inflation, unemployment rate, tourists' arrivals, seasonal variation and the economic crisis., Results: Our study showed that the implementation of the smoke-free policy did not have negative effects on the hospitality industry profitability., Conclusions: We conclude that even in regions with relatively high smoking rates, pro-smoking societal attitudes and weak social norms against tobacco control, and even during periods of economic crisis, smoke-free legislation does not impact negatively on hospitality industry revenues and if anything may lead to a small positive increase., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

In choosing the scale of public services, such as hospitals, both economic and public administrative considerations play important roles. The scale and the corresponding spatial distribution of public institutions have consequences for social costs, defined as the institutions' operating costs and the users' travel costs (which include the money and time costs). Insight into the relationship between scale and spatial distribution and social costs provides a practical guide for the best possible administrative planning level. This article presents a purely economic model that is suitable for deriving the optimal scale for public services. The model also reveals the corresponding optimal administrative planning level from an economic perspective. We applied this model to hospital care in Flanders for three different types of care. For its application, we examined the social costs of hospital services at different levels of administrative planning. The outcomes show that the social costs of rehabilitation in Flanders with planning at the urban level (38 areas) are 11% higher than those at the provincial level (five provinces). At the regional level (18 areas), the social costs of rehabilitation are virtually equal to those at the provincial level. For radiotherapy, there is a difference of 88% in the social costs between the urban and the provincial level. For general care, there are hardly any cost differences between the three administrative levels. Thus, purely from the perspective of social costs, rehabilitation should preferably be planned at the regional level, general services at the urban level and radiotherapy at the provincial level., (Copyright © 2014 John Wiley & Sons, Ltd.)

Background/purpose: Indirect expenses for accessing health care may place significant fiscal strain on Canadian families. Telemedicine alternatives, using email, telephone, and video conferencing, can mitigate such financial burdens by reducing travel and related costs. Our objectives were to assess costs that families incur visiting an outpatient pediatric surgical clinic, and family attitudes toward telemedicine alternatives., Methods: A survey was offered pre-consult to all families who attended pediatric urology and general surgery outpatient clinics over a three-month period., Results: A total of 1032 of 1574 families screened participated (66.0%). Less than half (18.5%) of participants traveled over 200 km, and 32.9% spent over 4 hours in transit, round-trip. The proportion of participants who spent over $50 on travel and ancillary expenses was 33.0%. In 74.0% of families, 1 or more adults missed work. The proportion of families who perceived costs as somewhat high or high was 29.1%. Perceived cost was positively correlated to distance traveled, money spent, and missed work (p<0.01). Most were comfortable with medical communication using technology; and 34.3%-42.7% would avoid an in-person clinic visit utilizing email, telephone, and video conferencing. Higher perceived cost (p<0.001) and distance traveled (p<0.01) were only weakly associated with greater willingness to substitute a clinic visit with video conferencing., Conclusions: Many families face high costs related to routine outpatient clinical visits, and there is a substantial willingness by them to access telemedicine alternatives, rather than the traditional face-to-face clinical visit., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Veterans who are hospitalized in both VA and non-VA hospitals within a short timespan may be at risk for fragmented or conflicting care. To determine the characteristics of these "dual users," we analyzed administrative hospital discharge data for VA-enrolled veterans of any age in seven states, including any VA or non-VA hospitalizations they had in 2004-2007., Method: For VA enrollees in Arizona, Iowa, Louisiana, Florida, South Carolina, Pennsylvania, or New York in 2007, we merged 2004-2007 discharge data for all VA hospitalizations and all non-VA hospitalizations listed in state health department or hospital association databases. For patients hospitalized in 2007, we compared those younger or older than 65 years who had one or multiple hospitalizations during the year, split into users of VA hospitals, non-VA hospitals, or both ("dual users"), on demographics, priority for VA care, travel times, principal diagnoses, co-morbidities, lengths of stay, and prior (2004-2006) hospitalizations, using chi-square analysis or ANOVA. Multiply hospitalized patients were compared with multinomial logistic regressions to predict non-VA and dual use. Payers for non-VA hospitalizations also were compared across groups., Results: Of unique inpatients in 2007, 38 % of those 65 or older were hospitalized more than once during the year, as were 32 % of younger patients; 3 and 8 %, respectively, were dual users. Dual users averaged the most index-year (3.7) and prior (1.5) hospitalizations, split evenly between VA and non-VA. They also had higher rates of admission for circulatory diseases, symptoms/signs/ill-defined conditions, and injury and poisoning, and more admissions for multiple diagnostic categories; among younger patients they had the highest rate of mental disorders admissions. Higher income, non-rural residence, greater time to VA care, lower VA priority, prior non-VA hospitalization, no prior VA hospitalization, and several medical categories predicted greater non-VA use. Among younger patients, however, mental disorders predicted more dual use but less exclusively non-VA use. Dual users' non-VA admissions were more likely than others' to be covered by payers other than Medicare or commercial insurance., Conclusions: Younger dual users require more medical and psychiatric treatment, and rely more on government funding sources. Effective care coordination for these inpatients might improve outcomes while reducing taxpayer burden.

Background: Telehealth can offer alternative options for receiving healthcare services in rural locations, improving access and reducing costs associated with traveling for services. However, the full potential of telehealth has not been realised with slow and fragmented uptake. This study describes the awareness, experiences and perceptions of telehealth in an Australian rural community., Methods: Semi-structured interviews were undertaken with 47 participants from three rural towns in the Darling Downs region of Queensland. Content analysis was used to abstract themes and core concepts from the interviews., Results: Three participants were healthcare providers who had all previously used telehealth in their clinical practice. Twenty-seven (57 %) participants regularly travelled to access specialist healthcare. While 28 (60 %) participants were aware of telehealth, only six (13 %) had actually used telehealth services; three as patients and three as healthcare providers. Major themes evident included: acceptance of the need to travel; paternalism and empowerment; and trust and misconceptions., Conclusions: For telehealth initiatives to be successful, there needs to be greater public awareness and understanding of the potential benefits of telehealth. Empowering patients as partners in the delivery of healthcare may be an important factor in the growth of telehealth services.

This paper employs the autoregressive distributed lag (ARDL) bounds methodological approach to investigate the relationship between economic growth, combustible renewables and waste consumption, carbon dioxide (CO2) emissions, and international tourism for the case of Tunisia spanning the period 1990-2010. The results from the Fisher statistic of both the Wald test and the Johansen test confirm the presence of a long-run relationship among the variables under investigation. The stability of estimated parameters has been tested, while Granger causality tests recommend a short-run unidirectional causality running from economic growth and combustible renewables and waste consumption to CO2 emissions, a bidirectional causality between economic growth and combustible renewables and waste consumption and unidirectional causality running from economic growth and combustible renewables and waste consumption to international tourism. In the long-run, the error correction terms confirm the presence of bidirectional causality relationships between economic growth, CO2 emissions, combustible renewables and waste consumption, and international tourism. Our long-run estimates show that combustible renewables and waste consumption increases international tourism, and both renewables and waste consumption and international tourism increase CO2 emissions and output. We recommend that (i) Tunisia should use more combustible renewables and waste energy as this eliminates wastes from touristic zones and increases the number of tourist arrivals, leading to economic growth, and (ii) a fraction of this economic growth generated by the increase in combustible renewables and waste consumption should be invested in clean renewable energy production (i.e., solar, wind, geothermal) and energy efficiency projects.

Background: Rates of active travel vary by socio-economic position, with higher rates generally observed among less affluent populations. Aspects of both social and built environments have been shown to affect active travel, but little research has explored the influence of physical environmental characteristics, and less has examined whether physical environment affects socio-economic inequality in active travel. This study explored income-related differences in active travel in relation to multiple physical environmental characteristics including air pollution, climate and levels of green space, in urban areas across England. We hypothesised that any gradient in the relationship between income and active travel would be least pronounced in the least physically environmentally-deprived areas where higher income populations may be more likely to choose active transport as a means of travel., Methods: Adults aged 16+ living in urban areas (n = 20,146) were selected from the 2002 and 2003 waves of the UK National Travel Survey. The mode of all short non-recreational trips undertaken by the sample was identified (n = 205,673). Three-level binary logistic regression models were used to explore how associations between the trip being active (by bike/walking) and three income groups, varied by level of multiple physical environmental deprivation., Results: Likelihood of making an active trip among the lowest income group appeared unaffected by physical environmental deprivation; 15.4% of their non-recreational trips were active in both the least and most environmentally-deprived areas. The income-related gradient in making active trips remained steep in the least environmentally-deprived areas because those in the highest income groups were markedly less likely to choose active travel when physical environment was 'good', compared to those on the lowest incomes (OR = 0.44, 95% CI = 0.22 to 0.89)., Conclusions: The socio-economic gradient in active travel seems independent of physical environmental characteristics. Whilst more affluent populations enjoy advantages on some health outcomes, they will still benefit from increasing their levels of physical activity through active travel. Benefits of active travel to the whole community would include reduced vehicle emissions, reduced carbon consumption, the preservation or enhancement of infrastructure and the presentation of a 'normalised' behaviour.

The Baltic Sea provides benefits to all of the nine nations along its coastline, with some 85 million people living within the catchment area. Achieving improvements in water quality requires international cooperation. The likelihood of effective cooperation is known to depend on the distribution across countries of the benefits and costs of actions needed to improve water quality. In this paper, we estimate the benefits associated with recreational use of the Baltic Sea in current environmental conditions using a travel cost approach, based on data from a large, standardized survey of households in each of the 9 Baltic Sea states. Both the probability of engaging in recreation (participation) and the number of visits people make are modeled. A large variation in the number of trips and the extent of participation is found, along with large differences in current annual economic benefits from Baltic Sea recreation. The total annual recreation benefits are close to 15 billion EUR. Under a water quality improvement scenario, the proportional increases in benefits range from 7 to 18% of the current annual benefits across countries. Depending on how the costs of actions are distributed, this could imply difficulties in achieving more international cooperation to achieve such improvements., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: The aim of the present study was to document the financial and psychosocial impact of relocation for specialist haematology treatment in Queensland., Methods: This study was a qualitative exploratory study comprising 45 in-depth interviews with haematology patients supported by the Leukaemia Foundation of Queensland., Results: The findings indicate that decentralisation of treatment is assisting haematology patients to overcome the profound difficulties associated with travelling to the metropolitan area for treatment., Conclusion: Fostering specialist outreach and building capacity in regional cancer centres are service delivery strategies that are greatly appreciated by regional, rural and remote haematology patients who are stressed by the many challenges associated with leaving home to travel distances for specialist treatment. It is the hope and expectation that these findings will make a contribution to informing future health policy and service delivery planning.

To achieve greater transit-time reduction and improvement in reliability of transport services, there is an increasing need to assist transport planners in understanding the value of punctuality; i.e. the potential improvements, not only to service quality and the consumer but also to the actual profitability of the service. In order for this to be achieved, it is important to understand the network-specific aspects that affect both the ability to decrease transit-time, and the associated cost-benefit of doing so. In this paper, we outline a framework for evaluating the effectiveness of proposed changes to average transit-time, so as to determine the optimal choice of average arrival time subject to desired punctuality levels whilst simultaneously minimizing operational costs. We model the service transit-time variability using a truncated probability density function, and simultaneously compare the trade-off between potential gains and increased service costs, for several commonly employed cost-benefit functions of general form. We formulate this problem as a constrained optimization problem to determine the optimal choice of average transit time, so as to increase the level of service punctuality, whilst simultaneously ensuring a minimum level of cost-benefit to the service operator.

In this paper, we analyse the relationship between climate, tourism and water in Benidorm (Spain), an international icon of Fordist tourism (mass tourism). In particular, we have studied the causes and effects of the water supply droughts Benidorm has suffered since becoming a major holiday destination. For this purpose, we consulted the local press in Benidorm over the period 1969-2003. Using qualitative and quantitative geographical techniques, we found that the water supply in the area has managed to keep up with rapidly increasing demand, with only occasional imbalances and periods of crisis. We focused in particular on the causes and effects of the water supply crisis of 1978, a moment of great uncertainty in the history of Benidorm as a holiday resort. We also examined the influence of atmospheric conditions on precipitation levels and how these precipitation levels affect the water supply. Our results highlight the importance of intense rainfall episodes associated with easterly winds, which provided large inputs for Benidorm's water supply system (Marina Baja Water Consortium). We also found that the water supply crisis of 1978 resulted in serious economic losses for Benidorm and damaged its image as a holiday destination and that the city is now less vulnerable to variations in the climate, as a result of its search for new water resources (both surface and ground water resources and from other nonconventional sources).

The nonlethal effects of wildlife tourism can threaten the conservation status of targeted animal populations. In turn, such resource depletion can compromise the economic viability of the industry. Therefore, wildlife tourism exploits resources that can become common pool and that should be managed accordingly. We used a simulation approach to test whether different management regimes (tax, tax and subsidy, cap, cap and trade) could provide socioecologically sustainable solutions. Such schemes are sensitive to errors in estimated management targets. We determined the sensitivity of each scenario to various realistic uncertainties in management implementation and in our knowledge of the population. Scenarios where time quotas were enforced using a tax and subsidy approach, or they were traded between operators were more likely to be sustainable. Importantly, sustainability could be achieved even when operators were assumed to make simple rational economic decisions. We suggest that a combination of the two regimes might offer a robust solution, especially on a small spatial scale and under the control of a self-organized, operator-level institution. Our simulation platform could be parameterized to mimic local conditions and provide a test bed for experimenting different governance solutions in specific case studies.

We examine sensitivity of estimates of recreation demand using the Travel Cost Method (TCM) to four factors. Three of the four have been routinely and widely discussed in the TCM literature: a) Poisson verses negative binomial regression; b) application of Englin correction to account for endogenous stratification; c) truncation of the data set to eliminate outliers. A fourth issue we address has not been widely modeled: the potential effect on recreation demand of the interaction between income and travel cost. We provide a straightforward comparison of all four factors, analyzing the impact of each on regression parameters and consumer surplus estimates. Truncation has a modest effect on estimates obtained from the Poisson models but a radical effect on the estimates obtained by way of the negative binomial. Inclusion of an income-travel cost interaction term generally produces a more conservative but not a statistically significantly different estimate of consumer surplus in both Poisson and negative binomial models. It also generates broader confidence intervals. Application of truncation, the Englin correction and the income-travel cost interaction produced the most conservative estimates of consumer surplus and eliminated the statistical difference between the Poisson and the negative binomial. Use of the income-travel cost interaction term reveals that for visitors who face relatively low travel costs, the relationship between income and travel demand is negative, while it is positive for those who face high travel costs. This provides an explanation of the ambiguities on the findings regarding the role of income widely observed in the TCM literature. Our results suggest that policies that reduce access to publicly owned resources inordinately impact local low income recreationists and are contrary to environmental justice., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

The use of forest land for ecotourism has been well accepted due to its ability to provide income to local people and to conserve the forest. Preparing the forest with infrastructure to attract and educate visitors has been reported of importance. This study applied Q methodology in a small rural community of the State of Puebla, Mexico, to reveal forest owners' perceptions to build infrastructure in their forest as part of their ecotourism project. It also discloses forest owners' underlying motives to use their forest for ecotourism. Ecotourism is perceived as a complementary activity to farming that would allow women to be involved in community development. Low impact infrastructure is desired due to forest owners' perception to preserve the forest for the overall community well-being.

How often do people visit the world's protected areas (PAs)? Despite PAs covering one-eighth of the land and being a major focus of nature-based recreation and tourism, we don't know. To address this, we compiled a globally-representative database of visits to PAs and built region-specific models predicting visit rates from PA size, local population size, remoteness, natural attractiveness, and national income. Applying these models to all but the very smallest of the world's terrestrial PAs suggests that together they receive roughly 8 billion (8 x 109) visits/y-of which more than 80% are in Europe and North America. Linking our region-specific visit estimates to valuation studies indicates that these visits generate approximately US $600 billion/y in direct in-country expenditure and US $250 billion/y in consumer surplus. These figures dwarf current, typically inadequate spending on conserving PAs. Thus, even without considering the many other ecosystem services that PAs provide to people, our findings underscore calls for greatly increased investment in their conservation.

The sinking of the Don Pedro merchant ship in 2007 near the island of Ibiza is a good example of the extreme sensitivity of the tourism sector to oil spills. Despite the limited scale of the spill (only some 20 tonnes), its minimal ecological impact, and the rapid deployment of personnel and equipment to contain it, the accident nonetheless caused significant economic damage to the island's tourism sector. This particular case demonstrates the importance of the beach as a factor of production in the holiday tourism sector, and the capacity of even small amounts of oil to render it unusable and cause heavy losses to holiday firms., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Introduction: This research explored the experience of receiving medical and rehabilitation intervention for rural and remote residents in North Queensland, Australia who had experienced a traumatic hand injury. This study contributes to larger project that seeks to propose a model of service delivery to rural and remote residents who have sustained a traumatic injury., Methods: Utilising an interpretive phenomenological research design, data was gathered through in-depth, semi-structured interviews. Fifteen participants were recruited into this study and questions were designed to explore the experience of receiving medical and rehabilitation intervention following a traumatic hand injury for residents in rural and remote areas of North Queensland., Results: The major themes that emerged were experience of medical intervention, experience of rehabilitation, travel, and technology. Participants felt that medical practitioners had a lack of local knowledge and were concerned that delays in medical intervention resulted in ongoing impairment. They reported following the exercise program they were given, often modifying it to fit with their daily routine. Metropolitan therapists appeared to have limited understanding of issues relevant to rural and remote lifestyles. There was, quite often, no occupational therapist or physiotherapist at their local facility due to staff turnover, and, when available, they had limited experience in hand injuries. The distance and cost of travel to appointments were of significant concern. The use of telehealth or telerehabilitation received a mixed response., Conclusion: Findings highlight the concerns regarding the provision of healthcare to rural and remote residents following a traumatic hand injury. These results provide the basis for recommendations surrounding the development of programs and service delivery models to address diverse needs in rural and remote areas.

In this paper, I describe the experience of 'outsourced' patients who are sent by their governments or insurers through contractual arrangements to a hospital in another country for treatment. I present case studies of nine patients and their accompanying families from the Gulf Cooperation Council (GCC) who were interviewed in a Thai hospital as part of a broader study of medical travel from patients' perspectives. The health systems of the GCC suffer shortages in infrastructure, human resources and management skills, and as a consequence patients with particular needs, especially in neurology, orthopaedics and oncology may be sent overseas for treatment. Patients experience long stays overseas producing a considerable burden to their families supporting them. Such patients complicate notions of medical travel but their status also contrasts markedly from stereotypes held about Gulf patients within Thailand. Despite their appreciation of government sponsoring, for many patients the experience of care in Thailand underscored perceived inadequacies of their home health systems and governments. For some, outsourcing represented a betrayal of the obligations of their states to its citizens.

This is a review of twenty-five years of the James Warden Guest Assistance Program of the Pacific Association of Pediatric Surgeons., (Published by Elsevier Inc.)

Objectives: The objectives of this project were to evaluate patient satisfaction with the clinical video telehealth (CVT) pain management clinic, and to evaluate possible benefits of this clinic., Methods: Data collected included the distance from the patient's home to the main Department of Veterans Affairs (VA) medical center, the distance from the patient's home to the community based outpatient clinic (CBOC), travel distance saved for the patient, and travel pay status. Following CVT clinic appointments patients were asked to complete a written feedback assessment to evaluate patient satisfaction. All data were analyzed using descriptive statistics., Results: Veterans saved 8,981 miles in travel distance, and the VA saved $2,317.51 due to averted travel reimbursement. There was a 90% satisfaction rate with the CVT pain management clinic services, and 90% of patients agreed that they would recommend telehealth to other veterans., Conclusions: Overall, patients are satisfied with the CVT pain management clinic. Furthermore, the substantial miles saved for the patients, as well as the cost savings for the VA, indicates that this service has tangible benefits. As this clinic continues to operate, it can be expected that miles saved for patients and cost savings for the VA will continue to grow.

The objective of the study is to examine the long-run and causal relationship between climate change (i.e., greenhouse gas emissions, hydrofluorocarbons, per fluorocarbons, and sulfur hexafluoride), air pollution (i.e., methane emissions, nitrous oxide emissions, and carbon dioxide emissions), and tourism development indicators (i.e., international tourism receipts, international tourism expenditures, natural resource depletion, and net forest depletion) in the World's largest regions. The aggregate data is used for robust analysis in the South Asia, the Middle East and North Africa, sub-Saharan Africa, and East Asia and the Pacific regions, over a period of 1975-2012. The results show that climatic factors and air pollution have a negative impact on tourism indicators in the form of deforestation and natural resource depletion. The impact is evident, as we have seen the systematic eroding of tourism industry, due to severe changes in climate and increasing strain of air pollution. There are several channels of cause-effect relationship between the climatic factors, air pollution, and tourism indicators in the World's region. The study confirms the unidirectional, bidirectional, and causality independent relationship between climatic factors, air pollution, and tourism indicators in the World. It is conclusive that tourism industry is facing all time bigger challenges of reduce investment, less resources, and minor importance from the government agencies because of the two broad challenges, i.e., climate change and air pollution, putting them in a dismal state.

Ecotourism development is closely associated with the sustainability of protected natural areas. When facilitated by appropriate management, ecotourism can contribute to conservation and development, as well as the well-being of local communities. As such, ecotourism has been proposed and practiced in different forms in many places, including China. This study assesses ecotourism development at Xingkai Lake National Nature Reserve in Heilongjiang Province, China. Key informant interviews were conducted with representatives from the provincial Forestry Department, the Nature Reserve, and the local community. Observation was undertaken on three site visits and secondary data were collected. The potential for providing quality natural experiences is high and tourism development is occurring rapidly. However, current relationships between people, resources, and tourism have yet to provide mutual benefits necessary for successful ecotourism. The multi-stakeholder management style and the ambiguity of landownership within the nature reserve constitute structural difficulties for ecotourism management and operation. Although participation in ecotourism could provide a livelihood opportunity and interests in involvement in tourism have been identified among the local fishing community, current involvement is limited mainly due to the lack of mechanisms for participation. Therefore, it is recommended that management programs and government policies should be established to provide a platform for community participation in ecotourism. Then, a positive synergistic relationship between tourism, environment, and community could be developed. Planning and policy requirements are discussed for ecotourism development in protected areas in China.

Background: Determining the costs of healthcare delivery is a key step for providing efficient nutrition-based care. This analysis tabulates the costs of delivering home parenteral nutrition (HPN) interventions and clinical assessments through encrypted mobile technologies to increase patients' access to healthcare providers, reduce their travel expenses, and allow early detection of infection and other complications., Methods: A traditional cost-accounting method was used to tabulate all expenses related to mobile distance HPN clinic appointments, including (1) personnel time of multidisciplinary healthcare professionals, (2) supply of HPN intervention materials, and (3) equipment, connection, and delivery expenses., Results: A total of 20 mobile distance clinic appointments were conducted for an average of 56 minutes each with 45 patients who required HPN infusion care. The initial setup costs included mobile tablet devices, 4G data plans, and personnel's time as well as intervention materials. The initial costs were on average $916.64 per patient, while the follow-up clinic appointments required $361.63 a month, with these costs continuing to decline as the equipment was used by multiple patients more frequently over time. Patients reported high levels of satisfaction with cost savings in travel expenses and rated the quality of care comparable to traditional in-person examinations., Conclusion: This study provides important aspects of the initial cost tabulation for visual assessment for HPN appointments. These findings will be used to generate a decision algorithm for scheduling mobile distance clinic appointments intermittent with in-person visits to determine how to lower costs of nutrition assessments. To maximize the cost benefits, clinical trials must continue to collect clinical outcomes., (© 2014 American Society for Parenteral and Enteral Nutrition.)

Background: How pediatricians manage bronchiolitis and the derived total costs (direct and indirect) in the emergency department (ED) have not been fully characterized. The aim of the present study is to calculate those costs in a European country., Methods: A prospective and observational study, including 10 EDs of tertiary hospitals throughout Spain and during the bronchiolitis season 2010-2011, was performed. Every ED recruited children on random days of the week (3 days per week; always including one non-working day per every week). Recruitment aimed at a total sample size of 600 children. Direct (diagnostic procedures, time spent in the ED and medication) and indirect costs (work hours lost by parents, babysitting, travels, and meals) were collected. Comparisons between bronchiolitis caused by respiratory syncytial virus (RSV) and non-RSV bronchiolitis, as well as costs across severity categories were performed with the Kruskal-Wallis test. A multiple regression model was built to assess the influence of several of the studied factors on the total costs, including a RSV positive test and episode severity as independent variables; and gender, age, attending nursery school, preterm birth, low birth weight, smoker mother during pregnancy, and current smoker father as covariates., Results: From the 664 recruited children, direct mean costs were €213.2 ± 91.8 and indirect ones were €35.9 ± 55.3; the total costs being €249.2 ± 122.9. Costs were significantly higher in children positive to RSV and rose with increased severity. Those associations were maintained in the multiple regression analysis., Conclusions: Although relatively low at the individual level (€249.2, mean total cost) the costs for just the ED expenses of bronchiolitis in Spain would add up to about €20 million per year., (© 2013 Wiley Periodicals, Inc.)

Background: The healthcare sector is a significant contributor to global carbon emissions, in part due to extensive travelling by patients and health workers., Objectives: To evaluate the potential of telemedicine services based on videoconferencing technology to reduce travelling and thus carbon emissions in the healthcare sector., Methods: A life cycle inventory was performed to evaluate the carbon reduction potential of telemedicine activities beyond a reduction in travel related emissions. The study included two rehabilitation units at Umeå University Hospital in Sweden. Carbon emissions generated during telemedicine appointments were compared with care-as-usual scenarios. Upper and lower bound emissions scenarios were created based on different teleconferencing solutions and thresholds for when telemedicine becomes favorable were estimated. Sensitivity analyses were performed to pinpoint the most important contributors to emissions for different set-ups and use cases., Results: Replacing physical visits with telemedicine appointments resulted in a significant 40-70 times decrease in carbon emissions. Factors such as meeting duration, bandwidth and use rates influence emissions to various extents. According to the lower bound scenario, telemedicine becomes a greener choice at a distance of a few kilometers when the alternative is transport by car., Conclusions: Telemedicine is a potent carbon reduction strategy in the health sector. But to contribute significantly to climate change mitigation, a paradigm shift might be required where telemedicine is regarded as an essential component of ordinary health care activities and not only considered to be a service to the few who lack access to care due to geography, isolation or other constraints.

Contingent valuation method (CVM) is the most widespread method to assess resources and value of environmental goods and services. The guidance technology of willingness to pay (WTP) is an important means of CVM. Therefore, the study on the WTP guidance technology is an important approach to improve the reliability and validity of CVM. This article conducted comprehensive evaluation on non-use value of eco-tourism water resources in Sanjiang Plain by using payment card, single-bound dichotomous choice and double-bound dichotomous choice. Results showed that the socio-economic attributes were consistent with the willingness to pay in the three formats, and the tender value, age, educational level, annual income and the concern level had significant effect on the willingness to pay, while gender and job did not have significant influence. The WTP value was 112.46 yuan per capita with the payment card, 136.15 with the single-bound dichotomous choice, and 168.74 with the double-bound dichotomous choice. Comprehensive consideration of the nature of the investigation, investigation costs and statistical techniques, the result of double-bound dichotomous choice (47.86 x 10(8) yuan · a(-1)) was best in accordance with the reality, and could be used as non-use value of eco-tourism water resources in Sanjiang Plain. The format of questionnaire was very important to improve its validity, and made a great influence on the WTP.

Purpose: To measure nonreimbursable, nonmedical costs incurred by patients attending a vitreoretinal clinic appointment., Methods: A nurse-administered questionnaire designed to capture the nonmedical costs for a single clinical appointment was administered to patients attending an appointment at a single-center, single-physician, university-based vitreoretinal clinic. First day postoperative visits were excluded. End points were time commitment, time missing work, and median total nonmedical costs incurred. A subgroup analysis of Medicare patients who lived locally was performed., Results: Three hundred and six patients completed the survey. The median nonreimbursable, nonmedical cost incurred was $23.32; the mean cost was $236.53 (range, $0-$7,259). The largest component of cost was transportation costs ($13.43). The patient took at least a day off from work in 27% cases. An accompanying person attended in 58%, and 27% took at least 1 day off from work to do so. The Medicare cohort who lived locally had similar median costs ($21.53); the mean cost was $51.29 (range, $0-$1,255.80). This cohort also had a lower incidence of missing work (6%), and a higher incidence of an accompanying person (68%) who had a lower incidence of missing work (16%). The costs and distributions varied minimally by visit type., Conclusion: Physicians and policymakers may not recognize or consider the potential impediment to care that nonreimbursable costs may present when developing treatment strategies and designing policies.

Humanitarian cleft surgery has long been provided by teams from resource-rich countries traveling for short-term missions to resource-poor countries. After identifying an area of durable unmet need through surgical missions, Operation Smile constructed a permanent center for cleft care in Northeast India. The Operation Smile Guwahati Comprehensive Cleft Care Center (GCCCC) uses a high-volume subspecialized institution to provide safe, quality, comprehensive, and cost-effective cleft care to a highly vulnerable patient population in Assam, India. The purpose of this study was to profile the expenses of several cleft missions carried out in Assam and to compare these to the expenditures of the permanent comprehensive cleft care center. We reviewed financial data from 4 Operation Smile missions in Assam between December 2009 and February 2011 and from the GCCCC for the 2012-2013 fiscal year. Expenses from the 2 models were categorized and compared. In the studied period, 33% of the mission expenses were spent locally compared to 94% of those of the center. The largest expenses in the mission model were air travel (48.8%) and hotel expenses (21.6%) for the team, whereas salaries (46.3%) and infrastructure costs (19.8%) made up the largest fractions of expenses in the center model. The evolution from mission-based care to a specialty hospital model in Guwahati incorporated a transition from vertical inputs to investments in infrastructure and human capital to create a sustainable local care delivery system.

Objective: To estimate the cost-effectiveness of a supported employment (SE) intervention that had been previously found effective in veterans with spinal cord injuries (SCIs)., Design: Cost-effectiveness analysis, using cost and quality-of-life data gathered in a trial of SE for veterans with SCI., Setting: SCI centers in the Veterans Health Administration., Participants: Subjects (N=157) who completed a study of SE in 6 SCI centers. Subjects were randomly assigned to the intervention of SE (n=81) or treatment as usual (n=76)., Intervention: A vocational rehabilitation program of SE for veterans with SCI., Main Outcome Measures: Costs and quality-adjusted life years, which were estimated from the Veterans Rand 36-Item Health Survey, extrapolated to Veterans Rand 6 Dimension utilities., Results: Average cost for the SE intervention was $1821. In 1 year of follow-up, estimated total costs, including health care utilization and travel expenses, and average quality-adjusted life years were not significantly different between groups, suggesting the Spinal Cord Injury Vocational Integration Program intervention was not cost-effective compared with usual care., Conclusions: An intensive program of SE for veterans with SCI, which is more effective in achieving competitive employment, is not cost-effective after 1 year of follow-up. Longer follow-up and a larger study sample will be necessary to determine whether SE yields benefits and is cost-effective in the long run for a population with SCI., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Patient flows across the regions of the Italian National Health Service can shed light on patient mobility, including cross-border flows within the European Union. We used 2009 data on 11,531 NHS admissions for aortic valve replacement operations to measure the extent of inter-regional patient mobility and to determine whether resident and non-resident patients differ. We also investigated whether public and private hospitals behave differently in terms of attracting patients. For this major cardio-surgical intervention, patient mobility in Italy is substantial (13.6% of total admissions). Such mobility mainly involves patients moving from southern to northern regions, which often requires several hundred kilometers of travel and a transfer of financial resources from poorer to richer regions. Patients admitted in the regions where they reside are older than those admitted outside their regions (69.2 versus 65.6, p<0.0001), and stay in hospital approximately 0.7 days longer (14.7 versus 14.0, p=0.017). Compared to public hospitals, private hospitals are more likely to admit non-resident patients (OR between 2.1 and 4.4). The extent and direction of patients' mobility raise equity concerns, as receiving care in locations that are distant from home requires substantial financial and relational resources., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Objective: To estimate the costs incurred by patients during the intensive and continuation phases of the current 6-month tuberculosis (TB) regimen in Bangladesh and Tanzania, and thus identify potential benefits to patients of a shorter, 4-month treatment regimen., Design: The validated Stop TB patient cost questionnaire was adapted and used in interviews with 190 patients in the continuation phase of treatment with current regimens., Results: In both countries, overall patient costs were lower during 2 months of the continuation phase (US$74 in Tanzania and US$56 in Bangladesh) than during the 2 months of the intensive phase of treatment (US$150 and US$111, respectively). However, continuation phase patient costs still represented 89% and 77% of the 2-month average national income in the respective countries. Direct travel costs in some settings were kept low by local delivery system features such as community treatment observation. Lost productivity and costs for supplementary foods remained significant., Conclusions: Although it is not a straightforward exercise to determine the exact magnitude of likely savings, a shorter regimen would reduce out-of-pocket expenses incurred by patients in the most recent 2 months of the continuation phase and allow an earlier return to productive activities.

Background: Childhood cancer represents a relevant economic burden on families. The preferred tool to investigate family expenditure is the retrospective questionnaire, which is subject to recall errors and selection bias. Therefore, in the present study the economic burden of caregiving on families of children and adolescents (0-19 years of age) with cancer was analysed using administrative data as an alternative to retrospective questionnaires., Procedure: Incident cases of cancer diagnosed in children and adolescents in 2000-2005 (N = 917) were identified from the Piedmont Childhood Cancer Registry and linked to available administrative databases to identify episodes of care during the 3 years after diagnosis (N = 13,433). The opportunity cost of informal caregiving was estimated as the value of the time spent by one of the parents, and was assumed to be equal to the number of days during which the child received inpatient care, day-care or outpatient radiotherapy. Factors affecting the level of economic burden of caregiving on families were analysed in a multivariable model., Results: The economic burden of caregiving increased when care was supplied at the Regional Referral Centre, or when treatment complexity was high. Families with younger children had a higher level of economic burden of caregiving. Leukaemia required a higher family commitment than any other cancer considered., Conclusions: Estimates of the economic burden of caregiving on families of children and adolescents with cancer derived from administrative data should be considered a minimum burden. The estimated effect of the covariates is informative for healthcare decision-makers in planning support programmes., (© 2013 Wiley Periodicals, Inc.)

Noroviruses are recognized as the leading cause of human acute viral gastroenteritis worldwide. The rate of outbreaks on cruise ships has grown significantly in recent years. Given the potentially harmful consequences of outbreaks for passengers and crewmembers and the subsequently high costs for cruise companies, disease outbreaks on cruise ships represent a serious public health issue. The aim of our study was to systematically review published studies related to Norovirus outbreaks on commercial cruise ships. We searched the PubMed and Scopus scientific databases. We included eligible studies published from January 1990 to July 2013 that were written in English and described infectious episodes involving at least two passengers and/or crewmembers on a commercial cruise ship. As a result, 15 studies and seven reviews met the inclusion criteria, describing a total of 127 outbreaks. The majority of the cases were reported in Europe and the USA, affecting <1 to 74% of the embarked passengers. In the majority of the studies, stool samples and/or serum specimens from ill passengers were collected and tested for laboratory confirmation. Twelve studies reported that an ad-hoc questionnaire was administered. Fifteen studies investigated the possible source of infection which was contaminated food in the majority of cases. Our findings suggest a strong need for the monitoring and implementation of preventive measures in semi-closed communities, such as cruise ships. It would be advisable to strengthen all relevant initiatives in order to improve the detection of, response to and control of Norovirus outbreaks on cruise ships.

Objective: The aim of this study was to calculate the economic losses during an outbreak of Simulium (Wilhelmia) spp. in the Cappadocia Region of Turkey., Methods: The economic costs associated with a 2006-2007 outbreak of Simulium (Wilhelmia) spp. in the Cappadocia region of Turkey were calculated by summing losses to the livestock (dairy) industry and tourism (hotels), plus ongoing control expenditures., Results: More than 2.000.000 domestic and foreign tourists, 60.000 animals, and the local population were disturbed by the flies. Tourism was the most affected sector from the Simulium outbreak., Conclusion: The calculated cost of the outbreak according to 2013 prices was 10.626.966 TL (US$ 5.45 million).