Large Regional Variations Research Articles

New Archaeozoological Data from the Fayum “Neolithic” with a Critical Assessment of the Evidence for Early Stock Keeping in Egypt

Faunal evidence from the Fayum Neolithic is often cited in the framework of early stock keeping in Egypt. However, the data suffer from a number of problems. In the present paper, large faunal datasets from new excavations at Kom K and Kom W (4850–4250 BC) are presented. They clearly show that, despite the presence of domesticates, fish predominate in the animal bone assemblages. In this sense, there is continuity with the earlier Holocene occupation from the Fayum, starting ca. 7350 BC. Domesticated plants and animals appear first from approximately 5400 BC. The earliest possible evidence for domesticates in Egypt are the very controversial domesticated cattle from the 9th/8th millennium BC in the Nabta Playa-Bir Kiseiba area. The earliest domesticates found elsewhere in Egypt date to the 6th millennium BC. The numbers of bones are generally extremely low at this point in time and only caprines are present. From the 5th millennium BC, the numbers of sites with domesticates dramatically increase, more species are also involved and they are usually represented by significant quantities of bones. The data from the Fayum reflect this two phase development, with very limited evidence for domesticates in the 6th millennium BC and more abundant and clearer indications in the 5th millennium BC. Any modelling of early food production in Egypt suffers from poor amounts of data, bias due to differential preservation and visibility of sites and archaeological remains, and a lack of direct dates for domesticates. In general, however, the evidence for early stock keeping and accompanying archaeological features shows large regional variation and seems to be mainly dependent on local environmental conditions. The large numbers of fish at Kom K and Kom W reflect the proximity of Lake Qarun.

Making Parents Pay: The Unintended Consequences of Charging Parents for Foster Care

Most families in the child protective services system also interact with the child support enforcement system. We exploit a natural experiment in Wisconsin, created by the large regional variation in child support referral policy, to estimate a potentially important effect of child support enforcement on the duration of out-of-home foster care placement. The effect we examine is whether requiring parents to pay support to offset the costs of foster care delays children's reunification with a parent or other permanent placement. We find evidence of this unintended effect, which is important not only because longer foster care spells are expensive for taxpayers, but also because extended placements in foster care may have consequences for child well-being. Our results highlight the potential importance of cross-systems analysis and the potential consequences when the policies and fundamental objectives of public systems are inconsistently coordinated. We discuss the implications of our findings for child support and child protective services policy.

Away with Tobacco? On the Early Understandings of Tobacco as a Problem and the Associated Attempts at Political Regulation of Tobacco in Norway 1900-1930

Background In the early 1900s, the industrialization of cigarette production rapidly created the first major expansion in tobacco consumption in modern times. Aims This article focuses on the “tobacco problem” as it was understood, debated and sought governed in Norway around the time of the First World War. I identify various attempts to define tobacco as a problem, including arguments put forward by the anti-tobacco movement, the medical profession and politicians. How were health, moral-aesthetic and economic conditions articulated and integrated in these arguments? What (if any) addictive elements of smoking were in focus? I also discuss the association between perceptions of the tobacco problem and political attempts to regulate it. There were repeated calls for a state tobacco monopoly to be introduced and municipal licensing system for the sale of cigarettes. Data The data are sourced from the journals Tobakskampen (The Tobacco Fight), the journal of the norwegian medical association and parliamentary documents. Findings The findings suggest that a) to the extent tobacco was perceived as a social problem, it was a moral one (vice), not a behavioural and dependency problem, which alcohol was perceived to be at the time; b) proposals to establish a tobacco monopoly were based on economic arguments only, and lacked any firm connection to social issues, health and morality; and c) the anti-tobacco movement was socially marginal and their commitment to the municipal licensing idea resulted in large regional variations in public support, too large in fact for the idea to be effective. Although the government did not introduce regulations in the 1920s, the industrialization of cigarettes and subsequent developments in advertising caused a “moral panic” among tobacco opponents and created the modern climate of opinion regarding tobacco.

“Flying geese” in China: The textile and apparel industry's pattern of migration

China has large regional variations in both factor endowments and levels of economic development. In principle, some industrial enterprises will relocate to the inland regions from the coastal regions to take advantage of lower wage rates and land prices, provided that the regions are different enough. However, few studies have empirically tested whether this kind of “flying geese” pattern of domestic industrial relocation has occurred on the ground or not. Using data from the textile and apparel industry from 1998 to 2011, this paper shows the existence of the “flying geese” pattern of industrial relocation. Data show that before around 2005, the textile and apparel industry was clustered in the eastern region of China, but it has since shifted toward the central and western regions.

Seroprevalence, Demographic and Blood Donation Characteristics of Blood Donors in the Santa Catarina State, Brazil

There is a paucity of publications on regional variations in seroprevalence of infectious diseases in blood donors within Brazilian states, so that suitable time trends can be derived for major demographic groups. A population study of blood donors in the southern state of Santa Catarina, Brazil, was conducted using all computerized records of the blood donors submitted to serologic screening in 2010. The subjects were predominantly male (57.8%), aged 18-25 years (33.5%), did not direct their donation to any specific recipient (55.6%), nor did they provide another blood donation in last 12 months (58.6%). The highest seroprevalence was observed for the hepatitis B markers (3.0% for anti-HBc and 0.2% for HBsAg), followed by those for syphilis (0, 08% VDRL), HIV-1 (0.06%), hepatitis C (0.05%), HTLV1/2 (0.01%) and Chagas disease (0.01%). The risk factors associated with higher seroprevalence were associated with the first time donation, being male and of older age. Large regional variations were observed, with the Far West region reaching 7% of anti-HBc and 0.5% of HBsAg positive, and the Midwest region showing 0.1% HIV-positive donors. Hepatits B markers of both lifetime and recent infection reached a high level among blood donor candidates in Santa Catarina in 2010 and remain the foremost serological deferral criterion, despite some evidence of the reduced transmission rate compared to the beginning of the decade. The seroprevalence of other sexually transmitted infections (HIV, syphilis) also persisted on a level too high for a blood donor population, implying even higher prevalence in the general population.

The regional variation in climate elasticity and climate contribution to runoff across China

Summary The climate elasticity of runoff is an important indicator that is used to quantify the relationship between changes in runoff and changes in climate variables. It is a function of both climate and catchment characteristics. Recently, Yang and Yang (2011) proposed an analytical derivation of climate elasticity (YY2011), in which a parameter n was used to represent the impact of the catchment characteristics. In China, both climate and catchment characteristics have large spatial variations. To understand the spatial variation of hydrologic response to climate change, this paper divided China into 210 catchments, further calculated the parameter n, and then estimated the climate elasticity and evaluated the contribution of climate change to runoff for each catchment. The results show that n ranges from 0.4 to 3.8 (with a mean of 1.3 and a standard deviation of 0.6), which has a logarithmic relationship with catchment slope; the precipitation elasticity ranges from 1.1 to 4.8 (with a mean of 1.9 and a standard deviation of 0.6), which shows a large regional variation, smaller values (1.1–2.0) mainly appearing in Southern China, the Songhua River basin and the Northwest, and larger values (2.1–4.8) mainly appearing in the Hai River basin, the Liao River basin and the Yellow River basin. In addition, climate contribution to runoff exhibits a large regional variation, the largest positive values (1.1–3.1%/a) occurring in the Northwest, the largest negative values (−1.0 to −0.5%/a) occurring in the Hai River basin and the middle reach of the Yellow River basin. In theory, the YY2011 method is a first-order approximation. The approximation underestimates the precipitation (P) contribution to runoff when P increases and overestimates that when P decreases, and the relative error has a median of ∼3% and a maximum of ∼20% when 10% precipitations change in those catchments of China.

Incidence and trends of acute pancreatitis in Albanian Population

Background: Acute pancreatitis is pathology with large regional variations in incidence and etiology. Aims: The aim of the study was performed to establish the incidence, etiology and severity of acute pancreatitis in the Albanian population. Patients & methods: We have studied all the files of all patients with acute pancreatitis admitted at the UHC ‘Mother Theresa” during a nine year period (2005-2013). Results: We had 964 admissions with the diagnosis acute pancreatitis, giving an incidence of 5.64 per 100 000 inhabitants. Mean age of patients was 54.5 ± 16.926 years old. We had 377 females or 39.1% and 587 males or 60.9%. 780 patients 80.9% had mild to moderate pancreatitis, while 184 patients or 19.1% had severe pancreatitis. Overall mortality was 2.8% (we had 27 deaths out of 964 diagnosed patients). Alcohol consumptionwas found to be the etiological factor in 382 patients (39.6%), gallstone in 362 patients (37.6%), and other etiologies including hipertriglideridemia, autoimmune pancreatitis, trauma and idiopathic causes in 220 patients (22.8%). There was a significant increase of the new cases during the last years, and there was also a significant increase of acute alcoholic pancreatitis in young patients. Conclusion: The incidence of acute pancreatitis was found to be 5.6 per 100 000 inhabitants, which is lower than the incidence of pancreatitis in the region. The alcoholic etiology (39.6%) and the young age of patients tend to be trend of the last years. Pancreatitis was found to be severe in 19.1% of patients, overall mortality was 2.8%.

Early nasogastric tube feeding versus nil-by-mouth in patients with mild and moderate acute pancreatitis: A randomised controlled trial

Background: Acute pancreatitis is pathology with large regional variations in incidence and etiology. Aims: The aim of the study was performed to establish the incidence, etiology and severity of acute pancreatitis in the Albanian population. Patients & methods: We have studied all the files of all patients with acute pancreatitis admitted at the UHC ‘Mother Theresa” during a nine year period (2005-2013). Results: We had 964 admissions with the diagnosis acute pancreatitis, giving an incidence of 5.64 per 100 000 inhabitants. Mean age of patients was 54.5 ± 16.926 years old. We had 377 females or 39.1% and 587 males or 60.9%. 780 patients 80.9% had mild to moderate pancreatitis, while 184 patients or 19.1% had severe pancreatitis. Overall mortality was 2.8% (we had 27 deaths out of 964 diagnosed patients). Alcohol consumptionwas found to be the etiological factor in 382 patients (39.6%), gallstone in 362 patients (37.6%), and other etiologies including hipertriglideridemia, autoimmune pancreatitis, trauma and idiopathic causes in 220 patients (22.8%). There was a significant increase of the new cases during the last years, and there was also a significant increase of acute alcoholic pancreatitis in young patients. Conclusion: The incidence of acute pancreatitis was found to be 5.6 per 100 000 inhabitants, which is lower than the incidence of pancreatitis in the region. The alcoholic etiology (39.6%) and the young age of patients tend to be trend of the last years. Pancreatitis was found to be severe in 19.1% of patients, overall mortality was 2.8%.

Balance in Opioid Prescription during Pregnancy

Balance in Opioid Prescription during Pregnancy

Regional distribution of hepatitis C virus infection in the Republic of Korea, 2007-2011.

Background/AimsIn Korea, hepatitis C is included as an infectious disease in a sentinel surveillance system. Recently, a large variation in hepatitis C incidence between different regions in Korea has been noticed. The current study verified the nationwide distribution of hepatitis C infection for effective prevention and management.MethodsWe counted the number of hepatitis C patients who visited a hospital per county using the National Health Insurance database from 2007 to 2011. The age-adjusted prevalence ratio was used, and the age adjustment method was used as an indirect standardization method. Disease mapping and spatial analysis were conducted using a geographic information system.ResultsThe annual prevalence of diagnosed hepatitis C was approximately 0.12% to 0.13% in Korea. The age-adjusted prevalence ratios in Busan, Jeonnam, and Gyeongnam were high (1.75, 1.4, and 1.3, respectively). The three regions in the southern coastal area of the Korean Peninsula were identified as a high-prevalence cluster (Moran’s index, 0.3636).ConclusionsThe present study showed that hepatitis C infection has very large regional variation, and there are several high-risk areas. Preventive measures focusing on these areas should be applied to block the transmission of hepatitis C and reduce the disease burden.

Incidence and Prevalence of Celiac Disease and Dermatitis Herpetiformis in the UK Over Two Decades: Population-Based Study

OBJECTIVES:Few studies have quantified the incidence and prevalence of celiac disease (CD) and dermatitis herpetiformis (DH) nationally and regionally by time and age groups. Understanding this epidemiology is crucial for hypothesizing about causes and quantifying the burden of disease.METHODS:Patients with CD or DH were identified in the Clinical Practice Research Datalink between 1990 and 2011. Incidence rates and prevalence were calculated by age, sex, year, and region of residence. Incidence rate ratios (IRR) adjusted for age, sex, and region were calculated with Poisson regression.RESULTS:A total of 9,087 incident cases of CD and 809 incident cases of DH were identified. Between 1990 and 2011, the incidence rate of CD increased from 5.2 per 100,000 (95% confidence interval (CI), 3.8–6.8) to 19.1 per 100,000 person-years (95% CI, 17.8–20.5; IRR, 3.6; 95% CI, 2.7–4.8). The incidence of DH decreased over the same time period from 1.8 per 100,000 to 0.8 per 100,000 person-years (average annual IRR, 0.96; 95% CI, 0.94–0.97). The absolute incidence of CD per 100,000 person-years ranged from 22.3 in Northern Ireland to 10 in London. There were large regional variations in prevalence for CD but not DH.CONCLUSIONS:We found a fourfold increase in the incidence of CD in the United Kingdom over 22 years, with large regional variations in prevalence. This contrasted with a 4% annual decrease in the incidence of DH, with minimal regional variations in prevalence. These contrasts could reflect differences in diagnosis between CD (serological diagnosis and case finding) and DH (symptomatic presentation) or the possibility that diagnosing and treating CD prevents the development of DH.

Systematic Review of Antibiotic Resistance Rates Among Gram-Negative Bacteria in Children With Sepsis in Resource-Limited Countries.

Gram-negative antimicrobial resistance (AMR) is of global concern, yet there are few reports from low- and low-middle-income countries, where antimicrobial choices are often limited. This study offers a systematic review of PubMed, Embase, and World Health Organization (WHO) regional databases of Gram-negative bacteremia in children in low- and low-middle-income countries reporting AMR since 2001. Data included 30 studies comprising 71 326 children, of whom 7056 had positive blood cultures, and Gram-negative organisms were isolated in 4710 (66.8%). In neonates, Klebsiella pneumoniae median resistance to ampicillin was 94% and cephalosporins 84% in Asia; 100% and 50% in Africa. Large regional variations in resistance rates to commonly prescribed antibiotics for Salmonella spp. were identified. Multidrug resistance (resistance to ampicillin, chloramphenicol, and cotrimoxazole) was present in 30% (interquartile range [IQR], 0-59.6) in Asia and 75% (IQR, 30-85.4) in Africa. There is a need for an international pediatric antimicrobial resistance surveillance system that collects local epidemiological data to improve the evidence base for the WHO guidance for childhood Gram-negative bacteremia.

Rates of Cardiopulmonary Resuscitation Training in the United States

Prompt bystander cardiopulmonary resuscitation (CPR) improves the likelihood of surviving an out-of-hospital cardiac arrest. Large regional variations in survival after an out-of-hospital cardiac arrest have been noted. To determine whether regional variations in county-level rates of CPR training exist across the United States and the factors associated with low rates in US counties. We used a cross-sectional ecologic study design to analyze county-level rates of CPR training in all US counties from July 1, 2010, through June 30, 2011. We used CPR training data from the American Heart Association, the American Red Cross, and the Health & Safety Institute. Using multivariable logistic regression models, we examined the association of annual rates of adult CPR training of citizens by these 3 organizations (categorized as tertiles) with a county's geographic, population, and health care characteristics. Completion of CPR training. Rate of CPR training measured as CPR course completion cards distributed and CPR training products sold by the American Heart Association, persons trained in CPR by the American Red Cross, and product sales data from the Health & Safety Institute. RESULTS During the study period, 13.1 million persons in 3143 US counties received CPR training. Rates of county training ranged from 0.00% to less than 1.29% (median, 0.51%) in the lower tertile, 1.29% to 4.07% (median, 2.39%) in the middle tertile, and greater than 4.07% or greater (median, 6.81%) in the upper tertile. Counties with rates of CPR training in the lower tertile were more likely to have a higher proportion of rural areas (adjusted odds ratio, 1.12 [95% CI, 1.10-1.15] per 5-percentage point [PP] change), higher proportions of black (1.09 [1.06-1.13] per 5-PP change) and Hispanic (1.06 [1.02-1.11] per 5-PP change) residents, a lower median household income (1.18 [1.04-1.34] per $10 000 decrease), and a higher median age (1.28 [1.04-1.58] per 10-year change). Counties in the South, Midwest, and West were more likely to have rates of CPR training in the lower tertile compared with the Northeast (adjusted odds ratios, 7.78 [95% CI, 3.66-16.53], 5.56 [2.63-11.75], and 5.39 [2.48-11.72], respectively). Annual rates of US CPR training are low and vary widely across communities. Counties located in the South, those with higher proportions of rural areas and of black and Hispanic residents, and those with lower median household incomes have lower rates of CPR training than their counterparts. These data contribute to known geographic disparities in survival of cardiac arrest and offer opportunities for future community interventions.

Nitrous oxide, climate change and agriculture.

Abstract Nitrous oxide is an important greenhouse gas with a global warming potential of 298 times that of carbon dioxide. It is also responsible for the destruction of stratospheric ozone. Concentrations of nitrous oxide have shown continuous growth in the atmosphere over the past century, and nitrogen (N) fertilizers and manures applied to agricultural soils are the main anthropogenic source. Precise measurements of emissions from soils are difficult to undertake, as a consequence of high levels of spatial and temporal variability. For this reason, national reports on emissions are based largely on an assumption that a fixed fraction of N is released from N use in agriculture. Attempts to reduce nitrous oxide emissions, resulting from the use of N fertilizer, conflict with the need to maintain or increase food production and to support a growing world population. There is a large regional variation in the growth of emissions, with Asia contributing to the largest growth rates. More efficient management of N fertilizer and improved soil management (particularly in Asia) offer the opportunity to reduce emissions whilst maintaining food production.

Revisiting Multi-Organ Transplantation in the Setting of Scarcity

In the setting of organ scarcity, the ethics of multi-organ transplantation (MOT) deserve new examination. MOT offers substantial benefits to certain recipients, including avoiding serial surgeries. However, MOT candidates in the United States commonly receive priority for their nonprimary organ over many individuals who need that organ, which may undermine equity. The absence of standard criteria for MOT eligibility also enables large and unfair regional variation in MOT, such as simultaneous liver-kidney transplantation. Unfortunately, MOT may also undermine utility (optimal patient and graft survival) in circumstances where providing multiple organs to one person fails to achieve the greater collective benefit attained by providing transplants to multiple people. Policy reforms should include the adoption of minimal clinical criteria for MOT candidacy with the attendant goal of decreasing regional variation in MOT. In the future, these minimal criteria can be revised to accommodate new research about which patients derive the most benefit from MOT. Incentives to perform MOT should also be reduced, such as by including MOT outcomes in center-specific reports. These reforms run the risk that the transplant community could be perceived as abandoning MOT candidates, but offer an opportunity to align transplant practice and ethical principles.

Bone properties of the humeral head and resistance to screw cutout.

Surgical treatment of fractures involving the proximal humeral head is hampered by complications. Screw cutout is the major pitfall seen in connection with rigid plating. We have exploited a bony explanation for this phenomenon.Materials and Methods:We examined the convex surface of the humeral head looking at the density and the topographical strength of the subchondral bone using mechanical testing of bone cylinders harvested from the humeral head. We also studied the osseous architecture of the subchondral bone and thickness of the boneplate of the humeral head using a 3-dimensional serial sectioning technique.Results:The bone strength and bone density correlated well and revealed large regional variations across the humeral head. Bone strength and stiffness of the trabecular bone came to a maximum in the most medial anterior and central parts of the humeral head, where strong textural anisotropy was also found. We found in particular a lower bone strength and density in the posterior and inferior regions of the humeral head. A rapid decline in bone strength within a few mm below a relatively thin subchondral plate was also reported.Clinical Relevance:We have in this paper explored some of the most important factors connected with screw stability at the cancellous bone level. We discovered large variations in bone density and bone strength across the joint surface rendering certain areas of the humeral head less suitable for screw placement. The use of rigid plate constructs with divergent screw directions will predictably place screws in areas of the humeral head comprising low density and low strength cancellous bone. New concepts of plates and plating techniques for the surgical treatment of complex fractures of the proximal humerus should take bone distribution, strength, and architecture into account.

Regional differences of relative sea level changes in the Northwest Atlantic: Historical trends and future projections

Mean sea level is one of the most important indicators for climate variability and change. Here, we use tide‐gauge data and satellite measurements to examine recent trends in the mean relative sea level (RSL) in the Northwest Atlantic. We then combine model output and satellite observations to provide sea level projections in the 21st century. The mean RSL trend based on historical tide‐gauge data shows large regional variations, from 2 to 4 mm/yr (above the global mean RSL rise rate) in the southeast to −2 mm/yr in the northwest along East Canada. This spatial difference can to a large degree be attributed to that in the vertical land motion measured by the Global Positioning System (GPS). The combination of altimeter‐measured sea level change with the GPS data can approximately account for tide‐gauge measurements at most stations over 1993–2011. When the GPS data are used, the projected mean RSL rise between 1980–1999 and 2090–2099 ranges from 38 to 63 cm along the Scotia‐Fundy and Newfoundland coasts and smaller along Labrador, the northern Gulf of St. Lawrence, and the St. Lawrence Estuary. In spite of considerable uncertainties the ocean steric and dynamical effect is the dominant contributor (35–70 cm) to the RSL rise along the Canadian east coast. The land‐ice (glaciers and ice sheets) melt contributes to the RSL rise by 10–15 cm except at Nain where it is negligible. The effect of the vertical land uplift is large (40–50 cm) at Nain, Sept‐iles and Rimouski, significantly reducing the magnitude of the RSL rise.

A dissection of the surface temperature biases in the Community Earth System Model

Based upon the climate feedback-responses analysis method, a quantitative attribution analysis is conducted for the annual-mean surface temperature biases in the Community Earth System Model version 1 (CESM1). Surface temperature biases are decomposed into partial temperature biases associated with model biases in albedo, water vapor, cloud, sensible/latent heat flux, surface dynamics, and atmospheric dynamics. A globally-averaged cold bias of −1.22 K in CESM1 is largely attributable to albedo bias that accounts for approximately −0.80 K. Over land, albedo bias contributes −1.20 K to the averaged cold bias of −1.45 K. The cold bias over ocean, on the other hand, results from multiple factors including albedo, cloud, oceanic dynamics, and atmospheric dynamics. Bias in the model representation of oceanic dynamics is the primary cause of cold (warm) biases in the Northern (Southern) Hemisphere oceans while surface latent heat flux over oceans always acts to compensate for the overall temperature biases. Albedo bias resulted from the model’s simulation of snow cover and sea ice is the main contributor to temperature biases over high-latitude lands and the Arctic and Antarctic region. Longwave effect of water vapor is responsible for an overall warm (cold) bias in the subtropics (tropics) due to an overestimate (underestimate) of specific humidity in the region. Cloud forcing of temperature biases exhibits large regional variations and the model bias in the simulated ocean mixed layer depth is a key contributor to the partial sea surface temperature biases associated with oceanic dynamics. On a global scale, biases in the model representation of radiative processes account more for surface temperature biases compared to non-radiative, dynamical processes.

Abstract P6-07-05: Regional variation in Medicare expenditures for older women with localized breast cancer

Abstract Objectives: To characterize variation in Medicare expenditures on initial breast cancer care across hospital referral regions (HRRs) and to examine the relative contribution of patient characteristics and treatment factors to such variation. Methods: This was a retrospective cohort study using the 2003-2007 Surveillance, Epidemiology and End Results (SEER)-Medicare linked database and the Medicare 5% random sample of non-cancer beneficiaries. Each woman with localized (stage I-III) breast cancer (“case”) was matched to a woman without cancer (“control”) based on HRR, age, comorbidity and Medicare expenditure in the year prior to cancer diagnosis. We defined initial phase of care as the period from two months prior to breast cancer diagnosis (for cases) or index date (for controls) through 12 months after the diagnosis or index date. For each HRR, we calculated the risk-standardized cancer-related Medicare expenditure as the difference in total expenditure between cases and controls, using hierarchical generalized linear models to control for clustering by HRR and adjust for patient characteristics (age, race, comorbidity, and tumor characteristics) and treatment factors. Treatment factors were first assessed by whether different treatments were used (surgery, radiation therapy, chemotherapy, growth factors, and imaging services), and then assessed by specific treatment modalities (breast conserving surgery, radical mastectomy, intensity modulated radiation therapy, external beam radiation therapy, brachytherapy, traditional chemotherapy, biological therapy, growth factors, and imaging). All estimates were reported in 2009 U.S. dollars. Results: There were 35,055 patients with breast cancer and an equal number of controls in our cohort. After excluding HRRs with fewer than 25 cases, there were 78 HRRs in our final analysis. Unadjusted Medicare expenditure on breast cancer-related care averaged $19,207 per patient. HRRs in the highest quintile had an average expenditure of $23,522 per patient, which was $8,032 higher than HRRs in the lowest quintile (mean expenditure = $15,490). Patient characteristics explained only 18.5% of the difference in total cancer-related expenditure between the highest and lowest-expenditure quintiles. Treatment factors explained more variation across the HRRs. Adjustment for whether different treatments were used (e.g., chemotherapy: yes/no; radiation: yes/no) explained an additional 26.0% of the difference between the highest and lowest-expenditure HRR quintiles. In contrast, adjustment for specific treatment modalities (e.g., specific type of radiation) explained 36.4% of the variation. Variation in expenditures on radiation therapy contributed the most to the difference in total cancer-related expenditure between the highest and lowest-expenditure HRR quintiles. Conclusions: There is large regional variation in Medicare expenditures on initial breast cancer care, even after accounting for patient characteristics. Treatment factors (whether cancer therapies were used at all and the specific modality of therapy used) were important contributors to such regional variation. Future work exploring the relation between cancer treatment intensity, costs, and outcomes is warranted. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-07-05.

What drives patient mobility across Italian regions? Evidence from hospital discharge data.

This chapter examines patient mobility across Italian regions using data on hospital discharges that occurred in 2008. The econometric analysis is based on Origin-Destination (OD) flow data. Since patient mobility is a crucial phenomenon in contexts of hospital competition based on quality and driven by patient choice, as is the case in Italy, it is crucial to understand its determinants. What makes the Italian case more interesting is the decentralization of the National Health Service that yields large regional variation in patient flows in favor of Centre-Northern regions, which typically are 'net exporters' of hospital treatments. We present results from gravity models estimated using count data estimators, for total and specific types of flows (ordinary admissions, surgical DRGs and medical DRGs). We model cross-section dependence by specifically including features other than geographical distance for OD pairs, such as past migration flows and the share of surgical DRGs. Most of the explanatory variables exhibit the expected effect, with distance and GDP per capita at origin showing a negative impact on patient outflows. Past migrations and indicators of performance at destination are effective determinants of patient mobility. Moreover, we find evidence of regional externalities due to spatial proximity effects at both origin and destination.