Attracting qualified physicians to underserved areas. Part 2. Pay physicians more to practice in underserved areas.

With health networks searching for additional market share and with a projected 30.2 million to be enrolled in Medicaid HMOs by 2000, more health executives will be weighing various strategies of how to attract qualified physicians to practice in poor inner-city and rural areas. Most frequently cited as solutions are supplying more physicians, encouraging more medical school graduates to pursue primary care residencies, and modifying the number of international medical graduates entering U.S. residency programs. Part I of this article, which appeared in the November/December issue of The Physician Executive, reviewed the efficacy of these approaches. The second part explores a more pragmatic option: to simply improve the working conditions and pay substantially more to physicians who practice in "less desirable" locations. Although this idea is consistent with economic principles, drawbacks must be considered, such as: (1) the American taxpayers' reluctance to finance a more costly health care delivery system for the poor; (2) the inherent conceptual difficulties of a capitated Medicaid HMO serving as the linchpin for organizing, financing, and delivering care for the underserved; and, (3) many providers being expected to react in a fairly litigious manner to such an approach.     

Real executives make career moves. Will you?

Not all physician executives have accepted the career move as a key part of executive life. They prefer to stay put and they often do just that. While clinicians may have the luxury of choosing a single geographic location and remaining there through retirement, physician executives often have to reorder their priorities to give the position greatest significance in career decision-making. Spouses and families need to be educated to the new reality of executive life--sometimes, to support an important career opportunity, a move is required. Physician executives unwilling to make career moves limit their career potential.     

A hazard model of the probability of medical school drop-out in the UK

Summary.  From individual level longitudinal data for two entire cohorts of medical students in UK universities, we use multilevel models to analyse the probability that an individual student will drop out of medical school. We find that academic preparedness—both in terms of previous subjects studied and levels of attainment therein—is the major influence on withdrawal by medical students. Additionally, males and more mature students are more likely to withdraw than females or younger students respectively. We find evidence that the factors influencing the decision to transfer course differ from those affecting the decision to drop out for other reasons.     

A note on the adaptive control of false discovery rates

Summary.  The use of a fixed rejection region for multiple hypothesis testing has been shown to outperform standard fixed error rate approaches when applied to control of the false discovery rate. In this work it is demonstrated that, if the original step-up procedure of Benjamini and Hochberg is modified to exercise adaptive control of the false discovery rate, its performance is virtually identical to that of the fixed rejection region approach. In addition, the dependence of both methods on the proportion of true null hypotheses is explored, with a focus on the difficulties that are involved in the estimation of this quantity.     

Interval estimation for log-linear models with one variable subject to non-ignorable non-response

Summary.  Log-linear models for multiway contingency tables where one variable is subject to non-ignorable non-response will often yield boundary solutions, with the probability of non-respondents being classified in some cells of the table estimated as 0. The paper considers the effect of this non-standard behaviour on two methods of interval estimation based on the distribution of the maximum likelihood estimator. The first method relies on the estimator being approximately normally distributed with variance equal to the inverse of the information matrix. It is shown that the information matrix is singular for boundary solutions, but intervals can be calculated after a simple transformation. For the second method, based on the bootstrap, asymptotic results suggest that the coverage properties may be poor for boundary solutions. Both methods are compared with profile likelihood intervals in a simulation study based on data from the British General Election Panel Study. The results of this study indicate that all three methods perform poorly for a parameter of the non-response model, whereas they all perform well for a parameter of the margin model, irrespective of whether or not there is a boundary solution.     

Markov chain Monte Carlo methods for high dimensional inversion in remote sensing

Summary.  We discuss the inversion of the gas profiles (ozone, NO₃, NO₂, aerosols and neutral density) in the upper atmosphere from the spectral occultation measurements. The data are produced by the 'Global ozone monitoring of occultation of stars' instrument on board the Envisat satellite that was launched in March 2002. The instrument measures the attenuation of light spectra at various horizontal paths from about 100 km down to 10–20 km. The new feature is that these data allow the inversion of the gas concentration height profiles. A short introduction is given to the present operational data management procedure with examples of the first real data inversion. Several solution options for a more comprehensive statistical inversion are presented. A direct inversion leads to a non-linear model with hundreds of parameters to be estimated. The problem is solved with an adaptive single-step Markov chain Monte Carlo algorithm. Another approach is to divide the problem into several non-linear smaller dimensional problems, to run parallel adaptive Markov chain Monte Carlo chains for them and to solve the gas profiles in repetitive linear steps. The effect of grid size is discussed, and we present how the prior regularization takes the grid size into account in a way that effectively leads to a grid-independent inversion.     

Reversible jump methods for generalised linear models and generalised linear mixed models

A reversible jump algorithm for Bayesian model determination among generalised linear models, under relatively diffuse prior distributions for the model parameters, is proposed. Orthogonal projections of the current linear predictor are used so that knowledge from the current model parameters is used to make effective proposals. This idea is generalised to moves of a reversible jump algorithm for model determination among generalised linear mixed models. Therefore, this algorithm exploits the full flexibility available in the reversible jump method. The algorithm is demonstrated via two examples and compared to existing methods.     

A revised Brown and Payne model of voting behaviour applied to the 2009 elections in Italy

When elections are close in time, voters may stick to their preferred party or chose a different option for several reasons; reliable estimates of the amount of transitions across the available options can allow to answer a number of relevant questions about electoral behaviour. We describe a modified version of the model due to Brown and Payne (J Am Stat Assoc 81:453–460, 1986) and argue that it is based on simple, yet realistic, assumptions with a direct interpretation in terms of individual behaviour and compares well with other models proposed more recently. We apply the model to an Italian borough where, during June 2009, two elections were held simultaneously and a runoff took place two weeks later. Estimates of the joint distribution of voters between the European Parliament election and the other two elections provide evidence of substantially different kinds of voting behaviour which, given the specific context, we interpret in the light of the recent literature on the subject.     

Spectral estimation for locally stationary time series with missing observations

Time series arising in practice often have an inherently irregular sampling structure or missing values, that can arise for example due to a faulty measuring device or complex time-dependent nature. Spectral decomposition of time series is a traditionally useful tool for data variability analysis. However, existing methods for spectral estimation often assume a regularly-sampled time series, or require modifications to cope with irregular or ‘gappy’ data. Additionally, many techniques also assume that the time series are stationary, which in the majority of cases is demonstrably not appropriate. This article addresses the topic of spectral estimation of a non-stationary time series sampled with missing data. The time series is modelled as a locally stationary wavelet process in the sense introduced by Nason et al. (J. R. Stat. Soc. B 62(2):271–292, 2000) and its realization is assumed to feature missing observations. Our work proposes an estimator (the periodogram) for the process wavelet spectrum, which copes with the missing data whilst relaxing the strong assumption of stationarity. At the centre of our construction are second generation wavelets built by means of the lifting scheme (Sweldens, Wavelet Applications in Signal and Image Processing III, Proc. SPIE, vol. 2569, pp. 68–79, 1995), designed to cope with irregular data. We investigate the theoretical properties of our proposed periodogram, and show that it can be smoothed to produce a bias-corrected spectral estimate by adopting a penalized least squares criterion. We demonstrate our method with real data and simulated examples.