To maximise the potential for reducing the risk of adverse pregnancy outcomes, preconception counselling (PCC) is used to inform couples contemplating pregnancy about general and personal risk factors. Many initiatives have been developed to provide PCC, but none offers it routinely in a presumed low-risk population.The objective of the study was to investigate the extent to which women contemplating pregnancy can be reached when a PCC programme is routinely offered by general practitioners (GPs).30 GPs actively offered PCC to all women aged 18 to 40 over a three-year period. GPs reviewed lists of these women and excluded women with adverse social circumstances. The remaining women received an invitation for PCC. They were requested to indicate whether they were interested in PCC, and if so, when they were contemplating pregnancy. Those both interested and contemplating pregnancy within one year were invited for PCC. All pregnancies occurring within one year of an invitation were monitored. Response rates and percentages of pregnancies preceded by an invitation or actual attendance to PCC were calculated.Overall, 72–75% of the interested responders, who returned the risk-assessment questionnaire (80%), actually attended PCC. However, the GPs excluded a large number of women. In 2002 27% of all pregnancies occurred in the group of women who had been interested and had indicated that they hoped to get pregnant within one year. Another 33% of the pregnancies occurred in the group of women who had been excluded, 13% in the group who had not responded, and 14% in the group who had not been interested.A quarter of the women who became pregnant in the year after the invitation were reached in time. In order to increase this number, methods should be developed to decrease the exclusion of women by the GPs and to increase women's response. To optimise maternal health before pregnancy and to make maximum use of the potential for reducing the risk of an adverse outcome, women should be offered information on risk factors – and thus take preventive measures as early as possible, preferably before pregnancy [At least 20% of the clinically recognised pregnancies in the Western world have an adverse outcome, such as miscarriage, stillbirth, preterm birth, low birth weight or a congenital abnormality. ,2. The rregnancy -10.Different ways of offering preconception counselling (PCC) have been introduced to reduce adverse pregnancy outcomes. Moos et al. have described the integration of PCC within a regional primary care family planning clinic in the United States ; in ChinIn the Netherlands, PCC has been offered to women known to be at a higher risk of an adverse pregnancy outcome . PCC hasThe Netherlands provides an ideal setting for investigating the implementation of a PCC programme routinely offered by GPs: nearly all inhabitants are registered at a general practice, and a high percentage of pregnancies are planned (~80%) . For thiTo identify possible risk factors with regard to a future pregnancy, a questionnaire was sent to women who were interested in PCC and had indicated contemplating pregnancy within one year. When the questionnaire had been returned, the general practitioner invited the women and their partners for PCC. On the basis of the information provided by the questionnaire, the couples were given information on general and personal risk factors for adverse pregnancy outcome.This new method of providing routine, systematic preconception counselling was introduced by 30 general practitioners in the western Netherlands. This article presents the results of this implementation, and quantifies the extent to which the programme was able to reach women contemplating pregnancy.The study "Parents to Be" was conducted as a randomised controlled trial in the Netherlands in order to investigate whether PCC would reduce adverse pregnancy outcomes. Sixty-seven general practitioners participated, mainly in the province of Zuid Holland (in the western Netherlands). All the GPs used the same electronic patient record . The general practitioners were matched on the basis of the characteristics both of the general practitioner and of the practice and they consented to randomisation. Mostly pairs were formed, but sometimes clusters were larger due to the location of the general practice. Within each cluster general practices were randomised to either the intervention or control group. After randomisation, the intervention group consisted of 30 GPs and the control group of 37. The difference in number of GPs was due to a larger extent of GP's working part-time in the control group.The mean total population size of the general practices in the intervention group was 2,662, ranging from 1,234 to 4,300 patients. The mean number of patients in our target group – women aged 18 to 40 – was 515, ranging from 268 to 1,145. The large differences in population size lay mainly in the fact that the majority of the general practitioners worked in health centres (with 33% working in a single-doctor practice), and that not every GP worked fulltime. The percentage of ethnic minorities among patients in the attending practices varied from 1 to 35%.The following procedure for PCC was implemented at the general practices in the intervention group.(i) In each practice, all women aged 18–40 years were selected, as most pregnancies occur in this age group in the Netherlands. GPs reviewed the selected women and excluded them for the following reasons: completed family, uterus extirpation, sterilisation, insufficient knowledge of the Dutch language, sub-fertility or infertility, pregnancy, definitive social circumstances , temporary social circumstances (such as a recent divorce), and "other" .(ii) Each woman included received a letter from her GP, informing her of the possibility of PCC, and inviting her to attend PCC with her partner. Each woman was asked to indicate if she was interested in receiving PCC, and, if so, at which point in time she was contemplating pregnancy.(iii a) Women who had indicated they were interested in advice and wished to become pregnant within a year were sent a risk-assessment questionnaire they could return to their GP. This contained questions on lifestyle, medical history, medicine use and hereditary diseases. Part of the questionnaire had to be completed by the partner (future father). After completion, the questionnaire had to be returned to the GP in a postage-paid envelope.(iii b) Women who were not interested in the advice were asked to state their reasons. The answers were categorised as follows: no partner, no desire to have children (yet/any longer), already pregnant, information perceived to be sufficient, and other.(iv) Together with their partner, women who had returned the questionnaire on their medical history were invited for preconception counselling by their GP. In summary, counselling comprised information on the general risk factors as well as information about preventive measures that are relevant to anyone contemplating pregnancy . Furthermore, information on personal risk factors relevant to the woman and her partner  was provided.This procedure was followed three times . In the first year, the GPs reviewed all women between 18 and 40 years old. In the second year, the procedure was limited to new female patients aged 18 to 40, women who had turned 18 since the first year, non-responders from the first year, and responders who had shown an interest in the first year but had stated that they would be contemplating pregnancy between one and five years in the future.second time, non-responders from the second year, responders who had shown an interest in the second year but had stated that they would be contemplating pregnancy in between one and five years; interested responders from the first year who had not specified a specific period in which they desired to get pregnant; and women who had been excluded in the first and second years for temporary social circumstances, assuming these circumstances might have changed in the mean time.In the third year, the GPs reviewed the new female patients aged 18 to 40, women who had turned 18 years since the In the first year (2000), the questionnaires were sent out in two-month batches. In the other two years, they were sent by the GPs' receptionists immediately after the answer-form had been returned.In the first year the appointment for PCC was made by the doctors' receptionists within six weeks of their receiving the completed questionnaires; in the other years the women who received the questionnaire were requested to schedule the appointment for PCC themselves. These changes were made so as to avoid situations in which women became pregnant before they received the questionnaire or PCC, as had happened with some women during the first year in which PCC was offered.As the response to and interest in new healthcare projects such as PCC always seems to follow an S-shaped curve – the response and interest being limited at first, but increasing rapidly until it levelled off – the results of the third year of PCC (2002) probably give the best impression of the way that the response and interest will evolve if PCC were implemented .The general practices in the control group provided standard care.The Medical Ethics Committee at Leiden University Medical Center approved this study.As well as ensuring the cumulative registration of women aged 18 to 40, we monitored all pregnancies occurring in this age group in which the first day of the last menstruation had fallen between 1 April 2000 and 1 April 2003. Data were collected on age of mother, duration of pregnancy, pregnancy outcome, place of birth, method of delivery, birth weight, gender, Apgar scores and congenital malformations.Other characteristics were obtained from two questionnaires, the risk-assessment questionnaire referred to above, and a questionnaire assessing knowledge of pregnancy-related risk factors and preventive measures, that was sent to women in the intervention group prior to the first invitation for PCC .The response rate was assessed for each year. Below we focus mainly on the last year that PCC was offered, as this best represents the situation that would pertain after implementation.Frequencies were calculated for demographic variables, reasons for exclusion and reasons for not being interested. Because one of the major issues was to assess the impact of the offer of PCC on women contemplating pregnancy, we also identified all the women who became pregnant within a year of each invitation. It was established whether they had received an invitation for PCC, and, if so, what their response to it had been.Table Due to repeated invitations to non-responders, 19% of the original non-responders responded of which 38% were interested in participating in the study in the following year. This response is included in the 56% overall response to the invitation.During the first year, it became apparent that many women had already become pregnant, either before receiving the risk-assessment questionnaire, or before the actual appointment for PCC. In the first year in which the GPs offered PCC, 72% of the women who returned the questionnaire actually attended PCC. When the time between sending the questionnaire and scheduling the appointment for PCC was reduced, this percentage increased to 76% in 2002 Table .The majority of the women who were interested in PCC were aged between 20 and 34. There were fewer women with a basic education [The aim of inviting women to attend PCC is to reach women before they become pregnant. We investigated all pregnancies that occurred within a year of the invitation Table . In 2002Many pregnancies that occurred within one year concerned women who had been excluded from PCC. Table In the last year, GPs who had routinely offered a PCC programme over three years excluded 45% of the women aged 18 to 40. Of the women who were approached, 56% responded to the invitation, 54% of them by indicating that they would be interested in PCC when contemplating pregnancy. In the same year, 20% of the pregnancies that occurred within one year of an invitation had been preceded by PCC. Participation by the population originally eligible increased after multiple invitations.In each of the three years, a large proportion of the women aged between 18 and 40 were excluded by the GP. Within 12 months, a considerable proportion of these women had become pregnant. It thus appears that something in the relationship between GPs and their patients may interfere with a GP's ability to assess which women aged between 18 and 40 should be invited for PCC. GPs could be trained, given strict instructions or given limited reasons for exclusion to prevent this large-scale exclusion. If the invitation for PCC were sent by another authority, such as a local health authority, exclusion would also be more limited. In this way, more women would receive an invitation for PCC, thereby increasing the response and the number of women who received PCC on time. The lower number of excluded women might also have beneficial effects in the long run, as a greater number of women who did not yet desire to get pregnant when they received the invitation to attend PCC would nonetheless become aware of the possibility of PCC.The way we offered PCC can be compared with other screening programmes offered by the GP, for instance cervical and mammal cancer screening programmes. The response to these programmes was initially rather low. In the following years the response to these programmes has increased and levelled off after several years . A similMany women who became pregnant within a year of an invitation did not fall into the group of women who had indicated that they were contemplating pregnancy within one year. About 27% of them had not responded to the offer at all, and had been sent a second invitation in the year after the initial non-response. Of the non-responders who did respond to this second invitation, 19% were interested in PCC.In addition, 10% of the pregnancies occurring within one year after an invitation occurred in the group of women who had wished to get pregnant between one and five years in the future. This shows that wishes or intentions regarding pregnancy can change quickly. Repeated invitations at short intervals might help to increase the response. Scheduling appointments for PCC for women who are contemplating becoming pregnant in one to five years may also lead to an increase in the number of PCC sessions that are given before women become pregnant.The Parents to Be study was initially started as a randomised controlled trial. The general practices providing standard care were situated largely in the same cities as the intervention practices. To prevent women of the control group becoming aware of the possibility of PCC, large-scale media attention such as advertising in local newspapers was not possible – which may have limited the response to and interest in the PCC programme.In the third year that PCC was offered, 27% of all women actually contemplating pregnancy had received an invitation for PCC before they became pregnant. This is in accordance with similar studies in the area of health-care projects. In a Dutch study in which couples were offered carrier screening for cystic fibrosis, it was shown that about 20% of the couples were actually contemplated pregnancy . When peThe results of our study indicate four main ways in which one might increase the interest in and subsequent attendance to PCC of women who wish to get pregnant. First of all, GPs should become more aware that many women contemplating pregnancy might not be reached if too many of them are excluded. Therefore a method should be developed to minimize exclusion by the GP or bypass the GP by sending the invitation by another health authority. Secondly, because it was difficult for women to estimate when they wished to become pregnant, invitations for PCC should not be limited to those indicating that they intended to become pregnant within a year. Thirdly, as a large proportion of pregnancies occurred in the group of non-responders a year after an invitation had been sent, the reasons for non-response should be explored. Finally, familiarity with PCC should be raised through education at school and increased focus in the mass media. As 80% of the pregnancies in the Netherlands are planned, it must surely be possible to improve the response. Simultaneous efforts in these areas may contribute to the successful implementation of PCC in the Netherlands.A quarter of the women who became pregnant in the year after the invitation were reached in time. In order to increase this number methods should be developed to decrease the exclusion of women by the GPs and to increase women's response.The author(s) declare that they have no competing interests.LCJ and SPV were involved in the study design.JE, LCJ enrolled participants and monitored data collection with KMP.JE, KMP, and SC were involved in analysing and interpreting the data.JE and KMP wrote the draft manuscript.KMP, WJJA and SPV supervised the project.All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Cancer Prevention for Alabama's Underserved Populations: A Focused Approach. The project's objectives are to provide the ADPH's cancer prevention programs with a more accurate and cost-effective means of planning, implementing, and evaluating its prevention activities in an outcomes-oriented and population-appropriate manner.The Alabama Department of Public Health (ADPH) is collaborating with the National Cancer Institute to develop detailed profiles of underserved Alabama communities most at risk for cancer. These profiles will be combined with geocoded data to create a pilot project, The project links geocoded data from the Alabama Statewide Cancer Registry with profiles generated by the National Cancer Institute's cancer profiling system, Consumer Health Profiles. These profiles have been successfully applied to market-focused cancer prevention messages across the United States.The ADPH and the National Cancer Institute will evaluate the efficacy of using geocoded data and lifestyle segmentation information in strategy development and program implementation. Alabama is the first state in the nation not only to link geocoded cancer registry data with lifestyle segmentation data but also to use the National Cancer Institute's profiles and methodology in combination with actual state data. The Alabama Department of Public Health (ADPH) estimates that in 2005, more than 24,000 people in Alabama will be diagnosed with cancer, and approximately 10,000 people will die of the disease . The socThe ADPH is working to reduce health disparities by implementing several comprehensive programs offering outreach, education, and cancer screenings to low-income and uninsured populations. Since 1996, the ADPH has provided free breast and cervical cancer screenings to more than 18,000 low-income women ,8.Healthy People 2010's two overarching goals  at all levels"  the development of profiles of poor and underserved Alabama communities most at risk for various types of cancer; 2) the development of the most effective and cost-efficient ways to reach those communities with prevention messages; 3) the ability to plan, implement, and evaluate cancer prevention activities using valid and reliable data at different geographic levels; and 4) assessment of the value and validity of profiles based on cancer incidence compared with profiles developed from self-reported national health behavior surveys.Gaining access to integrated commercial planning and marketing software was not a quick or an inexpensive process. More than a year was spent working with various programs within the ADPH to discuss the value and usefulness of such an investment. Concerns such as costs, compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), ease of use, and training were addressed. Ultimately, three programs decided to underwrite the cost of the software contract for the first year; during the first year, three additional programs signed on. This arrangement allowed all participating programs to bear a smaller burden of the cost and made the information more widely available. We found that diffusing the cost of the contract across multiple program areas eliminated the cost barrier for most programs that wanted to participate. We selected a specific vendor for two primary reasons. First, the vendor had several national public health clients, including the Centers for Disease Control and Prevention (CDC), the Centers for Medicare & Medicaid Services (CMS), the ACS, the National Cancer Institute (NCI), and the National Heart, Lung, and Blood Institute (NHLBI). Both the CDC and the NCI had been sharing this type of data with the ADPH programs for several years, and we saw value in having unlimited, direct access to the data source.Second, this commercial vendor was the only one to link data from the BRFSS, the U.S. census, and several other national health surveys with its proprietary health care use survey  and with lifestyle segmentation clusters. The cluster methodology organizes the U.S. population into 66 segments based on several dozen demographic, geographic, and lifestyle variables as well as consumer-purchase records and media-preference data.One of the programs to sign on during the first year was the Alabama Statewide Cancer Registry (ASCR). After using the data for several months, the ADPH began the process of geocoding its state cancer registry data in May 2004 with the intention of linking the geocoded cancer data to the various health behavior and socioeconomic databases included in the software, including the lifestyle segmentation clusters. Cluster data are linked to a variety of other data within the software, including market research data. These data provide detailed information about each cluster's media preferences , Internet access, and other types of consumer information . We believed that linking consumer market research, socioeconomic, and health behavior data with 7 years of Alabama state cancer data would offer an unprecedented understanding of who was becoming ill and how best to reach them. The vendor brought to our attention that one of its clients, the NCI, had developed a series of cluster-based Consumer Health Profiles (CHPs) to help focus cancer prevention outreach to underserved populations. CHPs are designed to profile audiences most in need of cancer education and outreach by potential cancer site  based on health behavior and lifestyle information. CHPs incorporate geodemographic, health status, and health care use data to allow the demographic, access-to-care, and behavioral components of prevention and treatment to be better understood. Moreover, CHPs provide lifestyle segmentation data that can be used to design focused outreach to communities based on lifestyle variables such as media preferences, consumer behavior, and the manner in which consumers choose to access information. The NCI's profiles have been successfully applied nationally to market-focused cancer prevention and screening messages and have been used extensively at the local and regional levels through the NCI's Cancer Information Service (CIS). For the past 7 years, the CIS Partnership Program staff has used CHPs data to identify underserved and minority populations and to plan and evaluate successful cancer education programs for these groups across the country.Through the vendor, the ADPH and the NCI decided to collaborate on the project to share expertise and data. We learned that the NCI's profiles were based on self-reported survey data and national data sets. Our data would be specific to the geographic area where implementation would occur and would be based on cancer incidence rates rather than self-reported screening and behavioral data. The NCI and the ADPH each identified individuals within their organizations to work on the project. Within the ADPH, representatives from the Social Marketing Branch and the ASCR participated. From the NCI, representatives from various groups within the Office of Communications participated. A series of conference calls between project partners over the summer of 2004 resulted in a preliminary program plan and a Memorandum of Understanding that would allow for the free sharing of data between the organizations while preserving confidentiality. We have identified the following seven steps to completion of the project:Geocode 7 years (1996–2002) of data from the ASCR and develop a custom software application to allow for various types of data analysis. (This step was completed in November 2004.)Assess the geocoded cancer data to discern trends in incidence and to link incidence data to information on socioeconomic status, access to care, screening behavior, and media or outreach preferences. The analysis will focus on several cancer sites: breast, cervix, colorectal, prostate, lung, and all cancer sites combined. (This step is currently underway.)Link Alabama's findings with the NCI's CHPs for further examination, validation, and strategy development.Collaboratively develop CHPs specific to Alabama for various cancer sites for underserved populations. This project phase will include recommendations on how best to reach profiled communities based on their media or outreach preferences and health behaviors.Select profiles in most urgent need of prevention messages, and conduct additional planning and baseline data collection around the communities where the intervention will be focused.Implement a focused cancer prevention outreach, education, or media campaign.Evaluate and report on the efficacy of the campaign.We are currently in the process of analyzing the geocoded cancer incidence data and linking the data to information on socioeconomic status, access to care, screening behavior, and media or outreach preferences. Although we are still in the early stages of the project, we have identified several important findings. First, there is a need for ongoing process evaluation. Fortunately, monthly conference calls with all the project partners have served as an excellent way to share suggestions, changes, and ideas on how to improve the project. The commercial vendor has become a partner through this process. This increased involvement has been especially helpful partly because unanticipated alterations to the software application were needed. Because the project has no direct funding and is underwritten by participating programs at the ADPH, the vendor's time, support, and good will have been invaluable.Second, cancer staging data should be included along with incidence data to ascertain cancer burden. To simplify the process, we did not include staging data in our initial upload of the cancer registry information to the vendor for geocoding. However, such data would have increased opportunities for analysis. For example, by linking this data set with mortality data, we could calculate 5-year survival rates and identify populations with the highest cancer burdens.Third, there are strengths and weaknesses in using a cluster-based model. Clusters are useful because so much information is already associated with them. However, such clusters are based on national statistics. For example, Alabama's general population is 26% African American, compared with 12.3% of the general U.S. population . TherefoFourth, we need to identify additional uses for data outside of the scope of this project. We are currently working to identify cancer prevention projects in Alabama's Black Belt region that 1) focus on the cancer sites we are assessing, 2) have had interventions occur during 1999 or 2000, and 3) are still in progress. That timeline will allow us to provide these programs with at least 2 years of preintervention and postintervention data to assist them in evaluating their efforts. We hope that this information will assist them with managing their programs and increasing their competitiveness in securing funds.Providing ongoing projects with this information would be useful for us because it would give us additional experience in applying our methodology and would allow us to examine outcomes data months ahead of what we had anticipated. It would also give us the opportunity to further disseminate this information, thus making the best possible use of our investment in the software and furthering the mission of public health by providing support to grassroots cancer prevention efforts.Fifth and finally, there is a need to conduct literature searches on cancer incidence, cancer sites, socioeconomic status, geocoding in public health data systems, and a variety of other issues related to the project. We have found that it was useful to place both the process and the preliminary findings in a broader context. This has also yielded the opportunity to speak with public health professionals across the country engaged in similar research who have offered valuable advice and feedback.The findings of this project are preliminary, and no outcome data are yet available. We hope to have such evaluative information in the next 12 to 18 months. By describing the project and the reasons for its inception, we hope to articulate some of the issues facing public health communications and cancer prevention programs and to outline one of the solutions the ADPH Bureau of Health Promotion and Chronic Disease has adopted to address them. While our solution may not be appropriate for our counterparts in state government across the country, we believe there is value in documenting our experience thus far and hope that it may provide some ideas on how to address the challenging environment in which we all function.


Emerging from civil distress carries with it major challenges to reforming a health system. One such challenge is to ensure an adequate supply of competent human resources. The objective of this study was to assess the supply of physicians in Lebanon in 1998, with an assessment of their practice patterns and capacity building.Lists of members of physician's associations were examined to determine the number of physicians in Lebanon and their geographical distribution. A self-administered survey targeted 388 physicians (5%) randomly stratified by the five regions of Lebanon. Some 377 providers reported information on their demographic profile, practice patterns and development. Further, information on continuing education activities was acquired.In Lebanon, the overall physician-to-population ratio was 248 per 100, 000, characterized by an evident maldistribution at the intracountry regional level. Physicians worked 38 hours per week examining on average 21 patients per day, with an average time of 30 minutes spent per visit. They also reported spending 11% of their time waiting for patients. Respondents reported a very wide range of income, with 90% earning less than USD 2,000 per month. Moreover, the continuing education profile revealed a total of 43.7 hours per year, similar to that required for board certification in many developed countries. Conference attendance was the dominant continuing education activity (95% of respondents) and consumed most of the time allotted for continuing education, reported at 32 hours per year.Various economic indicators point to an oversupply of physicians in Lebanon and a poor allocation of their time for capacity building. Therefore, it is crucial for decision-makers to closely monitor the increasing supply of providers and institute appropriate intervention strategies, taking into consideration appropriate provision of good-quality services and ensuring that continuing education activities are well established, organized and monitored. Human resources in the health care services field continue to play a crucial role in shaping the delivery of health care across the globe. Policies to discipline their practice, shape their jurisdictions and decide their reimbursement schemes have never been simple and have always been faced with various political and economic barriers.Lebanon is a small country situated on the south-eastern side of the Mediterranean Sea with close to 4 million residents. The country has recently emerged from 17 years of civil disturbance 1975–1992) that has left any surveillance statistics in the country struggling with a large margin of error. One such example is the reported physician-to-population ratio. In 1998, one source claimed that there was one physician for every 770 inhabitants  [ that hasIn addition to an imprecise assessment of physician numbers, one economic observation and another geopolitical fact complicate our understanding of the dynamics of physicians practice. From an economic perspective, the supply of physicians has increased significantly after the end of the civil disturbance for three main reasons: physicians returning to practise in their home country; new medical schools opening in the country; and Lebanese students targeting eastern European universities to attain their medical degree . Reports show an annual increase of 500 to 700 physicians . On the 2) and the closeness of regions to each other and to Beirut, the capital, allow much cross-practice between regions. But physicians are unequally distributed between two orders  that oversee their practice, although all physicians must pass the same government licensure test. The two orders have slightly different rules for membership and benefits. The two orders advise physicians to seek continuing medical education, but do not require them to do so to maintain the licence to practise medicine. One caters for the physicians of North Lebanon, while the other four regions are under the jurisdiction of the second order (Lebanon order of physicians).From a geopolitical angle, Lebanon is divided into five regions (muhafazat) with observed differences in their urban/rural mix of areas. The small geographical area of the country . To our knowledge, no special policies were developed to target physicians' licensure, practice and reimbursement.The cost attributable to human resources is complicated by the product of two components: expenditures attributable to the providers, and the number of such providers. Therefore, any reform related to supply would definitely have its impact on the magnitude of health care expenditures ,4. From All physicians who had passed the colloquium test up till the year 1998 and were registered with one of the two orders were included in the universe for our analysis. The list for this study was acquired from the physicians' two orders and included information about the specialty and subspecialty (where applicable) of the physician, practice address and home and work phone numbers. The database was checked to ensure no duplicates in memberships. To calculate the physician-to-population ratio in 1998, we used the World Health Organization estimate of Lebanon's population: 3.2 million. This figure represents the best available estimate of the population size, as no national population census has been conducted since 1932.The sample for this study (n = 388) represented 5% of the general population of registered physicians, randomly selected and stratified by the five major regions (muhafazat) of the country Table . After aThe self-administered questionnaire was designed to include questions on demographic characteristics, educational background, specialty, job characteristics and activities, and practice setting. In addition, the physicians were asked about their workload: work hours, number of work sites, and proportion of time spent in clinical, managerial, educational and scientific activities, including literature appraisal and research, and time spent for their private life away from their professional practice. Moreover, a subsection was devoted to inquiring about continuing education (CE) activities. Continuing education included activities such as conferences, university CE, non-university CE, meetings of scientific societies, reading scientific journals and audiovisual sessions.To ensure clarity and comprehensiveness, the questionnaire was face-validated within a group of health services researchers and it was pilot-tested with a sample of residents from the school of medicine at the American University of Beirut. As there is no official classification of the distribution as to rural or urban areas, a panel of experts was asked to classify the site of practice by districts (qazas) into urban or rural. The index was used to investigate if urbanization has an effect on practice style in a small country where areas are in close proximity.Data were entered and analysed using SPSS 11.5 software. Frequency distributions were first explored, and afterwards chi-square and student t-tests were used to test associations between variables.This study validated that the supply of physicians according to the orders' lists was 7726 physicians registered with the two professional associations for the year 1998, thus yielding an average of 248 physicians per 100, 000 population. Furthermore, the density of practitioners ranged from as high as 625 physicians per 100, 000 population in Beirut, the capital, to as low as 141 physicians per 100 000 population in the Bekaa – generally classified as a rural region (muhafaza) , with an average age of 42.5 years and an average of 13 years of experience. Slightly above 75% of the respondents were between 30 and 49 years of age.2 = 4.71, P-value = 0.029). In addition, most of the female physicians in our sample were general practitioners . Though of all the 44% who were general practitioners , it was observed that a great proportion (57%) was practising in rural areas , followed by Lebanese medical schools (29.6%), while only 2.6% graduated from medical schools in the United States and Canada  and 27% from privately insured patients, while the Ministry of Public Health contributed 4.8% to the physician's source of income Table . For thoClose to 90% of the physicians had sought CE activities during the year prior to the study. Most of the respondents reported that attending conferences was the main CE activity , while reading scientific journals  was of lesser importance. Moreover, the respondents spent an average time of 43.7 hours/year on CE. Of those, 32 hours/year were spent in attending conferences, while 3.15 hours/year were spent on reading scientific journals Table . FurtherHuman resources play a crucial role in the development and the successful implementation of a health services delivery system. Of importance is their dynamics as a labour force in the provision of health services, their education and continuing education in order to provide good-quality services, and the appropriate use of their services. In spite of its limitations, this descriptive study provides an assessment of physicians' practice patterns and continuing education activities on a national scale.Currently the ratio of physicians to population in Lebanon is one of the highest in the Eastern Mediterranean region. A ratio of 248 physicians per 100,000 population is rather close to figures reported in the United States and OECD countries Table . A numbeA change in government regulations or a change in market conditions could lead to a surplus in human resources . StabiliThis suspected surplus is further complicated by an uneven geographical distribution of practitioners. The physician-per-population ratio greatly varied between regions (muhafazat). Beirut, its suburbs and the Mount Lebanon region (the region closest to Beirut) drained the bulk of physicians.One indication of surplus is when physicians are making a below-normal "rate of return" . In refeFurthermore, in the early 1990s, Kronfol et al. indicated that after the war ended, there was an influx of medical graduates from the eastern European countries, resulting in a change in the ratio of graduates from different parts of the world, and warned that these would greatly affect the quality of care in Lebanon . It is cIt was postulated that graduates of schools in the Americas and western Europe would be more concentrated in the urban areas and graduates from schools in less-developed and developing countries would locate in less urbanized and rural areas. Contrary to expectations, these graduates were almost evenly distributed between urban and rural areas. The very few differences in practice patterns between rural and urban areas may be explained by the absence of any geographical barriers that would induce major differences in the practice patterns of physicians. The country's small geographical area and the relative ease of transportation make it possible for physicians to maintain strong contacts with leading medical institutions in the country and be able to refer their patients to these institutions, no matter how remotely they are located.In this study, we found significant differences in the choice of specialty and practice patterns between men and women. Women in Lebanon still tend to avoid specialties that are technically and physically demanding in nature and culturally unfavourable. Most of the female physicians in this sample were GPs and very few (only two) were surgeons. This finding is in accordance with the trends reported in the many European countries .In terms of practice patterns, female physicians were similar to their male counterparts with regard to most of the indicators we examined. Their involvement with their private life might force them to restrict their appointment schedule to certain hours of the day, thus spending less time waiting for patients. Further research in this area will enhance our understanding of the role and effectiveness of women in medical practice in Lebanon and the Middle East, given the very few studies in this area.Continuing medical education forms an integrated activity in a health professional's career and for that it should be well-structured and well-organized. In this study, the total number of hours for which the physicians sought CE per year is comparable to that in the USA and other developed countries. In other countries in the world where CE is not a requirement, studies showed that physicians pursued CE as a signalling strategy to attract patients . As suchThe study findings raise concerns about medical CE activities in Lebanon. One concern is that this might support the earlier notion of oversupply of providers, where a proportion of them have plenty of time to spend on conferences, given their economic distress. The other concern is that conference activities are not monitored, which nurtures doubt about the quality of information disseminated in these conferences. For example, it is well known that the pharmaceutical industry has been very active worldwide in marketing its products to physicians and using CE activities (mostly conferences) as one of its marketing tools . No one One cannot but notice that other avenues to continuing education were poorly used. In an age where medicine is rapidly advancing, it is essential that physicians, and other human resources for health, keep abreast of the growing health literature in order to provide the best care. Medical curricula have been emphasizing evidence-based medicine as a process of lifelong, self-directed learning in which caring for patients creates the need for clinically important information about diagnosis, prognosis and therapy . To suppIn conclusion, human resources for health are the key to proper functioning of any health care system, depending on their adequacy and suitability . They heGiven the abundance of physicians in Lebanon, this study calls for reform. Limiting the number of physicians entering the market is a key control factor and can be achieved through many regulations, the most important of which is requiring a higher passing grade for the colloquium exam. Another strategy is to limit the number of students admitted to the Lebanese medical schools, thus restricting entry to the physicians' market. Providing incentives for individuals to seek and practise other health professions (e.g. nursing) may be another key factor in resolving the problem.Policy-makers must pay more attention to other health professionals, their supply and practice patterns. While physicians are key players in shaping the medical system, of equal importance is the availability and practice style of other health professionals, such as nurses. They help deliver care at different levels within health systems . At presCountries recovering from civil distress must be careful in monitoring and evaluating the influx of human resources, as it might lead to new forms of social and economic distress. This will definitely manipulate the supply side of health care delivery, which will affect and be affected by the country's economy. To minimize such distress to the economy as well as to the individual physician, major policies aimed at restructuring the provision of health services and the entry of the professionals into the system should be enacted, or else another migration will emerge, but this time because of a different war – that with the economy and survivorship. Hand-in-hand with the reforming is the issue of licensing and practice standards. The medical profession must critically evaluate its portals of entry and sustained memberships with appropriate quality checks. Continuing education must be obligatory and not just an option.The author(s) declare that they have no competing interests.KMK, HMKG, AMAO and HK have made substantial contributions to conception and design of questionnaire as well as analysis and interpretation of data. KMK, HMKG and AMAO were involved in drafting the manuscript and revising it critically for important intellectual content. All listed authors read and approved the final manuscript.


The sharing of information resources is generally accepted as the key to substantial improvements in productivity and better quality of care. In addition, due to the greater mobility of the population, national and international healthcare networks are increasingly used to facilitate the sharing of healthcare-related information among the various actors of the field. In the context of HYGEIAnet, the regional health telematics network of Crete, an Integrated Electronic Health Record environment has been developed to provide integrated access to online clinical information, accessible throughout the island.To make available comprehensive medical information about a patient by means of incorporating all the distributed and heterogeneous health record segments into an Integrated Electronic Health Record that can be viewed on-line through a unified user interface and visualization environment.The technological approach for implementing this Integrated Electronic Health Record environment is based on the HYGEIAnet Reference Architecture, which provides the necessary framework for the reuse of services, components, and interfaces. Seamless presentation of information is achieved by means of the Extensible Markup Language (XML), while its underlying capabilities allow for dynamic navigation according to personalized end-user preferences and authorities.The Integrated Electronic Health Record environment developed in HYGEIAnet provides the basis for consistent and authenticated access to primary information over the Internet in order to support decision-making. Primary information is always kept at the place where it has been produced, and is maintained by the most appropriate clinical information system, contrasting traditional store and forward techniques, or centralized clinical data repositories.Since documents are much more easily accessible rather than data inside a database, Extensible Markup Language has the potential of becoming a very cheap technology provided, of course, that the underlying Healthcare Information Infrastructure exists. XML can be introduced incrementally and its implementation is completely transparent to the end user. Parts of patients' medical records are located in all the places where they have received clinical services . All of these segments, which are related to personal healthcare delivery and well being, reside in places that are disparate and, in most cases, not directly accessible. Moreover, a number of restrictive policies do not allow personal, sensitive clinical information to be carried outside the corresponding organization's boundaries, while the healthcare providers continue to maintain detailed and confidential notes about their cases. This is true even when healthcare providers use electronic clinical record systems and communication between them is by electronic means. Although the World Wide Web (WWW) provides the means for global access to all kinds of information, personal health information still remains fragmented and not directly accessible in a unified way.Any Integrated Electronic Healthcare Record (I-EHR) environment should be capable of handling these issues and provide uniform ways for accessing authentic, physician-generated, patient record information that is physically located in different clinical information systems. Furthermore, it needs to provide fast and authorized on-line access to longitudinal views of each patient's personal health record, in order to allow for the timely delivery of health care. Such an environment is expected to allow patients to become more actively involved in the monitoring and assessment of their own wellness. At this point, the main reason driving the need for integrated access to clinical information is information sharing. Issues that need to be resolved on the way towards providing integrated solutions are mainly focused around patient identification, interoperability among cooperating software components and the involved clinical information systems, and all the security related medico-legal issues.The technological approach for implementing the I-EHR environment is based on the HYGEIAnet Reference Architecture (HRA), which provides the necessary framework for the reuse of services, components, and interfaces . At the The HRA applications and services model that was used provides a logical paradigm of the relationships between applications, end-user services and the underlying middleware enabling services. At the bottom layer, generic services and tools , the Internet and software component infrastructures  form the technological infrastructure for storing and managing information. Autonomous clinical information systems are the information sources to be integrated. These information sources can be accessed by means of a number of alternative interfaces . On top, the presentation layer provides the end-user with the means for accessing advanced I-EHR services and supporting activities in the various areas of the organization. Visualization can be delivered by means of, for example, the Web or Wireless Access Protocol (WAP) over a number of different possible devices . The heart of the whole I-EHR environment, and core of the underlying Healthcare Information Infrastructure (HII), consists of middleware services that provide the mechanisms for information provision, filtering, and fusion. The currently available execution architecture is based on CORBA interfaces , X.500/ Light Directory Access Protocol ( LDAP) , dedicated Structured Query Language (SQL)/ODBC-LDAP gateways (for accessing primary information and maintaining up-to-date indexing), and the Extensible Markup Language (XML) . Primary information is usually kept on commercial data base management systems, and this is expected to continue in the years to come. A key strength of existing databases is their ability to allow complex queries about clinical information that is kept in single data repositories. On the other hand, the emerging directory technology promises enhanced integrity offering personalized user environments, simplified service and application configurations, security service integration, and improved bandwidth allocation. Key strengths of the emerging directory technology are its distribution provisions and fast lookup based on name. The International Telecommunication Union's (ITU) X.500 and LDAP are the most promising approaches for building global directories . Well-doRecently, the Extensible Markup Language (XML) has gained great attention and is becoming the preferred language for data interchange over the WWW. Its origins are in the Standard Generalized Markup Language (SGML), but in comparison, XML is simpler . It lookThe I-EHR is a front-end to an EHR indexing service, managed by the Patient Clinical Data Directory (PCDD)  which inReferences to recorded data are obtained and used to retrieve actual information by means of the Object Management Group's (OMG) Clinical Observation Access Service (COAS) implementations. COAS seems to be generic and simple, yet powerful, expressing the clinical observations and the relationship between them, composition being the most common. On the other hand, the terms used to describe and identify these observations may come from different coding schemes, and so a terminology service implementation is also necessary. This terminology service is responsible for concept mapping and translation between coding schemes. OMG's Terminology (or Lexicon) Query Service (TQS) is used at this point to provide both conceptual mappings among the different clinical information systems available and the coding schemes they use for recording clinical findings. This is a requirement in order for the existing information to be capable of providing comparable patient data among different institutions.In this context, a generic mapping between observations and attributes of database tables has been deployed. Composite observations have been mapped to database views while atomic observations have been mapped to attributes. The composite observations contain other observations, and this composition in the database is implemented through links and references from one table to another . ObservaAs far as the Graphical User Interface (GUI) for accessing the I-EHR environment is concerned, apart from the lifeline view of all the available encounters of the patient, a number of alternative views are currently supported: a per-clinical system view of the encounter's history, as well as the traditional tabular view of old generation GUIs. When requested, primary information is collected and presented to the end user by initiating remote COAS servers. The COAS data returned need further transformation in order to be properly presented to the user. The underlying data model supported by the Patient Clinical Data Directory (PCDD) is based on the Subjective Objective Assessment Plan (SOAP) model that originates from the primary healthcare domain .In this context, XML has not only been used to describe the COAS observation data in a human readable format but also to be the central point of the transformation process. The composition and recursion concepts that are an integral part of the COAS representation of clinical observations are inherently supported in XML. An XML tag represents each COAS observation. If this is a composite observation, then this tag contains other tags that represent the component observations, and so on, until an atomic observation is reached. An atomic observation is a different tag that can have a "value" attribute or "parsed character data" as its content.The COAS results are represented in XML through a DTD that has been developed .Currently a COAS server and a COAS client have been implemented using the Java Programming Language  with CORHYGEIAnet builds on a regional healthcare information infrastructure to improve the quality and accessibility of health care and to enable the delivery of integrated health care services. It provides the information and services that are the foundation for accountability, continuous improvement to health care, and better understanding of the determinants of the population's health. The design of HYGEIAnet is based on the existing regional healthcare system in Greece. Its goal is to serve local the local population, regardless of whether they are patients, healthcare professionals, researchers, or managers. The I-EHR environment, as it has been developed and set up, provides a decentralized view of the patient's medical record, by dynamically composing information that resides in a variety of heterogeneous clinical information systems. Under a secure Internet/ Intranet environment, the full personal health history can be rapidly collected and composed totally transparently and sent to the authorized health professional (the Internet/ Intranet is not limited in capacity). In addition, maintaining electronic health record information is extremely economical to the very end users and consumers of the system (the citizens themselves), since the cost is transferred to the healthcare practitioners keeping primary information and to telecom operators and ISPs maintaining regional or national networks. The I-EHR, as used in the current context, is "virtual" in that it provides a uniform view of data (metadata) possibly configured to work differently at different locations.Users seek selective information following specific paths, depending on their personal preferences, so it is expected that the I-EHR concept will eventually lead to a uniform applications and services environment. Since electronic records can provide much easier navigational facilities, navigational issues are expected to become even more important in the future, mainly because end-users require interfaces which are similar in look and feel.The lack of a standardized interface for accessing clinical objects has forced the current implementation to follow an open architecture approach that utilizes the best available technologies for accessing clinical multimedia data. It is indeed a fact that information systems use different technologies and terms for accessing the same clinical objects. CORBAmed currently leads the definition of the interoperable specification effort that can support activities related to directly accessing a greater variety of healthcare information. XML provides the appropriate technology and makes up the most convenient vehicle towards a common format for delivering and presenting information content. Elaboration of the standard DTD logical structure and related XML infrastructure will make information personalization flexible and generic enough to adapt to various types of users and client devices. Since documents (accompanied of course by the physician's signature) are much more easily accessible than data inside a database, XML has the potential of becoming a very cheap technology, provided of course, that the underlying HII exists. XML can be introduced incrementally, and its implementation is completely transparent to the end user. One of the main advantages of this approach is the support of context searching capabilities.Currently, major organizations like Health Level Seven (HL7) , the Com


The widespread availability of powerful tools in commercial geographic information system (GIS) software has made address geocoding a widely employed technique in spatial epidemiologic studies.The objective of this study was to determine the effect of the positional error in geocoding on the analysis of exposure to traffic-related air pollution of children at school locations.For a case study of Orange County, Florida, we determined the positional error of geocoding of school locations through comparisons with a parcel database and digital orthophotography. We used four different geocoding techniques for comparison to establish the repeatability of geocoding, and an analysis of proximity to major roads to determine bias and error in environmental exposure assessment.Results indicate that the positional error in geocoding of schools is very substantial: We found that the 95% root mean square error was 196 m using street centerlines, 306 m using TIGER roads, and 210 and 235 m for two commercial geocoding firms. We found bias and error in proximity analysis to major roads to be unacceptably large at distances of < 500 m. Bias and error are introduced by lack of positional accuracy and lack of repeatability of geocoding of school locations.These results suggest that typical geocoding is insufficient for fine-scale analysis of school locations and more accurate alternatives need to be considered. Advances in geographic information systems (GIS), statistical methodology, and availability of high-resolution georeferenced health and environmental data have created unprecedented opportunities for spatial epidemiology to investigate local geographic variation in disease . GIS hasThere are many potential problems with geocoding, which have been well described in the literature . ResearcSeveral studies have determined quantitative estimates of the positional accuracy of geocoding. Estimates of typical positional errors range from 38 to 75 m  based onVehicular traffic–related emissions are a major source of air pollution, especially in urban areas. Proximity to busy roads has been associated with health effects in children, particularly respiratory symptoms and asthma . SeveralChildren were chosen as the subject of our study because they represent the largest portion of the population that is susceptible to environmental health risks, and air pollution in particular . The selMany studies have documented that the concentration of traffic pollution drops off rapidly with increasing distance from the road , 2002b. Studies on the effect of traffic-related air pollution have also considered traffic volume in the determination of environmental exposure conditions; adverse effects are observed for traffic counts starting at about 25,000 vehicles per day  . The widThese errors are potentially additive, presenting a major challenge to fine-scale analysis which relies on small positional error. Of the several types of errors listed above, only the positional error of the major roads has received attention in the literature on the effects of traffic-related air pollution on children . Both thThe main objective of our study was to determine the influence of the quality of geocoding on the analysis of the effect of traffic-related air pollution on children at school locations. Two aspects of geocoding quality are considered: positional accuracy  and repeatability (difference between the results of different geocoding techniques). We selected school locations for this study because they represent the second most important location where children spend their time, after the home residence, and because geocoding has been widely employed in studies that have tried to determine exposure potential to air pollution at school locations e.g., . We seleThe study design relies on a comparison between the results of geocoding and the actual school locations. We obtained addresses for all public schools in Orange County, Florida, for 2005 from the n = 126).We geocoded the schools using a 1:5,000 street centerline network from Orange County for 2005  and the We determined the positional accuracy of the geocoded locations by measuring the straight-line distance between the geocoded location and the actual location of the particular school. This was repeated for each of the four sets of geocoded results. We characterized error distributions using descriptive statistics and cumulative distribution functions.We determined exposure potential to traffic-related air pollution using proximity to high traffic intensity roads. We obtained a detailed 1:24,000 road network for the State of Florida from the Florida Department of Transportation  with aveWe determined bias and error introduced by geocoding by comparing the results of proximity analysis using the actual school locations and the fours sets of geocoding results. Specifically, we determined the number of correctly and incorrectly classified schools using geocoding for the buffer zones described above. This required determining for each buffer zone which schools are actually located within that distance, which schools are correctly classified as being located within that distance using geocoding (confirmed positives), which schools are incorrectly classified as being located outside that distance , which schools are incorrectly classified as being located within that distance , and which schools are correctly classified as being located outside that distance (confirmed negatives). We determined the overall agreement between the results for actual school locations and geocoded locations for each distance using percentage false negatives, percentage false positives, sensitivity, and specificity. We repeated this analysis for each of the four sets of geocoded locations.The distributions are relatively similar for the four techniques considered, but the error is consistently larger for the TIGER results. For example, the 50th percentile is 155 m for street centerlines, 178 m for TIGER roads, 153 m for Firm A, and 151 m for Firm B. At higher percentiles, the curves are a bit further apart, suggesting that street centerline geocoding is the most accurate technique. For example, the 95th percentiles are 227 m for street centerlines, 302 m for TIGER roads, 255 m for Firm A, and 237 m for Firm B. To characterize the overall distribution the 95% root mean square error (RMSE) is a robust statistic for non-normally distributed positional errors; the 95% RMSE is 196 m for street centerlines, 306 m for TIGER roads, 235 m for Firm A, and 210 m for Firm B. These results strongly suggest that the positional error in school locations for all types of geocoding is quite large, and that the error is much higher when using TIGER roads.Although the results in n = 126). The percentage false of positives is consistently higher than the percentage of false negatives, confirming the strong bias toward an overestimation of the number of schools at risk.Although the number of false positives and negatives as a percentage of the total sample is relatively small, at short distances the error in classification is very substantial. For example, three schools are actually located within 100 m of a major road, and street centerline geocoding correctly identifies only one of them. Centerline geocoding identifies four other schools within 100 m, but these are all false positives. This error is more formally expressed in the measure for sensitivity, which is the percentage of schools located within a specific buffer radius that were correctly identified using geocoding. As can be seen in When comparing the results of the four geocoding techniques, the results using TIGER roads are the least reliable, with the highest counts of false positives and the lowest values for sensitivity and specificity. Results from Firm A are the second least reliable, with the second highest counts of false positives and the second lowest values for sensitivity and specificity. Results for street centerlines and commercial Firm A are very similar, and a determination of which method is most reliable varies with the exact distance value and parameter chosen.The results in The positional error in geocoded locations of schools was very high relative to the accuracy requirements for fine-scale proximity analysis; a median error of 155 m for street centerline geocoding, 178 m for TIGER roads, 153 m for Firm A, and 151 m for Firm B, and 95% RMSE values of 196, 306, 235 and 210 m, respectively. These estimates are substantially higher than those found in previous studies , which hThe amount of bias and error introduced by the positional error in geocoding is substantial. As a general rule, spatial data must be much more accurate than the minimum distance used in spatial analysis for the results to be meaningful ; this ruThe first general observation from A related observation from When comparing the four different sets of geocoded locations in One final pattern that emerges from the four scenarios is that most of the error in the classification of schools results from errors in the placement of the geocoded locations along the street segment, not from the error in the distance from the road. This is clearly illustrated in The four scenarios presented in When considering the results for the four sets of geocoded locations, several observations regarding the accuracy and repeatability of geocoding emerge. First, the results from the TIGER 2000 roads were by far the least accurate, and the use of these data for fine-scale spatial analysis should be discouraged despite their widespread availability and low cost. When updated versions of the TIGER data become available for a particular area, they should be checked to determine whether they provide improved accuracy and reliability. Second, the differences between the results from the two commercial geocoding firms suggest a substantial lack of repeatability, which is not reflected in the cost (Firm B was more accurate and cheaper). Commercial geocoding is available for most areas at relatively low cost, but results typically do not include a measure of positional accuracy, and their use for fine-scale analysis needs to be carefully considered. Third, the use of street centerlines produced the most accurate and reliable results (and results for Firm B were very similar), but this type of data may not be available everywhere, and their quality may vary between jurisdictions, limiting usefulness for larger data sets across multiple jurisdictions.One very important limitation of this study is that school locations are somewhat unusual in that they are typically located on large parcels relative to other types of locations (such a private residences). As a result, even a geocoded location very close to or inside the correct parcel may be at a substantial distance from the actual school building(s). The presence of large parcels along a street segment also causes errors in the linear interpolation used in the placement of geocoded locations along the street segment. In addition, many schools in suburban areas are off-set from the street with a private driveway. Combined, these factors result in large positional errors in geocoded locations. These errors are typically larger than for other types of locations. For example, A second limitation is that our study employed only a relatively small sample of schools for a single county. As a result, our findings are limited to similar areas where schools are located primarily in suburban areas on relatively large parcels. Positional errors in geocoding in higher-density urban areas are likely to be smaller, with corresponding lower bias and error in proximity-based analysis of environmental exposure. A related limitation is the fact that the study area is located in the United States and that the geocoding results therefore are typical for the street reference data commonly available in the United States. Results in other jurisdictions may be more reliable if more accurate geocoding techniques are available.Positional errors in geocoding of school locations introduce substantial bias and error in the analysis of the effects of traffic-related air pollution on children. Alternatives to street geocoding need to be considered, including parcel-based geocoding, address point geocoding, the use of ortho-imagery, and field observations using global positioning systems. Digital parcel data in GIS format and high resolution ortho-imagery are becoming more widely available, although coverage might be spotty across a large study area of multiple jurisdictions. The skill level required to use these types of data in GIS is not much higher than that needed for street geocoding, and the data are mostly available for free. However, the effort required to compile and process these detailed data is substantial, and presents a major barrier to more widespread adoption. For very large data sets, including those covering more than a few individual counties, street geocoding is likely to remain a more cost-effective solution.The widespread availability of powerful geocoding tools in commercial GIS software and the interest in spatial analysis at the individual level have made address geocoding a widely employed technique in epidemiologic studies. Although some of the limitations of geocoding have been addressed in recent review articles in public health and epidemiology journals , most stLimitations of this study include the unique nature of school locations, which results in larger errors than are typically encountered for residential locations, and the fact that only a single county in the United States was considered. Despite these limitations, the study provides insights into the nature of the errors that can be expected for other types of locations and jurisdictions.Geocoding is very appealing as a data processing step because it provides a high degree of automation, but the results are not accompanied by reliability estimates for its quality other than match scores. The use of street reference data of high positional accuracy and currency is also no guarantee the positional accuracy of geocoding will be sufficient, and the use of alternatives should be considered when fine-scale analysis is required.


A number of countries worldwide have structured horizon scanning systems which provide timely information on the impact of new health technologies to decision makers in health care. In general, the agencies that are responsible for horizon scanning have limited resources in terms of budget and staff. In contrast, the number of new and emerging health technologies, i.e. pharmaceuticals, medical devices, and medical and surgical procedures, is growing rapidly. This requires the Horizon Scanning Systems (HSSs) to devise efficient procedures for identification of new health technologies. The role of the Internet for this purpose has as yet not been documented.To describe and analyse how the Internet is used by horizon scanning systems to systematically identify new health technologies.A questionnaire was developed and distributed among 10 agencies known to work within this specific area. The questionnaire specifically focussed on type of sites scanned, frequency of scanning, and importance of a site for the identification of a new health technology.A 100% response rate was obtained. Seven out of 10 agencies used the Internet to systematically identify new health technologies, of which 6 provided complete information. A total of 110 web sites were scanned by these 6 agencies. The number of sites scanned per agency ranged from 11 to 27. Most sites were scanned weekly (41%) or monthly (33%). Thirty-one percent (31%) of the total number of sites was considered as highly important. The agencies spent at least 2 hours a week and at most 8 hours per week scanning the Internet. Although each agency's remit differed somewhat in scope, on average the same types of sites were scanned. These include sites from regulatory agencies, sites with information on new drugs or new devices, and sites with news from newswires. However, within these types there was not much correlation between the individual sites that agencies judged important to scan.The use of the Internet for identifying new health technologies is increasing in the majority of horizon scanning systems around the world. At the same time there is considerable variation between individual agencies in their approach to this source of information. This can only be partially explained by differences in scope of scanning activities of the individual agencies. A coordinated effort to develop Internet search strategies for either different categories of health technologies or different clinical specialties may improve efficiency and quality of scanning in terms of the number of potentially relevant technologies identified. Of the three major pressures on health services worldwide, changing demography, growing expectations of the public, and new health care interventions (technologies), the last is generating the most concern among decision makers in health care and also the most dramatic responses .Health technologies are the drugs, devices, and medical and surgical procedures used in health care, and the organisational and supportive systems within which such care is provided . Thus, aIdeally, the introduction of new health technologies is aimed at improving the health of patients, but not all new technologies bring about health improvement or show a reasonable balance between patient benefit and costs . HistoriThese examples illustrate that decision making on the uptake and use of a health technology needs to be supported by high quality information. An important tool for decision makers is health technology assessment (HTA). This is defined as the analysis of the implications of a health technology in terms of its safety, efficiency, effectiveness, accessibility and equity, with the aim of supporting appropriate use of health technologies by providing input to decision-making in policy and practice .Diethylstilbestrol (DES) is a synthetic female hormone first produced in 1938. It has a number of uses. This case focuses on the use of DES for complications of pregnancy. DES was approved for marketing in the United States in 1941. Several uncontrolled studies carried out by the advocates of the drug presented reduced pregnancy accidents. These studies led to its frequent use in pregnancy, and were used by the industry to actively promote the use in complicated pregnancies. During the period 1950-55 there were 7 controlled studies showing DES to be ineffective. Nonetheless, promotion continued, and in the 1960's DES was frequently used over much of the world. In 1970, a rare cancer of the vagina was noted in 7 young women. In all cases, their mothers had taken DES during pregnancy. DES then gradually fell out of use in both America and Europe.DES was a case of a treatment that was both useless and harmful. It is a reminder that technologies should be proven beneficial before they are widely used.HTA was developed in the United States in the `70's and has since gained momentum in Europe and the rest of the world. Besides concerns on the benefits and harms of health technologies, concerns on rising expenditures for health care were an important motivation for development of the field. Increasing health care costs can partly be attributed to the growing numbers of new health technologies. To provide an illustration, during the entire decade of the 1990s, 370 new drugs were brought to market in the U.S., an increase from 239 in the 1980s. The Pharmaceutical Research and Manufacturers of America (PhRMA) states that currently, pharmaceutical and biotechnology companies have well over a thousand new medicines in clinical trials or awaiting approval by the Food and Drug Administration (FDA) [Historically, most health technology assessments focused on technologies that were in relatively widespread use in the health care setting. However, when HTA of established technologies became common practice, the need of more timely assessments was recognized. In the nineties, it was increasingly recognized that being proactive, by identifying technologies before they were licensed or launched and by producing timely assessments of these technologies, would be advantageous. In general, early notice allows decision makers time to consider possible approaches to handling a new technology within a health care system . To ratiThe Netherlands was among the first countries to establish a HSS . NowadayThe majority of these systems are members of The European Information Network on New and Changing Health Technologies, EuroScan , representing agencies in Canada, Denmark, France, Israel, Norway, Spain, Sweden, Switzerland, The Netherlands, and The United Kingdom . All HSSIn general, HSSs are interested in identifying potentially significant technologies for health and health care that might become available on the market in 0 to 5 years time. To identify these technologies, various sources have been recommended including consultation of individual manufacturers and clinicians, written sources such as pharmaceutical and medical journals, and the World Wide Web . A combiOf the different types of sources, the Internet holds the promise of timely and efficient searching. However, although HSSs have begun to use the Internet as a source of information, anecdotal evidence suggests that its use varies and is generally unsystematic. As the efficient identification of new health care technologies is of the utmost importance for HSSs, this paper describes and analyses the current use of the Internet for this purpose by members of EuroScan and other selected horizon scanning agencies.Drawing on a previous survey carried out internally within EuroScan, those horizon scanning agencies who use the Internet in one way or another in the operation of their system were identified. A questionnaire was sent to these agencies (n= 8) in April 2002. In addition, it was sent to two agencies outside the network that identify and assess emerging health technologies.The questionnaire included 10 questions covering the following topics:The scope of the scanning activityThe sources used and strategy employed for identification of new health technologiesThe amount of time available to scanThe first questions addressed what type of technologies the agencies scanned for, and which clinical specialties were priority areas for the scanning activity. Furthermore, agencies were asked which web sites they visited and were asked to appraise the selected sites to establish which sites were the most useful for them. The reason for these questions was to see if the agencies employed a strategy for which sites to scan based on type, importance of the site and the frequency of scanning. Finally, the agencies were consulted on how in general they prioritise web sites, and how much time they had available per week for scanning.All 10 agencies responded (100% response rate). At the time of the survey, three agencies (30%) indicated that they did not use the Internet to systematically identify new health technologies. These are the Health Council in the Netherlands, the Committee for Evaluation and Diffusion of Innovative Technologies (CEDIT) in France, and the Agencia de Evaluacion de Tecnologias Sanitarias (AETS) in Spain. In these agencies the Internet was used as a secondary source that is, to search for information on already identified technologies to enable them to prioritise these. The remaining agencies (n=7) all used the Internet as a primary source of information see . Six of                                         Of the seven agencies that use the Internet as a primary source of information to identify new health technologies, six provided information on the frequency of scanning, the URL of sites scanned, and their relative importance. In total, the agencies scanned 110 different web sites. One agency, University HealthSystem Consortium, provided us with a list of 52 sites scanned, which have been described as part of a chapter in an electronic textbook on resources for Health Technology Assessment. This textbook is located at the web site of the National Library of Medicine .The total number of sites scanned by the 6 agencies that provided us with complete information ranged from 11 to 27. The frequency of scanning is shown in                     Thirty-one percent of the total number of websites is considered highly important for the identification of new health technologies. Forty-three percent of sites were considered important, and 24% less important. Two sites were not evaluated, as there had been limited experience of scanning these sites see .Six agencies provided information on the relative importance of individual web sites in their selection of routinely scanned sites. The web sites that were judged `highly important', `important' and `less important' for the identification of new health technologies are listed in The sites have been categorised into different types, according to their main features and purpose, such as sites containing regulatory information on drugs and devices for the US and Europe, information on specific types of technologies , information on specific specialties, information from newswires, and information on new health technologies identified and/or evaluated by other agencies see .http://www.thepinksheet.com/FDC/Weekly/pink/TOC.htm). The `Gray Sheet' focuses on medical devices, diagnostics and instrumentation (http://www.fdcreports.com/grayout.shtml).Of the sites containing regulatory information, the FDA (United States Food and Drug Administration) web sites are scanned by both European and North American agencies and are rated as highly important. The FDA provides a free e-mail service for news on both newly approved drugs and medical devices, FDA-NewsDigest-L , which users rated as highly important. In addition, the European Agency for the Evaluation of Medicinal Products (EMEA) web site provides information on approved drugs in the European Union, and outlines the evidence base for approval. On a commercial basis, the F-D-C reports' site allows access to the table of contents and brief summaries of information contained in F-D-C publications. Of these, the `Pink Sheet' covers the latest regulatory, legislative and business news affecting the US prescription pharmaceutical industry (http://www.ndapipeline.com/c3/welcome/welcome.plex).One of the agencies, the University HealthSystems Consortium (UHC), further recommends the NDA pipeline compiled by F-D-C reports, a weekly updated database for tracking drug and biological product research, clinical trials and approvals. It is accessible on subscription basis only . The site includes, amongst others, a database of recent drug launches, a patents database, and drug reviews. Furthermore, it provides a free daily e-mail service with news from a number of sources including newslines such as Reuter's health, medical journals, pharmaceutical journals and other health-related web sites. The PharmaLive site was scanned by one agency. It is a web site targeted towards the pharmaceutical industry, providing news items on research, marketing, and regulation of drugs. It is a commercial web site. Access to more detailed pipeline information is on paid subscription basis only. The only web site rated as highly important that Horizontal Scanning Systems agencies identified as providing valuable information about medical devices is Medical Data International. However, this news service has recently introduced subscription fees. Reuters Health's web site is recommended for news on new health technologies in general. This web site is used as a primary source by many other health information web sites as well. Examples of specialty-specific web sites are SurgeryLinx, providing summaries and access to journal articles on new surgical procedures, and Doctor's Guide Haematonews, which lists news items on all types of cancer.                                                            Compared to                                         Reuters Health is scanned by 4 agencies. This site is valued very differently, from highly important by one agency, important by another and less important by a further 2 agencies. In general, Reuters Health is considered a valuable source for news related to health and medicine. The site provides abstracts on news items that enable users to judge the item's value.The EuroScan web site is valued as either highly important or important by the four agencies that scan this site. The site is mostly visited by members of this information network. The site contains a database, only accessible to member agencies, which includes information from members on new health technologies, enabling exchange of information between the members.The responses to this question indicate that new web sites are mostly found through word of mouth (colleagues), or through links from one site to another site. Frequently, new sites are prioritised by an information specialist in an informal way. One agency's response was that sites are trialled for 1-2 months and that after that a recommendation is made to include or exclude the site in the routine scanning activity. In either method of prioritising sites, the same set of criteria is used to prioritise one site above another. The agencies responded that sites that appear to produce more or a similar amount of useful information than sites that are already scanned are likely to be added to the list of sites to scan. Furthermore, sites are most attractive when they are easy to scan, provide an e-mail service, are free of charge, and when they appear to provide objective information.The responding agencies use at least 2 hours, and at most 8 hours per week to scan. Of the agencies, one scans less than 3 hours, 4 scan between 3-6 hours a week, and another up to 8 hours a week. One agency provided a range of 2-8 hours.Although the absolute number of agencies that have been covered by the survey is small, we have reasons to believe that it has covered most, if not all, HSS in the industrialized world. . Firstly, through cooperation with EuroScan it was possible to identify all member agencies that in one way or another use the Internet as part of their horizon scanning system. These agencies were complemented by two other agencies that carry out horizon scanning activities but who were not members of EuroScan. Because of the nature of the horizon scanning activity the vast majority of agencies in our sample is publicly funded, mostly by central governments. Agencies also tend to be relatively small, consisting of 1.5 to 7 full-time equivalents . In addiThe general picture that emerges from the results is that around half of the horizon scanning agencies actively uses the Internet as a source of information for identifying new health technologies. Furthermore, the agencies that have made this step on average spend considerable time on this activity. This is illustrated by the fact that the majority of the agencies scan for 3-6 hours a week, and that around 40% of selected sites are scanned weekly with some being scanned daily.In total, the agencies scan a large number of sites (n=110). However, only 15% of these sites are scanned routinely by more than one agency. The relative lack of overlap in sites scanned can be partly explained by differences in scope of scanning between different agencies . Other factors that contribute to the diversity of sites being scanned and the lack of overlap of scanning activities between agencies include the great number of web sites available on the Internet, and the fact that sites are frequently selected in an unsystematic, informal way. Individual preferences of local information specialists may therefore be of paramount importance for the outcome of the selection process.Similarly, differences between agencies in their rating of individual sites may occur due to the factors listed above. In this regard, the finding that 24% of the sites scanned were judged as less important has been surprising. One may wonder why agencies scan less important sites, when at the same time resources are limited? One explanation could be in what Wagner  defines We feel that this subjective assessment by the agencies, of the relative importance of web sites that they scan, could serve as a starting point for discussion between agencies in order to arrive at common criteria to determine the usefulness and importance of web sites for identifying new and emerging health technologies.Although a large number of sites are scanned (n=110), these can be categorised into a much smaller number of types of sites (n=10) that have a similar purpose. The categorization has been made on the basis of the main feature and purpose of a web site, and is as such not totally mutually exclusive. Of these categories, some are used more and are rated higher than others. Prominent types are `Regulatory information', `Information on new drugs', `Specialty-specific sites', `Newswires', sites of `Other Horizon Scanning or Health Technology Assessment organisations', and possibly `Health Portals'. This might point to their importance to include in a search strategy for identification of new health technologies.We conclude from the survey that there is marked variation between horizon scanning agencies in the way they use the Internet for identifying new health technologies. We have the impression that these differences can only partly be explained by differences between individual agencies in terms of e.g. source of funding, scope of scanning, and so forth. Factors that may be equally or even more important in explaining variation are that identification of technologies using the Internet is a rather new activity, and that so far there has only been limited exchange of information on this subject between agencies. We therefore recommend, given the resources used on scanning, that agencies become more selective in their choice of web sites and perhaps try to define a more transparent, operational distinction between highly important, important, and less important sites for the identification of new health technologies.Horizon scanning agencies may benefit from further investigation into which sites deliver most output. Exchange of information between agencies about valuable sites, and a more formal selection process of new web sites on the basis of selected criteria could result in a more efficient scanning process. A future activity could include a coordinated effort to develop Internet scanning strategies for different categories of health technologies or different clinical specialties. This may improve efficiency and quality of scanning in terms of numbers of potentially relevant technologies identified.In practice, the Internet does not stand alone as a source. Most agencies use a combination of sources, such as information from clinical experts and manufacturers, scientific journals, grey literature, and conference material. It is therefore furthermore recommended that future Internet scanning strategies fit into the broader search strategy of agencies.