BACKGROUND: Many studies have found considerable variations in the resource intensity of physical therapy episodes. Although they have identified several patient- and provider-related factors, few studies have examined their relative explanatory power. We sought to quantify the contribution of patients and providers to these differences and examine how effective Swiss regulations are (nine-session ceiling per prescription and bonus for first treatments). METHODS: Our sample consisted of 87,866 first physical therapy episodes performed by 3,365 physiotherapists based on referrals by 6,131 physicians. We modeled the number of visits per episode using a multilevel log linear regression with crossed random effects for physiotherapists and physicians and with fixed effects for cantons. The three-level explanatory variables were patient, physiotherapist and physician characteristics. RESULTS: The median number of sessions was nine (interquartile range 6-13). Physical therapy use increased with age, women, higher health care costs, lower deductibles, surgery and specific conditions. Use rose with the share of nine-session episodes among physiotherapists or physicians, but fell with the share of new treatments. Geographical area had no influence. Most of the variance was explained at the patient level, but the available factors explained only 4% thereof. Physiotherapists and physicians explained only 6% and 5% respectively of the variance, although the available factors explained most of this variance. Regulations were the most powerful factors. CONCLUSION: Against the backdrop of abundant physical therapy supply, Swiss financial regulations did not restrict utilization. Given that patient-related factors explained most of the variance, this group should be subject to closer scrutiny. Moreover, further research is needed on the determinants of patient demand.
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Satellite images where provided by Joel Sudre at LEGOS. 5 ELSEVIER SCI LTD OXFORD OCEAN MODEL ; We investigate the influence of bottom topography on the formation and trapping of long upwelling filaments using a 2-layer shallow water model on the f-plane. A wind forced along-shore current, associated with coastal upwelling along a vertical wall, encounters a promontory of finite width and length, perpendicular to the coast. In the lower layer, topographic eddies form, which are shown to drive the formation of a filament on the front. Indeed, as the upwelling current and front develop along the coast, the along shore flow crosses the promontory, re-arranging the potential vorticity structure and generating intense vortical structures: water columns with high potential vorticity initially localized upon the promontory are advected into the deep ocean, forming cyclonic eddies, while water columns from the deep ocean with low potential vorticity climb on the topography forming a trapped anticyclonic circulation. These topographic eddies interact with the upper layer upwelling front and form an elongated, trapped and narrow filament. Sensitivity tests are then carried out and it is shown that: baroclinic instability of the front does not play a major role on the formation of long trapped filaments; increasing the duration of the wind forcing increases the upwelling current and limits the offshore growth of the filament; modifying the promontory characteristics (width, length, height and slopes) has strong impact on the filament evolution, sometimes leading to a multipolarisation of the potential vorticity anomaly structure which results in much more complicated patterns in the upper layer (numerous shorter and less coherent filaments). This shows that only specific promontory shapes can lead to the formation of well defined filaments; adding bottom friction introduces a slight generation of potential vorticity in the bottom layer over the promontory, but does not significantly alter significantly the formation of the filament along the outcropped front in the present configuration; modifying the stratification characteristics, in particular the density jump between the layers, has only a weak influence on the dynamics of topographic eddies and on filament formation; the influence of capes is also modest in our simulations, showing that topography plays the major role in the formation of long and trapped upwelling filaments.
