bluuebunny/crossref_metadata_2025 huggingface dataset:
Atypical antipsychotics and suicide in mood and anxiety disorders
Authors: Sharma Verinder
Published: December 2003

Abstract:  Globally, a million people commit suicide every year, and 10–20 million attempt it. Mood disorders, especially major depressive disorder (MDD) and bipolar disorder, are the most common psychiatric conditions associated with suicide. Primary (psychiatric and physical illness), secondary (psychosocial), and tertiary (demographic) risk factors for suicide have been identified. Comorbid psychiatric illness, particularly anxiety symptoms or disorders, significantly increase the risk of suicidal behavior. Current standard risk assessments and precautions may be of limited value, while assessing the severity of anxiety and agitation may be more effective in identifying patients at risk. Lithium is the medication that has most consistently demonstrated an antisuicidal effect. The effects of antidepressants and conventional antipsychotics on suicide risk are uncertain, but atypical antipsychotics appear promising. Atypical antipsychotics have beneficial effects on depressed mood both in patients with MDD and in patients with bipolar disorder. In addition, data in patients with schizophrenia have demonstrated a significant improvement in the incidence of suicidal behavior with clozapine compared with olanzapine. Electroconvulsive therapy appears to have an acute benefit on suicidality.
Cognitive Behavioural Therapy: A Study of Rural General Practitioners’ Understanding and Expectations
Authors: Pierce David , Pearce Chris
Published: December 2003

Introduction:  Cognitive behavioural therapy (CBT) has been extensively used to manage depression and anxiety. It has been offered to general practitioners (GPs) as a technique suited to primary care.

Methods and results:  Forty‐two GPs, who had participated in workshops on CBT, in rural Victoria, were surveyed about their use, expectations and understanding of CBT. Most of the GPs either occasionally or regularly used CBT. Respondents expressed concern that CBT would lengthen their consultations, while recognising its usefulness in their practice and capacity to enhance doctor–patient communication.

Conclusions:  The GPs in this study, while regarding CBT as an appropriate technique in general practice, expressed both broad outcome expectations from its use and concerns about its time management impact. This study indicates the need for further research on the role of CBT in rural general practice.
Screening for Diabetic Retinopathy in Remote Australia: A Program Description and Evaluation of a Devolved Model
Authors: Mak Donna B. , Plant Aileen J. , McAllister Ian
Published: December 2003

Objectives:  To describe the diabetic retinopathy screening program operating in the Kimberley and evaluate recruitment into and the quality and timeliness of, the screening procedure.

Method:  Review of the documents relating to the Kimberley diabetic retinopathy screening program and analysis of Kimberley diabetic retinopathy screening database.

Results:  The Kimberley Public Health Unit developed and maintains a program of training, credentialing and ongoing professional development for retinal camera practitioners and a Kimberley‐wide database of retinal photographs taken for diabetic retinopathy screening. As a result of this program, diabetic retinopathy screening is available in or close to most diabetics’ home towns/communities and 58% had undergone retinopathy screening in the preceding 2 years. Over 90% of sets of photographs were of excellent or adequate quality. There was a positive relationship between credentialing and photograph quality and timeliness of photographs being sent away for reporting.

Conclusions:  Quality diabetic retinopathy screening, at prevalences comparable to, or higher than, other urban and rural populations, can be achieved in a remote area.

What is already known:  Screening and early treatment of diabetic retinopathy can prevent visual loss associated with diabetes. However, there is little published literature about the operational aspects of diabetic retinopathy screening programs in remote area settings.

What this study adds:  Diabetic retinopathy screening in remote areas can be successfully implemented using non‐mydriatic retinal photography performed by credentialed local health professionals, such as Aboriginal health workers and nurses.
Rural General Practitioner Experience of Work‐Related Violence in Australia
Authors: Tolhurst Helen , Baker Louise , Murray Gillian , Bell Pam , Sutton Amber , Dean Sara
Published: December 2003

Aims:  To identify prevalence, precipitants and risk factors of violence and aggression towards Australian rural general practitioners (GPs).

Method:  Six focus groups were held with GPs from rural Western Australia and from two rural Divisions of General Practice in New South Wales and Victoria. A questionnaire was developed and all GPs in these three geographical areas were surveyed.

Results:  The survey results showed that 73% of respondents had experienced some form of violent or aggressive behaviour from patients and 20% had been subjected to physical abuse during their careers as rural doctors. Physical abuse mostly occurred after hours and in a hospital or multipurpose centre. Violence and aggression were often associated with patient drug and alcohol intoxication and psychological disorders.

Conclusion:  Workplace violence and aggression against rural GPs is a frequent problem. Adequate funding and safe facilities for after‐hours care and training for GPs in managing dangerous situations should be provided.

What Is Already Known:  A number of overseas studies have shown that work‐associated violence is common among GPs and an Australian study has shown that work associated violence is common among remote area nurses.

 No research investigating the prevalence of work‐associated violence among Australian GPs and factors associated with this violence have previously been undertaken.

What this study adds:  The study showed that violence against the Australian rural GPs surveyed was common, with 73% having been abused in some way during their careers as rural doctors. Physical violence most commonly occurred at the hospital or multipurpose centre with most recent incidents of physical abuse occurring after hours and usually associated with a range of psychiatric problems or alcohol abuse in the patients.
Community Perception of Rural Hospital Conversion/Closure: Re‐conceptualising as a Critical Incident
Authors: Petrucka Pammla M. , Wagner P. Susan
Published: December 2003

Background:  In this article, a consideration of the role and meaning of the rural hospital is contextualised within the health reform environment in Saskatchewan (Canada). Individual and community perceptions of the impact of the conversion/closure of a rural hospital are often unheard and more often unheeded. Some researchers suggest hospital conversion/closure is a devastating event in the life of rural communities, yielding long‐lasting medical, economic and psychological consequences.

Method:  This article examines the concept of critical incidents with the intent of proposing a working definition of the concept. Lazarus and Folkman's (1984) construct of appraisal provides the framework for discussion and re‐conceptualisation of critical incidents.

Results and Conclusions:  The recommendation is to consider the adoption of an alternate definition of critical incident shifting away from professional or external delineation of an event's meaning. The proposed definition states that a critical incident is any external event that alters an individual's or community's life from the perspective of that individual or community. Finally, the conversion/closure of a rural hospital is considered within this re‐conceptualised ‘critical incident’ definition.
Tiny nodule in the testicle: Case report of a sertoli cell tumor
Authors: NAGATA MASAYOSHI , KURIMOTO SHIGEHARU , TAKEUCHI TAKUMI , OHTA NOBUTAKA , MINOWADA SHIGERU , KITAMURA TADAICHI
Published: December 2003

Abstract Sex cord‐stromal tumors of the testis are rare. We report on a small Sertoli cell tumor in the testicle. According to published reports, a nodular lesion on the testicle has a variety of differential diagnoses. Preoperatively, it is very difficult to differentiate between a tumorous lesion and an inflammatory change. When a tiny nodule in the testicle is encountered, we propose limited, testicular‐sparing surgery according to the frozen section diagnosis.
Coexistence of renal replacement lipomatosis with xanthogranulomatous pyelonephritis
Authors: SAKATA YUKO , KINOSHITA NOBUTAKA , KATO HIROMI , YAMADA YASUSHI , SUGIMURA YOSHIKI
Published: December 2003

Abstract We report on a case of coexistence of replacement lipomatosis with xanthogranulomatous pyelonephritis (XGP) in the same kidney associated with staghorn calculi. A 63‐year‐old man was admitted to hospital complaining of a right abdominal mass. Computed tomography (CT) showed renal parenchymal atrophy with extremely increased perirenal fat. Right nephrectomy was performed. Postoperative diagnosis was renal replacement lipomatosis with XGP. Renal replacement lipomatosis and XGP have several similarities in terms of clinical background and CT findings. Sometimes it is difficult to differentiate them from malignant diseases. It is extremely rare that both conditions coexist in the same kidney. To our knowledge, only one such case has been reported.
Retroperitoneoscopic heminephroureterectomy for children with duplex anomaly: Initial experience
Authors: KAWAUCHI AKIHIRO , FUJITO AKIRA , NAITO YASUYUKI , SOH JINTETSU , UKIMURA OSAMU , YONEDA KIMIHIKO , MIZUTANI YOICHI , MIKI TSUNEHARU
Published: December 2003

Abstract Objectives:  To evaluate the feasibility of retroperitoneoscopic heminephroureterectomy for children with duplex anomaly.

Methods:  Retroperitoneoscopic heminephroureterectomy was performed in five children (four girls and one boy) with complete duplication of the ureter, of whom four (age range 1–5 years; mean age 3.3 years) had upper pole ectopic megaureters and one (3 years old) had an upper pole megaureter with ureterocele. In the patient with ureterocele, distal ureterectomy and ureterocelectomy were performed by Pfannenstiel incision.

Results:  The mean operation time was 346 min (range 270–450 min) in the four patients with ectopic megaureter and 420 min (330 min for heminephroureterectomy) in the patient with ureterocele. The mean estimated blood loss was 43 mL (range 5–100 mL) in the four patients with ectopic megaureter and 40 mL in the patient with ureterocele. No postoperative complications were observed. Postoperative intravenous pyelography showed normal pyelogram and renal function of the preserved lower pole in all cases.

Conclusions:  Retroperitoneoscopic heminephroureterectomy for children is feasible, safe and has good postoperative results, including cosmetic results. However, the operation time needs to be reduced.
Written Language, Standard Language, Global Language
Authors: Halliday Michael A. K.
Published: December 2003

English, along with a small number of other languages in the modern period, has expanded away from local through national to international domains, changing significantly along the way. But the changes are not simply those that take place in the normal course of the history of a language; other changes come about as a language takes on new cultural, economic and political responsibilities. Critical moments occur when a language comes to be written as well as spoken, and then when it comes to function as a standard language for some sort of nation‐state. In that socio‐historical perspective English is now acquiring a new identity as the global language of the late capitalist world. Some of the consequences of this development are beginning to show; but we have yet to find out what the long‐term effects are that arise when a language finds itself globalized.
Globalization, Literacy and Ideology
Authors: Hasan Ruqaiya
Published: December 2003

Globalization has aroused mixed reactions: some regard it as a blessing while others are convinced that it is simply the old game of domination under a new name. There is an urgent need to understand the nature of the semantic processes that support this contradictory reading. It is important to realize that the resolution of this contradiction does not lie in a simplistic choice between truth and falsehood. Rather what we are witnessing is the deployment of language in a struggle to control the very picture of reality. Whatever the outcome, one thing seems certain: to understand how globalization might affect our lives, we will need a form of literacy that goes beyond simple interpretation to reflection on the social significance of acts of meaning: literacy must enable one to decide whose meanings are voiced in which acts of semiosis and for whose benefit.
Towards A Norm in South African Englishes: The Case for Xhosa English
Authors: Klerk Vivian De
Published: December 2003

Black South African English (BSAE) is generally regarded today as the variety of English commonly used by mother‐tongue speakers of South Africa's indigenous African languages in areas where English is not the language of the majority. Its roots lie in the history of the teaching of English to the black people of this country, where the role models who teach English are second language learners themselves. To date, BSAE has mainly been studied within an applied linguistic framework with emphasis on its character as a second language which is deviant from standard English. An alternative view is to see it as a variety in its own right, a new or world English (Coetsee Van Rooy and Verhoef, 2000; van der Walt and van Rooy, 2002). As a consequence, a new look at norms is becoming increasingly necessary, so that decisions about learners' language competence can be made in terms of this variety. This paper reports on preliminary analyses of a recently collected corpus of Xhosa English (XE) (a sub‐category of BSAE) which consists of naturalistic spoken data, and comprises some 540,000 words of Xhosa English. This large database enables empirical analysis of actual patterns of use in language, making it possible to test earlier speculations which have been based on intuition, and to explore the possibility of systematic differences in the patterns of structure and use in this particular variety. The paper focuses on 20 separate linguistic characteristics, most of which have been previously identified in the literature as being features of BSAE, and analyses each of them in turn, in order to ascertain their usage patterns and frequency of occurrence in the corpus.
The Ownership of English in Japanese Secondary Schools
Authors: Matsuda Aya
Published: December 2003

Sociolinguistic studies of English in various parts of the world suggest the increasing role of so‐called nonnative speakers in defining the forms and functions of the English language. Their role is crucial especially in English as an international language (EIL) contexts, where the interactions do not necessarily involve native speakers of English. This view, however, does not seem to be as widespread among the users of EIL in the expanding circle as it is among scholars. A qualitative case study of Japanese secondary school students suggests that, although they perceive English as an international language in a sense that it is being used internationally, they do not believe it belongs internationally. The author questions the appropriateness of this view vis‐à‐vis the current status and function of EIL and suggests ways to raise awareness of English varieties and better prepare students for the use of English as an international language.
Word Formative Processes in Camfranglais
Authors: Kouega Jean‐Paul
Published: December 2003

This paper discusses word formation processes in Camfranglais, a composite language developed by Cameroon secondary pupils to communicate among themselves to the exclusion of non‐members. To render their language mysterious and reinforce incomprehensibility, they use various techniques of word formation such as borrowing from various languages, coinage, shortening, affixation, inversion, idiomatic formation and reduplication, to name only these few.
Whose Norms? International Proficiency Tests in English
Authors: Davies Alan , Hamp‐Lyons Liz , Kemp Charlotte
Published: December 2003

The paper reports on research into the claim that widely used English language proficiency tests are unfair (unfair in the sense that a test favouring boys could be said to be unfair to girls). The global spread of English opens a major debate on the acceptability of competing norms, whether they should be exonormative or endonormative (Davies, 1999; Gill, 1999). An International English (IE) view insists that the only acceptable norms are those of native English speakers (NES). A strong World Englishes (WES) view maintains that to impose IE on users of WEs may be discriminatory against non‐native English speakers (NNES). The theoretical and practical aspects of the issue come together in institutionalized English language proficiency testing. The paper reports on comparative definitions by expert local judges of the norms used in international (IELTS and TOEFL) and national (Hong Kong, Singapore, Malaysia, India, China) English language proficiency tests and considers in what ways the differing definitions have in practice influenced language test construction. It further reports on the findings so far with regard to three basic questions:

1. How possible is it to distinguish between an error and a token of a new type?

2. If we could establish bias, how much would it really matter?

3. Does an international English test privilege those with a metropolitan anglophone education?
Tradition and Sacred Texts
Authors: Murray Robert
Published: December 2003

Abstract:  Having defined ‘tradition’ and ‘sacred texts’, this article traces the developing Roman Catholic understanding of the relationship of tradition and scripture, looking especially at the formation of the canon and the attitude to inspiration. It places a particular stress on the central place of liturgy in this relationship. It then compares Catholic views with those of the Eastern Orthodox, noting particularly what Syrian exegesis has to teach Western readers, and with those of Protestant and Anglican Christianity. It then addresses the claims of the heirs of tradition, believers, to be interpreters of scripture vis‐à‐vis scientific biblical scholarship, concluding that they have great advantages in sympathy and imagination in entering into dialogue with the texts.
Clinical Features of Migraine: A Cross-Sectional Study in Patients Aged Three to Sixty-Nine
Authors: Wöber-Bingöl Ç , Wöber C , Karwautz A , Auterith A , Serim M , Zebenholzer K , Aydinkoc K , Kienbacher C , Wanner C , Wessely P
Published: December 2003

We investigated 260 consecutive patients classified as migraine cases aged 3-69 at two tertiary headache centres, one for children and adolescents and the other for adults to evaluate the relationship between age and clinical features of migraine cross-sectionally. We only included subjects with definite migraine without or with aura and we excluded subjects with coexisting tension-type headache, medication overuse and/or other clinically relevant disorders. The percentage of males decreased markedly from childhood to adulthood and this affected the evalution of age-related changes in male patients, as only large differences reached the level of statistical significance. In females, the headache duration and the prevalence of unilateral, pulsating pain, photophobia and phonophobia increased, whereas the prevalence of aggravation by physical activity decreased with age. In conclusion, this cross-sectional, clinic-based study on a strictly defined sample of 260 consecutive patients with definite migraine covering a wide range of age from the very young to the old suggests marked age-related differences of the clinical features of migraine in females and failed to demonstrate similar differences in males due to the small number of adult male migraineurs.
Suppression of Pain and the R2 Component of the Blink Reflex During Optokinetic Stimulation
Authors: Drummond PD
Published: December 2003

The effect of exposure to a rotating optokinetic drum on the electrically evoked blink reflex was investigated in 20 healthy volunteers. Pain ratings and the area under the curve of the R2 component of the blink reflex to innocuous and nociceptive trigeminal stimulation decreased substantially during and after optokinetic stimulation. At low shock intensities, R2 decreased most during optokinetic stimulation in subjects who did not develop symptoms of motion sickness. In contrast, during the recovery period after optokinetic stimulation, suppression of R2 to moderate and intense stimuli was greatest in the most nauseated subjects. These Findings suggest that a mechanism that suppresses symptoms of motion sickness during sensory conflict also inhibits activity in wide dynamic range neurones in the trigeminal nucleus caudalis. Nausea in the absence of sensory conflict may inhibit R2 to intense electrical stimulation by provoking diffuse noxious inhibitory controls.
Neutrophil-Free Radical Generation and Enzymatic Antioxidants in Migraine Patients
Authors: Shukla R , Barthwal MK , Srivastava N , Sharma P , Raghavan SAV , Nag D , Srimal RC , Seth PK , Dikshit M
Published: December 2003

The present study was undertaken to elucidate the role of circulating neutrophils if any in oxidative stress in migraine by evaluating free radical generation and activities of enzymatic antioxidants in the blood in 55 patients with migraine and 60 healthy controls. Free radical generation was assessed by flow cytometry, while activity of catalase, superoxide dismutase (SOD) and glutathione peroxidase (GPx) was estimated in blood polymorphonuclear neutrophils (PMNs) by standard procedures. Platelet SOD was also measured. No significant change was found in free radical generation and in the activity of catalase, SOD and GPx in migraine patients. Univariate analysis of PMN catalase level revealed that migraineurs with a positive family history had significantly lower catalase activity compared with those with a negative family history. No correlation was found in the activity of antioxidant enzymes with age, duration of disease, time since last attack and headache index. The platelet SOD also did not show any significant change in patients of migraine without aura. Platelet aggregation in the presence or absence of PMNs was also not altered significantly. Thus the findings of the present study suggest that neutrophils are not the cause of oxidative stress observed in migraine patients.
Botulinum Toxin a for Chronic Daily Headache: A Randomized, Placebo-Controlled, Parallel Design Study
Authors: Ondo WG , Vuong KD , Derman HS
Published: December 2003

Sixty patients with headaches of more than 15 days per month were recruited for this double-blind, placebo-controlled, parallel study of botulinum toxin type A (BTX) for chronic tension type and chronic migraine headaches. The primary efficacy point was the number of headache-free days as assessed by diary for 12 weeks after BTX injection. Secondary efficacy points included global impressions, the use of abortive headache medications, and palpation. After recruitment, subjects kept diaries for 4 weeks prior to randomization, at which time they received either 200 U of BTX or matching placebo and were followed. After the week-12 evaluation, patients were offered 200 U of BTX (open label), and were similarly followed for another 12 weeks. The mean days with headache of the 60 subjects (49 female, mean age 47 ± 11 years) was 23 ± 7 out of 30. Both groups were demographically similar (58 completed). Over a 12-week period after injections, headache-free days had improved in the BTX group from week 8 to 12 ( P < 0.05), and strongly tended to improve over the entire 12-week period, 33 ± 23 vs. 24 ± 16 days without headache ( P = 0.07), but did not meet the a priori significance criteria. The subject global impressions ( P < 0.05), subject change in headache impressions ( P < 0.005), and investigator global impressions ( P < 0.001) all improved in the BTX group compared with placebo. Adverse events were mild and did not differ between groups. At week 24 (open label), headache-free days were less in the twice BTX injected group compared with the once injected group, 40 ± 26 vs. 26 ± 19 ( P < 0.05). BTX may help chronic daily headache and appears to have a cumulative effect with subsequent injections. The treatment was very well tolerated.
Association between Adolescent Chronic Daily Headache and Childhood Adversity: A Community-Based Study
Authors: Juang K-D , Wang S-J , Fuh J-L , Lu S-R , Chen Y-S
Published: December 2003

The relationship of chronic daily headache (CDH) and childhood adversity is still controversial. We therefore conducted a survey for CDH (≥15 days/month, average ≥ 2 h/day) among all students in three public schools in Taiwan. The Global Family Environment Scale (GFES), which yields a score according to childhood adverse events in the family, was used to compare childhood adversity between cases of CDH and their age- and sex-matched controls. In total, 4645 students were surveyed and 58 with CDH were identified. Significantly lower GFES scores, indicative of worse childhood adversities, were evident in the CDH group (76.7 ± 19.2), compared with the control group (86.0 ± 8.9, P = 0.001). Physical abuse (10% vs. 0, P = 0.012) and parental divorce (17% vs. 3%, odds ratio = 5.8, P = 0.015) were more frequent in the CDH group. The results indicate that childhood adversitys may contribute to greater risk of the development of CDH in young adolescents.
Introduction: Contextualizing and Interrogating the GKI Case for Redistributive Land Reform
Authors: Byres Terence J.
Published: December 2003

The GKI case for redistributive land reform is first contextualized historically: by considering its broad historical context that extends back to ancient times, and its more recent context, that of the effort to secure ‘development’ in poor countries in the post‐1945 era. Two broad forms are briefly considered: tenurial reform and redistributive reform. The decline of land reform in policy agendas from the late 1960s onwards, and its recent reappearance are noted. That reappearance has included ‘market friendly’ reform, strongly pushed by the World Bank. It is in these contexts that the bold and radical GKI case for redistributive land reform has been made. A brief résumé of that case is provided. Thereafter, the nature of the interrogation of GKI by contributors to the special issue is outlined, this including treatment of the GKI methodological/ideological context. This interrogation covers a questioning of: the nature of their neo‐populist/neo‐classical logic and the theoretical problems associated therewith; the existence of an inverse relationship between land productivity and land size; the supposed impact on agricultural growth; the postulated effects of urban bias; and the ignoring of the ‘real politics of land’. This encompasses treatment of Japan, Taiwan, China, former Soviet bloc countries, Southern Africa (with a focus on South Africa and Zimbabwe) and Bangladesh.
Chinese Land Reform in Long‐Run Perspective and in the Wider East Asian Context
Authors: Bramall Chris
Published: December 2003

The claims made by Griffin et al. for the impact of land reform in China are unconvincing. The land reform of 1947–52 did not lead to a pronounced increase in agricultural output. Nor was it egalitarian; indeed, but for the deliberate preservation of the rich peasant economy, growth might have been non‐existent. The second land reform of 1981–3 was equally ineffectual. Agricultural growth had shifted on to a faster growth path before decol‐lectivization, and the surge of 1980–4 was little more than a temporary response to decent weather, procurement price rises, the abandonment of the Dazhai system and a reduction in output under‐reporting. Rural income inequality has been held in check since 1984 because of local government intervention, not because family farming is intrinsically egalitarian. China's experience of land reform is mirrored by those of other East Asian countries. A century of land reform has not resolved Japan's deep‐seated agricultural problems, nor those of Taiwan and South Korea.
Visual fields in hornbills: precision‐grasping and sunshades
Authors: Martin Graham R. , Coetzee Hendri C.
Published: December 2003

Retinal visual fields were determined in Southern Ground Hornbills Bucorvus leadbeateri and Southern Yellow‐billed Hornbills Tockus leucomelas (Coraciiformes, Bucerotidae) using an ophthalmoscopic reflex technique. In both species the binocular field is relatively long and narrow with a maximum width of 30° occurring 40° above the bill. The bill tip projects into the lower half of the binocular field. This frontal visual field topography exhibits a number of key features that are also found in other terrestrial birds. This supports the hypothesis that avian visual fields are of three principal types that are correlated with the degree to which vision is employed when taking food items, rather than with phylogeny. However, unlike other species studied to date, in both hornbill species the bill intrudes into the binocular field. This intrusion of the bill restricts the width of the binocular field but allows the birds to view their own bill tips. It is suggested that this is associated with the precision‐grasping feeding technique of hornbills. This involves forceps‐like grasping and manipulation of items in the tips of the large decurved bill. The two hornbill species differ in the extent of the blind area perpendicularly above the head. Interspecific comparison shows that eye size and the width of the blind area above the head are significantly correlated. The limit of the upper visual field in hornbills is viewed through the long lash‐like feathers of the upper lids and these appear to be used as a sunshade mechanism. In Ground Hornbills eye movements are non‐conjugate and have sufficient amplitude (30–40°) to abolish the frontal binocular field and to produce markedly asymmetric visual field configurations.
The Impact of the Prospective Payment System for Skilled Nursing Facilities on Therapy Service Provision: A Transaction Cost Approach
Authors: Zinn Jacqueline S. , Mor Vincent , Intrator Orna , Feng Zhanlian , Angelelli Joseph , Davis Jullet A.
Published: December 2003

Objective.To examine skilled nursing facilities (SNFs) “make‐or‐buy” decisions with respect to rehabilitation therapy service provision in the 1990s, both before and after implementation of Medicare's Prospective Payment System (PPS) for SNFs.

Data Sources.Longitudinal On‐line Survey Certification and Reporting (OSCAR) data (1992–2001) on a sample of 10,241 freestanding urban SNFs.

Study Design.We estimated a longitudinal multinomial logistic regression model derived from transaction cost economic theory to predict the probability of the outcome in each of four service provision categories (all employed staff, all contract, mixed, and no services provided).

Principal Findings.Transaction frequency, uncertainty, and complexity result in greater control over therapy services through employment as opposed to outside contracting. For‐profit status and chain affiliation were associated with greater control over therapy services. Following PPS, nursing homes acted to limit transaction costs by either exiting the rehabilitation market or exerting greater control over therapy services by managing rehabilitation services in‐house.

Conclusions.The financial incentives associated with changes in reimbursement methodology have implications that extend beyond the boundaries of the health care industry segment directly affected. Unintended quality and access consequences need to be carefully monitored by the Medicare program.
Measuring Hospital Quality: Can Medicare Data Substitute for All‐Payer Data?
Authors: Needleman Jack , Buerhaus Peter I. , Mattke Soeren , Stewart Maureen , Zelevinsky Katya
Published: December 2003

Objectives. To assess whether adverse outcomes in Medicare patients can be used as a surrogate for measures from all patients in quality‐of‐care research using administrative datasets.

Data Sources. Patient discharge abstracts from state data systems for 799 hospitals in 11 states. National MedPAR discharge data for Medicare patients from 3,357 hospitals. State hospital staffing surveys or financial reports. American Hospital Association Annual Survey.

Study Design. We calculate rates for 10 adverse patient outcomes, examine the correlation between all‐patient and Medicare rates, and conduct negative binomial regressions of counts of adverse outcomes on expected counts, hospital nurse staffing, and other variables to compare results using all‐patient and Medicare patient data.

Data Collection/Extraction. Coding rules were established for eight adverse outcomes applicable to medical and surgical patients plus two outcomes applicable only to surgical patients. The presence of these outcomes was coded for 3 samples: all patients in the 11‐state sample, Medicare patients in the 11‐state sample, and Medicare patients in the national Medicare MedPAR sample. Logistic regression models were used to construct estimates of expected counts of the outcomes for each hospital. Variables for teaching, metropolitan status, and bed size were obtained from the AHA Annual Survey.

Principal Findings. For medical patients, Medicare rates were consistently higher than all‐patient rates, but the two were highly correlated. Results from regression analysis were consistent across the 11‐state all‐patient, 11‐state Medicare, and national Medicare samples. For surgery patients, Medicare rates were generally higher than all‐patient rates, but correlations of Medicare and all‐patient rates were lower, and regression results less consistent.

Conclusions. Analyses of quality of care for medical patients using Medicare‐only and all‐patient data are likely to have similar findings. Measures applied to surgery patients must be used with more caution, as those tested only in Medicare patients may not provide results comparable to those from all‐patient samples or across different samples of Medicare patients.
Measuring the Quality of Diabetes Care Using Administrative Data: Is There Bias?
Authors: Keating Nancy L. , Landrum Mary Beth , Landon Bruce E. , Ayanian John Z. , Borbas Catherine , Guadagnoli Edward
Published: December 2003

Objectives. Health care organizations often measure processes of care using only administrative data. We assessed whether measuring processes of diabetes care using administrative data without medical record data is likely to underdetect compliance with accepted standards for certain groups of patients.

Data Sources/Study Setting. Assessment of quality indicators during 1998 using administrative and medical records data for a cohort of 1,335 diabetic patients enrolled in three Minnesota health plans.

Study Design. Cross‐sectional retrospective study assessing hemoglobin A1c testing, LDL cholesterol testing, and retinopathy screening from the two data sources. Analyses examined whether patient or clinic characteristics were associated with underdetection of quality indicators when administrative data were not supplemented with medical record data.

Data Collection/Extraction Methods. The health plans provided administrative data, and trained abstractors collected medical records data.

Principal Findings. Quality indicators that would be identified if administrative data were supplemented with medical records data are often not identified using administrative data alone. In adjusted analyses, older patients were more likely to have hemoglobin A1c testing underdetected in administrative data (compared to patients <45 years, OR 2.95, 95 percent CI 1.09 to 7.96 for patients 65 to 74 years, and OR 4.20, 95 percent CI 1.81 to 9.77 for patients 75 years and older). Black patients were more likely than white patients to have retinopathy screening underdetected using administrative data (2.57, 95 percent CI 1.16 to 5.70). Patients in different health plans also differed in the likelihood of having quality indicators underdetected.

Conclusions. Diabetes quality indicators may be underdetected more frequently for elderly and black patients and the physicians, clinics, and plans who care for such patients when quality measurement is based on administrative data alone. This suggests that providers who care for such patients may be disproportionately affected by public release of such data or by its use in determining the magnitude of financial incentives.
How Robust Are Health Plan Quality Indicators to Data Loss? A Monte Carlo Simulation Study of Pediatric Asthma Treatment
Authors: Stuart Bruce , Singhal Puneet K. , Magder Laurence S. , Zuckerman Ilene H.
Published: December 2003

Objectives. (1) To test the robustness of a health plan quality indicator (QI) for persistent asthma to various forms of data loss and (2) to assess the implications of the findings for other health plan quality measures.

Data Sources/Study Settings. Maryland Medicaid fee‐for‐service (FFS) claims. Children with asthma (n=5,804) were selected from Medicaid enrollment records and medical and pharmacy FFS claims filed between June 1996 and December 1997.

Study Design. A variant of a HEDIS measure for treatment of persistent asthma (the percent of asthma patients filling two or more rescue medications who also filled a controller medication) was selected to test the robustness of proportion‐based QIs to loss of data. Data loss was simulated through a series of Monte Carlo experiments.

Data Collection/Extraction Methods. Merged FFS medical and prescription claims.

Principal Findings. The asthma QI measure was highly robust to systematic and random data loss. The measure declined by less than 2 percent in the presence of up to a 35 percent data loss. Redundancy in the numerator of the QI significantly increased the robustness of the measure to data loss.

Conclusions. A HEDIS‐related QI measure for persistent asthma is robust to data loss. The findings suggest that other proportion‐based quality indicators, particularly those in which plan members have multiple opportunities to meet the numerator criterion, are likely to reflect true levels of health plan quality in the face of incomplete data capture.
Variability in Asthma Care and Services for Low‐Income Populations among Practice Sites in Managed Medicaid Systems
Authors: Lozano Paula , Grothaus Lou C. , Finkelstein Jonathan A. , Hecht Julia , Farber Harold J. , Lieu Tracy A.
Published: December 2003

Objective. To characterize and describe variability in processes of asthma care and services tailored for low–income populations in practice sites participating in Medicaid managed care (MMC).

Study Setting. Eighty‐five practice sites affiliated with five not‐for‐profit organizations participating in managed Medicaid (three group‐model health maintenance organizations [HMOs] and two Medicaid managed care organizations [MCOs]).

Study Design/Data Collection. We conducted a mail survey of managed care practice site informants using a conceptual model that included chronic illness care and services targeting low‐income populations. The survey asked how frequently a number of processes related to asthma care occurred at the practice sites (on a scale from “never” to “always”). We report mean and standard deviations of item scores and rankings relative to other items. We used within‐MCO intraclass correlations to assess how consistent responses were among practice sites in the same MCO.

Principal Findings. Processes of care related to asthma varied greatly in how often practice sites reported doing them, with information systems and self‐management support services ranking lowest. There was also significant variation in the availability of services targeting low‐income populations, specifically relating to cultural diversity, communication, and enrollee empowerment. Very little of the site‐to‐site variation was attributable to the MCO.

Conclusions. Our conceptual framework provides a means of assessing the provision of chronic illness care for vulnerable populations. There is room for improvement in provision of chronic asthma care for children in managed Medicaid, particularly in the areas of self‐management support and information systems. The lack of consistency within MCOs on many processes of care suggests that care may be driven more at the practice site level than the MCO level, which has implications for quality improvement efforts.
Managed Care Organizational Characteristics and Health Care Use among Children with Special Health Care Needs
Authors: Shenkman Elizabeth , Wu Samuel S. , Nackashi John , Sherman James
Published: December 2003

Objective. To examine the relationship between features of managed care organizations (MCOs) and health care use patterns by children.

Data Sources. Telephone survey data from 2,223 parents of children with special health care needs, MCO‐administrator interview data, and health care claims data.

Study Design. Cross‐sectional survey data from families about the number of consequences of their children's conditions and from MCO administrators about their plans' organizational features were used. Indices reflecting the MCO characteristics were developed using data reduction techniques. Hierarchical models were developed to examine the relationship between child sociodemographic and health characteristics and the MCO indices labeled: Pediatrician Focused (PF) Index, Specialist Focused (SF) Index, and Fee‐for‐Service (FFS) Index, and outpatient use rates and charges, inpatient admissions, emergency room (ER) visits, and specialty consultations.

Data Collection/Extraction Methods. The telephone and MCO‐administrator survey data were linked to the enrollment and claims files.

Principal Findings. The child's age, gender, and condition consequences were consistent predictor variables related to health care use and charges. The PF Index was associated with decreased outpatient use rates and charges and decreased inpatient admissions. The SF Index was associated with increased ER visits and decreased specialty consultations, while the FFS Index was associated with increased outpatient use rates and charges.

Conclusion. After controlling for sociodemographic and health characteristics, the PF, SF, and FFS indices were significantly associated with children's health care use patterns.
Measuring Contextual Characteristics for Community Health
Authors: Hillemeier Marianne M. , Lynch John , Harper Sam , Casper Michele
Published: December 2003

Objective.To conceptualize and measure community contextual influences on population health and health disparities.

Data Sources.We use traditional and nontraditional secondary sources of data comprising a comprehensive array of community characteristics.

Study Design.Using a consultative process, we identify 12 overarching dimensions of contextual characteristics that may affect community health, as well as specific subcomponents relating to each dimension.

Data Collection.An extensive geocoded library of data indicators relating to each dimension and subcomponent for metropolitan areas in the United States is assembled.

Principal Findings.We describe the development of community contextual health profiles, present the rationale supporting each of the profile dimensions, and provide examples of relevant data sources.

Conclusions.Our conceptual framework for community contextual characteristics, including a specified set of dimensions and components, can provide practical ways to monitor health‐related aspects of the economic, social, and physical environments in which people live. We suggest several guiding principles useful for understanding how aspects of contextual characteristics can affect health and health disparities.
Racial Segregation and Longevity among African Americans: An Individual‐Level Analysis
Authors: Laveist Thomas A.
Published: December 2003

Objective To test the relationship between racial segregation and mortality using a multidimensional questionnaire‐based measure of exposure to segregation.

Data Sources Data for this analysis come from the National Survey of Black Americans (NSBA), a national multistage probability sample of 2,107 African Americans (aged 18–101). The NSBA was conducted as a household survey. The NSBA was matched with the National Death Index (NDI).

Study Design Prospective cohort study, where Cox regression analysis was used to examine the effect of baseline variables on time to death over a 13‐year period.

Principal Findings Respondents who were exposed to racial segregation were significantly less likely to survive the study period after controls for age, health status, and other predictors of mortality.

Conclusion The results support previous studies linking segregation with health outcomes.
Distributional Issues in the Analysis of Preventable Hospitalizations
Authors: Delia Derek
Published: December 2003

Objective. To describe patterns in ambulatory care sensitive (ACS) admissions at the zip code level based on zip code demographic and other characteristics. These patterns include trends over time, persistence within zip codes over time, and variation between and within socioeconomic strata.

Data Sources. New York State hospital discharge data 1990–1998, U.S. census data 1990, and New York State birth records 1990.

Study Design. Age‐ and sex‐adjusted rates and volumes of ACS admissions are calculated at the zip code level. Descriptive statistics are analyzed cross‐sectionally and over time. Kernel density functions are estimated across income strata. Ordinary and quantile regression techniques are used to determine the impact of socioeconomic variables on average and extreme values of the distribution of ACS admission rates.

Principal Findings. Ambulatory care sensitive admissions rates declined during the study period but in conjunction with a greater decline in overall admission rates. Thus, as a percentage of total admissions, they actually rose by 4 percent. Ambulatory care sensitive admissions are geographically concentrated and rates are highly persistent within zip codes over time. Even on a log scale ACS admissions are typically greater and exhibit more variability among low‐income zip codes. Other variables positively associated with ACS admissions are total population, births to unwed mothers (a proxy for family structure), black population, Hispanic population, and the number of non‐ACS admissions. Births to immigrant mothers (a proxy for immigrant population) are negatively associated with ACS admissions.

Conclusions. The concentration and persistence of ACS admissions point to a chronic, geographically limited deficiency of primary ambulatory care in the most underserved neighborhoods. Much of the difference in preventable hospitalization levels between high‐ and low‐income areas is driven by very high volumes in the low‐income areas unrelated to population density. New York data suggest that most costs from preventable hospitalizations could be saved by focusing on targeted neighborhoods. Socioeconomic and area utilization variables play a role in both average and extreme values of the rate of preventable hospitalizations at the zip code level. Since variables that affect the average volume of preventable hospitalizations can change the distribution of that volume, analysis based on averages alone may be inadequate. The findings on area demographics and non‐ACS admissions point to the need to better understand social and cultural issues as well as local admitting practice patterns to encourage appropriate and efficient use of the health care delivery system.