bluuebunny/crossref_metadata_2025 huggingface dataset:
Increased fluoroquinolone resistance with time in Escherichia coli from >17,000 patients at a large county hospital as a function of culture site, age, sex, and location
Authors: Boyd Lauren Becnel , Atmar Robert L , Randall Graham L , Hamill Richard J , Steffen David , Zechiedrich Lynn
Published: January 2008

Background

Escherichia coli infections are common and often treated with fluoroquinolones. Fluoroquinolone resistance is of worldwide importance and is monitored by national and international surveillance networks. In this study, we analyzed the effects of time, culture site, and patient age, sex, and location on fluoroquinolone resistance in E. coli clinical isolates.

Methods

To understand how patient factors and time influenced fluoroquinolone resistance and to determine how well data from surveillance networks predict trends at Ben Taub General Hospital in Houston, TX, we used Perl to parse and MySQL to house data from antibiograms (n ≅ 21,000) for E. coli isolated between 1999 to 2004 using Chi Square, Bonferroni, and Multiple Linear Regression methods.

Results

Fluoroquinolone resistance (i) increased with time; (ii) exceeded national averages by 2- to 4-fold; (iii) was higher in males than females, largely because of urinary isolates from male outpatients; (iv) increased with patient age; (v) was 3% in pediatric patients; (vi) was higher in hospitalized patients than outpatients; (vii) was higher in sputum samples, particularly from inpatients, than all other culture sites, including blood and urine, regardless of patient location; and (viii) was lowest in genital isolates than all other culture sites. Additionally, the data suggest that, with regard to susceptibility or resistance by the Dade Behring MicroScan system, a single fluoroquinolone suffices as a "surrogate marker" for all of the fluoroquinolone tested.

Conclusion

Large surveillance programs often did not predict E. coli fluoroquinolone resistance trends at a large, urban hospital with a largely indigent, ethnically diverse patient population or its affiliated community clinics.
Chemoradiotherapy with or without consolidation chemotherapy using cisplatin and 5-fluorouracil in anal squamous cell carcinoma: long-term results in 31 patients
Authors: Cho Byoung Chul , Ahn Joong Bae , Seong Jinsil , Roh Jae Kyung , Kim Joo Hang , Chung Hyun Cheol , Sohn Joo Hyuk , Kim Nam Kyu
Published: January 2008

Background

The objectives of this study were to evaluate long-term results of concurrent chemoradiotherapy (CRT) with 5-fluorouracil and cisplatin and the potential benefit of consolidation chemotherapy in patients with anal squamous cell carcinoma (ASCC).

Methods

Between January 1995 and February 2006, 31 patients with ASCC were treated with CRT. Radiotherapy was administered at 45 Gy over 5 weeks, followed by a boost of 9 Gy to complete or partial responders. Chemotherapy consisted of 5-fluorouracil (750 or 1,000 mg/m2) daily on days 1 to 5 and days 29 to 33; and, cisplatin (75 or 100 mg/m2) on day 2 and day 30. Twelve patients had T3–4 disease, whereas 18 patients presented with lymphadenopathy. Twenty-one (67.7%) received consolidation chemotherapy with the same doses of 5-fluorouracil and cisplatin, repeated every 4 weeks for maximum 4 cycles.

Results

Nineteen patients (90.5%) completed all four courses of consolidation chemotherapy. After CRT, 28 patients showed complete responses, while 3 showed partial responses. After a median follow-up period of 72 months, the 5-year overall, disease-free, and colostomy-free survival rates were 84.7%, 82.9% and 96.6%, demonstrating that CRT with 5-fluorouracil and cisplatin yields a good outcome in terms of survival and sphincter preservation. No differences in 5-year OS and DFS rates between patients treated with CRT alone and CRT with consolidation chemotherapy was observed.

Conclusion

our study shows that CRT with 5-FU and cisplatin, with or without consolidation chemotherapy, was well tolerated and proved highly encouraging in terms of long-term survival and the preservation of anal function in ASCC. Further trials with a larger patient population are warranted in order to evaluate the potential role of consolidation chemotherapy.
Enhancement of hybridoma formation, clonability and cell proliferation in a nanoparticle-doped aqueous environment
Authors: Gavrilov-Yusim Natalie , Hahiashvili Ekaterina , Tashker Marina , Yavelsky Victoria , Karnieli Ohad , Lobel Leslie
Published: January 2008

Background

The isolation and production of human monoclonal antibodies is becoming an increasingly important pursuit as biopharmaceutical companies migrate their drug pipelines away from small organic molecules. As such, optimization of monoclonal antibody technologies is important, as this is becoming the new rate-limiting step for discovery and development of new pharmaceuticals. The major limitations of this system are the efficiency of isolating hybridoma clones, the process of stabilizing these clones and optimization of hybridoma cell secretion, especially for large-scale production.

Many previous studies have demonstrated how perturbations in the aqueous environment can impact upon cell biology. In particular, radio frequency (RF) irradiation of solutions can have dramatic effects on behavior of solutions, cells and in particular membrane proteins, although this effect decays following removal of the RF. Recently, it was shown that nanoparticle doping of RF irradiated water (NPD water) produced a stabilized aqueous medium that maintained the characteristic properties of RF irradiated water for extended periods of time. Therefore, the ordering effect in water of the RF irradiation can now be studied in systems that required prolonged periods for analysis, such as eukaryotic cell culture. Since the formation of hybridoma cells involves the formation of a new membrane, a process that is affected by the surrounding aqueous environment, we tested these nanoparticle doped aqueous media formulations on hybridoma cell production.

Results

In this study, we tested the entire process of isolation and production of human monoclonal antibodies in NPD water as a means for further enhancing human monoclonal antibody isolation and production. Our results indicate an overall enhancement of hybridoma yield, viability, clonability and secretion. Furthermore, we have demonstrated that immortal cells proliferate faster whereas primary human fibroblasts proliferate slower in NPD water.

Conclusion

Overall, these studies indicate that NPD water can enhance cell proliferation, clonability and secretion. Furthermore, the results support the hypothesis that NPD water is effectively composed of stable microenvironments.
Polymorphisms of TNF-enhancer and gene for FcγRIIa correlate with the severity of falciparum malaria in the ethnically diverse Indian population
Authors: Sinha Swapnil , Mishra Shrawan K , Sharma Shweta , Patibandla Phani K , Mallick Prashant K , Sharma Surya K , Mohanty Sanjib , Pati Sudhanshu S , Mishra Saroj K , Ramteke Bheshaj K , Bhatt RM , Joshi Hema , Dash Aditya P , Ahuja Ramesh C , Awasthi Shally ,   Indian Genome Variation Consortium, Venkatesh Vimala , Habib Saman
Published: January 2008

Background

Susceptibility/resistance toPlasmodium falciparummalaria has been correlated with polymorphisms in more than 30 human genes with most association analyses having been carried out on patients from Africa and south-east Asia. The aim of this study was to examine the possible contribution of genetic variants in theTNFandFCGR2Agenes in determining severity/resistance toP. falciparummalaria in Indian subjects.

Methods

Allelic frequency distribution in populations across India was first determined by typing genetic variants of theTNFenhancer and theFCGR2AG/A SNP in 1871 individuals from 55 populations. Genotyping was carried out by DNA sequencing, single base extension (SNaPshot), and DNA mass array (Sequenom). Plasma TNF was determined by ELISA. Comparison of datasets was carried out by Kruskal-Wallis and Mann-Whitney tests. Haplotypes and LD plots were generated by PHASE and Haploview, respectively. Odds ratio (OR) for risk assessment was calculated using EpiInfo™ version 3.4.

Results

A novel single nucleotide polymorphism (SNP) at position -76 was identified in theTNFenhancer along with other reported variants. FiveTNFenhancer SNPs and theFCGR2AR131H (G/A) SNP were analyzed for association with severity ofP. falciparummalaria in a malaria-endemic and a non-endemic region of India in a case-control study with ethnically-matched controls enrolled from both regions.TNF-1031C and -863A alleles as well as homozygotes for the TNF enhancer haplotype CACGG (-1031T>C, -863C>A, -857C>T, -308G>A, -238G>A) correlated with enhanced plasma TNF levels in both patients and controls. Significantly higher TNF levels were observed in patients with severe malaria. Minor alleles of -1031 and -863 SNPs were associated with increased susceptibility to severe malaria. The high-affinity IgG2 binding FcγRIIa AA (131H) genotype was significantly associated with protection from disease manifestation, with stronger association observed in the malaria non-endemic region. These results represent the first genetic analysis of the two immune regulatory molecules in the context ofP. falciparumseverity/resistance in the Indian population.

Conclusion

Association of specificTNFandFCGR2ASNPs with cytokine levels and disease severity/resistance was indicated in patients from areas with differential disease endemicity. The data emphasizes the need for addressing the contribution of human genetic factors in malaria in the context of disease epidemiology and population genetic substructure within India.
The role of aldosterone blockade in murine lupus nephritis
Authors: Monrad Seetha U , Killen Paul D , Anderson Marc R , Bradke Amanda , Kaplan Mariana J
Published: January 2008

Background

The purpose of this study was to examine the effect of aldosterone receptor blockade on the immunopathogenesis and progression of nephritis in the (NZB × NZW) F1 murine lupus model.

Methods

Female NZB/W F1 mice (11 weeks old) were treated daily with 25 or 50 mg/kg oral spironolactone or vehicle. Proteinuria, renal function, and serum autoantibody levels were monitored. Renal histopathology, immune complex deposition, and immunohistochemistry were analyzed at various time points. Targeted microarray analysis was performed on renal tissue, with subsequent real-time PCR analysis of several differentially expressed genes.

Results

Treatment with spironolactone was well tolerated by the mice throughout the course of their disease progression, with no significant differences in azotemia or serum potassium levels between vehicle-treated and spironolactone-treated animals. By 36 weeks of age, fewer spironolactone-treated mice developed nephrotic range proteinuria as compared with the control mice (control 70.8%, 25 mg/kg spironolactone 51.3%, and 50 mg/kg spironolactone 48.6%). Compared with control mice, mice treated with 25 mg/kg spironolactone had significantly lower serum anti-single-stranded DNA levels (2,042 μg/ml versus 1,036 μg/ml; P = 0.03) and anti-double-stranded DNA levels (3,433 μg/ml versus 614 μg/ml; P = 0.05). Spironolactone-treated mice exhibited decreased histopathologic evidence of inflammation and tissue damage, as compared with control mice. Additionally, spironolactone treatment resulted in decreased expression in the kidney of several inflammatory and proapoptotic genes, including those encoding interferon-γ, B lymphocyte stimulator (BlyS), tumor necrosis factor related apoptosis inducing ligand (TRAIL), tumor necrosis factor related weak inducer of apoptosis (TWEAK), and Fas ligand.

Conclusion

Aldosterone receptor blockade is safe and well tolerated in progressive murine lupus nephritis, and it results in decreased levels of clinical proteinuria, lower serum levels of autoantibodies, and decreased kidney damage. It appears to modulate inflammatory changes during the progression of glomerulonephritis and may also have a previously undescribed role in attenuating apoptosis.
Effects of plasma expansion with albumin and paracentesis on haemodynamics and kidney function in critically ill cirrhotic patients with tense ascites and hepatorenal syndrome: a prospective uncontrolled trial
Authors: Umgelter Andreas , Reindl Wolfgang , Wagner Katrin S , Franzen Michael , Stock Konrad , Schmid Roland M , Huber Wolfgang
Published: January 2008

Introduction

Circulatory dysfunction in cirrhotic patients may cause a specific kind of functional renal failure termed hepato-renal syndrome (HRS). It contributes to the high incidence of renal failure in cirrhotic intensive care unit (ICU) patients. Fluid therapy may aggravate renal failure by increasing ascites and intra-abdominal pressure (IAP). This study investigates the short-term effects of paracentesis on haemodynamics and kidney function in volume resuscitated patients with HRS.

Methods

Nineteen consecutive cirrhotic patients with HRS were studied. Circulatory parameters and renal function were analysed before and after plasma expansion and paracentesis. Haemodynamic monitoring was performed by transpulmonary thermodilution.

Results

After infusion of 200 ml of 20% human albumin solution, mean arterial pressure (MAP) and central venous pressure remained unchanged. Global end-diastolic volume index (GEDVI) increased from 791 ml m-2 (693 to 862) (median and 25th to 75th percentile) to 844 ml m-2 (751 to 933). Cardiac index (CI) increased from 4.1 l min-1 m-2 (3.6 to 5.0) to 4.7 l min-1 m-2 (4.0 to 5.8), whereas systemic vascular resistance index (SVRI) decreased from 1,422 dyn s cm-5 m-2 (1,081 to 1,772) to 1,171 dyn s cm-5 m-2 (893 to 1,705). Creatinine clearance (CC) and fractional excretion of sodium (FeNa) were not affected. During paracentesis, IAP decreased from 22 mmHg (18 to 24) to 9 mmHg (8 to 12). MAP decreased from 81 mmHg (74 to 100) to 80 mmHg (71 to 89), and CI increased from 4.1 l min-1 m-2 (3.2 to 4.3) to 4.2 l min-1 m-2 (3.6 to 4.7), whereas SVRI decreased from 1,639 dyn s cm-5 m-2 (1,168 to 2,037) to 1,301 dyn s cm-5 m-2 (1,124 to 1,751). CC during the 12-hour interval after paracentesis was significantly higher than during the 12 hours before (33 ml min-1 (16 to 50) compared with 23 ml min-1 (12 to 49)). CC remained elevated for the rest of the observation period. FeNa increased after paracentesis but returned to baseline levels after 24 hours.

Conclusion

Paracentesis with parameter-guided fluid substitution and maintenance of central blood volume may improve renal function and is safe in the treatment of ICU patients with hepato-renal failure.
Policymaking Cycles in Mental Health: Critical Examination of a Conceptual Model
Authors: Rochefort David A.
Published: January 2008

Analysts have frequently used the concept of a cycle to describe the historical development of mental health policy in the United States. According to the “cyclical” perspective, the mental health system alternates between crests of high policy and program activity and troughs of stagnation and decline. Analysts also observe that past policy themes are periodically rediscovered, only to eventually lose favor and recede into the background once again. This article critically examines the cyclical model of mental health policymaking, placing it within a context of broader theoretical work on the dynamics of public policy formation. The purpose is to organize in a conceptually coherent way what has emerged as the leading theoretical approach to understanding the evolution of the mental health system; to identify major issues and ambiguities in the application of the cyclical framework to mental health policy analysis; and to derive some general insights about problems and possibilities in modeling policy change.
Age as a Basis for Allocating Lifesaving Medical Resources: An Ethical Analysis
Authors: Kilner John F.
Published: January 2008

In light of the growing prominence of an age criterion in patient selection, it is essential to scrutinize the ethical legitimacy of arguments being offered both for and against using age as a criterion. Accordingly, the present study first explores the primary justifications for an age criterion, then examines the criterion's weaknesses. Weaknesses are grouped into two areas: deficiencies in the justifications of the criterion, and overarching critiques. Finally, a way forward in the midst of the present controversy is suggested. The study's conclusion is that an age criterion per se is unjustified, though age may play a carefully defined role in medical assessments relevant to patient selection.
Purchasing Power: Business and Health Policy Change in Massachusetts
Authors: Bergthold Linda A.
Published: January 2008

As in many states around the country, health care costs in Massachusetts had risen to an unprecedented proportion of the state budget by the early 1980s. State health policymakers realized that dramatic changes were needed in the political process to break provider control over health policy decisions. This paper presents a case study of policy change in Massachusetts between 1982 and 1988. State officials formulated a strategy to mobilize corporate interests, which were already awakening to the problems of high health care costs, as a countervailing power to the political monopoly of provider interests. Once mobilized, business interests became organized politically and even became dominant at times, controlling both the policy agenda and its process. Ultimately, business came to be viewed as a permanent part of the coalitions and commissions that helped formulate state health policy. Although initially allied with provider interests, business eventually forged a stronger alliance with the state, an alliance that has the potential to force structural change in health care politics in Massachusetts for years to come. The paper raises questions about the consequences of such alliances between public and private power for both the content and the process of health policymaking at the state level.
Do Consensus Conferences Work? A Process Evaluation of the NIH Consensus Development Program
Authors: Wortman Paul M. , Vinokur Amiram , Sechrest Lee
Published: January 2008

The purpose of this evaluation study is to identify problems and suggest modifications in the NIH Consensus Development Program. The current program consists of three-day conferences in which experts assess medical technologies for issues of efficacy, safety, conditions of use, and other related topics (e.g., costs and social impact). Eight consensus conferences held between 1980 and 1982 were studied in depth using a variety of methods; five of the conferences were investigated concurrently. In addition, archival material was examined for all but one of the 33 conferences held up to that time, and four planning meetings for future conferences were observed. The delay in publishing our findings provided an opportunity to examine the changes introduced by NIH; it also allowed us to avoid the criticism of numerous prior evaluations for finding fault with programs that are still developing. NIH adopted many of the recommendations in our evaluation report and has investigated others. Based on our evaluation and more recent evidence, however, we conclude that the major problem that was uncoveredselection bias, particularly with respect to the choice of questions and panelistsremains a significant threat to the credibility of the consensus process. More specifically, the results indicate that controversial issues cannot be properly addressed within the present conference format, although that was one of its major purposes. Recommendations for improving the consensus process are presented, as are their implications for a larger set of consensus activities that are currently being conducted.
The Organization of Organ Procurement
Authors: Prottas Jeffrey M.
Published: January 2008

The American organ procurement system has improved and matured in the last five years. At the same time, the basic challenges facing it have remained substantially the same because the moral and legal framework of the system has not changed. Success at organ procurement continues to depend on the voluntary cooperation of medical professionals and the families of potential organ donors. The generosity of the American public is so great that the primary challenge facing organ procurement agencies is obtaining cooperation from hospitals and medical professionals. This calls for a “marketing” orientation aimed at those hospitals and professionals who are most likely to treat potential donors. The last five years have seen a more general acceptance of this appreciation of the central task of organ procurement. As a result, the overall effectiveness of the system has improved, as measured by the number of organs procured on a per capita basis and by the number of multiorgan donors obtained. Much of this improvement can be attributed to the diffusion of organizational techniques and approaches, and this diffusion has been encouraged by the involvement of national organizations and public bodies in the organ procurement community. The system remains uneven in its effectiveness and further improvement is possible. It is also possible that the next general round of improvement will result from the application of businesslike information management and marketing techniques.
Government's Role in Organ Transplantation Policy
Authors: Blumstein James F.
Published: January 2008

This paper initially considers ways of thinking about organ transplantation: Should it be treated as a catastrophic disease or as an ordinary and accepted medical procedure? The analysis then shifts to the role the government has played in influencing organ transplantation policy. The federal government's involvement initially stemmed from its role as payer for end-stage renal disease services. In recent years, the rationale for intervention has changed, and the mechanism for implementing regulatory oversight has shifted to a private network run for the government by the United Network for Organ Sharing (UNOS). The government has delegated much policymaking authority to UNOS, although the author demonstrates that this is not required by the applicable legislation. The article raises questions about the relationship between UNOS and the federal government, about potential conflicts between UNOS guidelines and state laws under the Uniform Anatomical Gift Act, and about the ideological stance undergirding much of current federal policy in the organ transplantation arena.
Ironies of Inclusion: Social Class and Deinstitutionalization
Authors: Wagenaar Hendrik , Lewis Dan A.
Published: January 2008

This paper discusses changes in the social organization of mental institutionalization as they relate to developments in the wider social and economic environment. Despite dramatic changes in the system of inpatient psychiatric care during the last three decades, the historic division of labor between the private and the public system (with the latter treating the poor, the unemployed, and the nonwhite) has not ceased to exist. At the same time, under the influence of the postwar trend towards greater political integration of disadvantaged and marginal groups into society's central value systems, treatment of the mentally ill has become less segregated and more voluntary. An important implication of these two interacting trends–the changed legal position of the patient vis-a-vis the provider and the deteriorating economic position of the user of public psychiatric facilities–has been the exceeding irrelevance of one of the basic tenets of psychiatric care: that clinical treatment precedes social functioning. With two vignettes of chronic patients the article illustrates how symptoms and survival are fused in the contemporary, inclusionary system of care.
Case-Mix Payment for Nursing Home Care: Lessons from Maryland
Authors: Feder Judith , Scanlon William
Published: January 2008

Even before Medicare adopted case-based payments for hospitals, some state Medicaid programs employed case-mix payment systems for nursing home care. Their purpose was less to promote cost containment than to improve access to nursing homes for the most costly patients. This paper evaluates one such system, adopted by the state of Maryland in 1983 as part of an overall reimbursement reform. Using data on nursing home patient characteristics, costs, and staffing, as well as interviews with officials and various providers of care, the article shows that Maryland's system was successful in shifting nursing home service away from light-care and toward heavy-care patients. Furthermore, the shift occurred without inducing readily measurable declines in quality of care and with little additional administrative cost (partly because the state built its case-mix system on preexisting patient review activities). Although states could learn from and improve upon Maryland's experience–most notably in offering incentives to improve quality of care and in targeting community care on the light-care patients that nursing homes become less willing to serve–Maryland demonstrates that case-mix payment can change nursing home behavior in desired directions without substantial negative consequences.
Effects of Tort Reforms on the Value of Closed Medical Malpractice Claims: A Microanalysis
Authors: Sloan Frank A. , Mergenhagen Paula M. , Bovbjerg Randall R.
Published: January 2008

Tort reforms enacted by state legislatures mainly seek to reduce the rate of increase in medical malpractice insurance premiums and other costs of the professional liability system, such as “defensive medicine.” We examine the effects tort reforms enacted during the 1970s have had on the probability that a claim will be paid, the amount of payment, and the speed with which the claim is resolved. Claims frequency is not used as a variable in this analysis, but findings from other studies pertaining to frequency are noted. This study uses two closed claims databases–one from the National Association of Insurance Commissioners, and one from the U.S. General Accounting Office. We merged the two data sets for purposes of this analysis. The observational unit was the individual claim. Data on tort reforms came from our own analysis of statutory changes by state. Dollar ceilings on recoveries (“caps”) are shown to be the strongest reforms in terms of their impact on paid claim size. Most caps limit recovery for noneconomic loss, though some limit dollar awards. Other reforms that reduced payments per claim were costs awardable provisions and mandatory collateral offsets.
IV Drug Use and Aids: Public Policy and Dirty Needles
Authors: Stryker Jeff
Published: January 2008

Users of intravenous heroin, cocaine, and amphetamines risk the transmission of human immunodeficiency virus (HIV) through the sharing of contaminated injection equipment. Although most users are aware of this risk, the scarcity of sterile needles and syringes, combined with various social and cultural factors, fosters dangerous sharing practices. This paper examines the legal and political contexts of proposals to ease access to sterile needles and injection equipment. The author seeks an explanation for the continued reluctance to institute such programs in the United States, while similar programs have been instituted in other countries where intravenous drug use has also contributed to the spread of HIV infection and AIDS.
Tension, Compression, and Shear: Directions, Stresses, and Outcomes of Health Care Cost Control
Authors: Evans Robert G.
Published: January 2008

“Control” of health care costs is often portrayed as a struggle between external, “natural” forces pushing costs up and individuals, groups, and societies trying to resist the inevitable. This picture is false. Control includes strenuous efforts by some to raise costs, and by others to resist those increases, and/or to transfer costs to someone else. But all such forces originate in the purposes and interests of individuals and groups. Health care cost control is a struggle among conflicting interests over the priorities of a society, and claims of “inevitability” are simply part of the political rhetoric of that struggle. International experience supports certain conclusions. First, there is no basis for the claim that limits on expenditure growth must threaten the health of (some members of) a society. Second, there is a substantial variety of experience with cost control. Failure in the United States is often presented as evidence of the impossibility of control, but most other countries have succeeded. Finally, control requires the direct confrontation of interests, with substantial build-up of stress. Advocates of expansion are more successful if they can transform compressive forces into efforts to shift the burden onto someone else. Pressures from providers in every country for “privatization” and/or payment by users reflect this recognition of economic interest.
The Medically Uninsured: Problems, Policies, and Politics
Authors: Brown Lawrence D.
Published: January 2008

The ranks of the medically uninsured have grown significantly in recent years, but no consensus on a policy solution has emerged. After summarizing the characteristics of the uninsured population, this paper reviews diverse policy responses and their troubled political prospects.
Finding Audiences, Changing Beliefs: The Structure of Research Use in Canadian Health Policy
Authors: Lomas Jonathan
Published: January 2008

The impact of research information depends on its ability to change beliefs or policy assumptions within the relevant audiences. As a hybrid of American and British systems, Canada's chosen decision-making structure for policy-making and its legislative framework for health insurance make these audiences unclear and not readily accessible. This factor and historical characteristics of the research community which made them only partially responsive to the values of decisionmakers provide an explanation for the limited past use of research information in Canadian health policy. More recently, improved responsiveness by researchers and an emerging definition of the audiences by legislative policymakers are bringing about a gradual increase in the potential impact of research at the levels of administrative and clinical policy. Because of continuing decision-making constraints on legislative policy, however, impact at this level is predicted to remain diffuse, with only cautious acceptance of the changes in beliefs implied by research.
Legislative Incapacity: The Congressional Role in Environmental Policy-Making and the Case of Superfund
Authors: Rabe Barry G.
Published: January 2008

Congress plays a central role in national environmental policy formation but appears ill equipped to set policy priorities and devise integrative legislation. Fragmentation of authority among a multiplicity of committees and subcommittees, especially in the House, contributes to these problems. This pattern is evident in the evolution of Superfund, the national program to clean up abandoned hazardous waste sites. The prolonged process of reauthorization in the 1980s contributed to serious program delay and failed to resolve a number of fundamental questions concerning the national cleanup effort. Institutional reforms could contribute to a more effective congressional role in future environmental policy deliberations.
Physician-Management Relationships at Hca: A Case Study
Authors: Campbell Paul , Kane Nancy M.
Published: January 2008

The question of whether Hospital Corporation of America (HCA), a for-profit hospital company, fostered an environment detrimental to the physician-patient relationship during the period of implementation of the Medicare Prospective Payment System (PPS) was explored. The transition to PPS provided an opportunity to evaluate whether hospital ownership differences affected responses to a payment system which encouraged institutional intervention in the practice of medicine. A case study approach was used to observe the influence of the then largest for-profit hospital corporation upon physicians' medical practice in four owned hospitals. Findings indicated that HCA hospital managers were most directly influenced by the local competitive environment and their own personal agendas in responding to PPS incentives. Corporate influence actually softened payment system incentives to intervene in medical practice by providing a generous supply of capital, and by fostering a corporate culture conducive to cooperative relationships with physicians. Better public understanding of the determinants of hospital behavior is needed to preserve or enhance important social goals such as the physician-patient relationship; easily measurable characteristics such as ownership or bed size explain little about hospital behavior or motivation.
The Development of National Medical Care Programs in the United Kingdom and Canada: Applicability to Current Conditions in the United States
Authors: Sakala Carol
Published: January 2008

After a hiatus in the early to mid-1980s, a growing number of policy leaders, policy organizations, and citizen groups are advocating programs that ensure basic medical care for all. Although a large literature examines the applicability to the U.S. of national medical care programs that have been established in other countries from the perspective of operations and effectiveness, little attention has been given to the applicability of the experience of other nations in securing these programs. This paper examines the development of national programs in the U.K. and Canada and addresses two questions. First, what factors were critical to the establishment of the British National Health Service and the Canadian hospital and physician insurance programs? Second, how applicable are those factors to current conditions in the U.S.? The paper reviews the roles played by dislocations in society, by established models of state-sponsored medical care programs, by political institutions and leaders, and by the major medical sectors. It shows that the U.S., while differing in many particulars, presents several parallels to the U.K. and Canada. The paper argues that the current environment in the U.S. offers the nation the opportunity to develop at state or local levels government-sponsored programs that guarantee basic medical benefits to all. A new and powerful coalition, moreover, may in the coming years advance the cause of broader, more substantive change at the national level.
The Willingness to Give: The Public and the Supply of Transplantable Organs
Authors: Prottas Jeffrey M. , Batten Helen Levine
Published: January 2008

We report the results of a representative random-sample telephone survey of the public's willingness to donate organs. Our goal was to identify differences within the public and target groups who might be receptive to educational efforts to increase donation. We distinguish differences in attitude and demographic characteristics in three groups: those committed to donation, those opposed, and those who might change their opinions with more specific information. While approval of donation is nearly universal, only about half of the public would donate a relative's organs when they do not know the relative's preference. Whites, higher-income individuals, and those with higher educational levels were more favorable. Those who might change their minds fall midway between those committed and those opposed, both demographically and by attitude. They include more nonwhites and more individuals with incomes less than $25,000 than members of the group committed to donation. Targeting public education messages to this group is likely to have the most success in reducing the gap between supply and demand for human organs.
Interest Groups or the Public Interest—why Do We Regulate Health Occupations?
Authors: Graddy Elizabeth
Published: January 2008

State regulation of occupations has become more prevalent even while its negative consequences are becoming understood. This raises questions about the source of such regulation and the extent to which the interests of the public are being represented. In my study of the regulation of health occupations, I explore the influence of organized interest groups, of the general public interest, and the structure of the legislature and the political environment. I analyze six health occupations (dietician, nurse-midwife, occupational therapist, physician assistant, psychologist, and social worker) and find that although organized interest groups do influence how these occupations are regulated, the public interest also plays an important role.
Practice Guidelines and Malpractice Litigation: Collision or Cohesion?
Authors: Brennan Troyen A.
Published: January 2008

Practice guidelines are standardized specifications for managing particular clinical problems and are intended to improve the outcomes of medical care by increasing adherence to standards of care. They are also meant to make medicine more cost-effective by eliminating unnecessary procedures. A relatively recent phenomenon, the practice guidelines now emerging will have implications for malpractice, which also intends to bring about better care. They will probably not revolutionize the procedures that courts use to determine negligence, but judges will integrate guidelines into their decision-making process. This development should be welcomed. Guidelines should prove to be useful as either inculpatory or exculpatory evidence of negligence. They are unlikely to generate much new litigation, although there is some potential for suits against those who issue guidelines, especially if guidelines are not revised as the technology of medical care changes.
Epidemics and Agendas: The Politics of Nightly News Coverage of AIDS
Authors: Colby David C. , Cook Timothy E.
Published: January 2008

We examine why the exponential growth of AIDS cases or the widespread professional perception of a health crisis did not move the epidemic more quickly onto the agenda of public problems. One possible explanation focuses on how the national news media's construction of AIDS shaped the meaning of the epidemic for mass and elite audiences. An examination of nightly news coverage by the three major networks from 1982 to 1989 reveals considerable variability and volatility in their coverage. Topic-driven saturation coverage occurred only during three short periods in 1983, 1985, and 1987, when the epidemic seemed likely to affect the “general population.” Only at such moments did public opinion shift and discussion and debate in government begin. Otherwise, the typical AIDS story tended less to sensationalize than to reassure, largely because journalists depended upon government officials and high-ranking doctors to present them with evidence of news. Such sources had interests either in avoiding coverage or in pointing toward breakthroughs; more critical sources, especially within the gay movement, had far less access to the news. In concluding, we considered the prospects and pitfalls of the news media's power to shape the public agenda.
How Do Uncompensated Care Pools Affect the Level and Type of Care? Results from New York State
Authors: Thorpe Kenneth E. , Spencer Christine
Published: January 2008

Uncompensated care pools have been used by several states in their attempt to aid hospitals and increase the volume of care provided to patients without health insurance. We examined the uncompensated care pool used in New York State between 1983 and 1987. Our primary interest was to estimate the impact of the pools on the level and type of care provided to uninsured patients. Our results indicate that hospitals responded to the pools by increasing the volume of care provided to uninsured patients. Without the pools, over 30,000 fewer adjusted hospital admissions would have been provided to the uninsured in a typical year. Many of these newly purchased admissions were for “nondiscretionary” medical care, suggesting that beneficial care to the indigent was rationed prior to the introduction of the uncompensated care pools.
Controlling Large Malpractice Claims: The Unexpected Impact of Damage Caps
Authors: Gronfein William P. , Kinney Eleanor DeArman
Published: January 2008

Indiana's comprehensive malpractice reforms, inaugurated in 1975, include a cap on damages, a mandated medical review before trial, and a state insurance fund to pay claims equal to or greater than $100,000. We have found that the amount of compensation going to claimants with such large malpractice claims in Indiana is, on average, substantially higher than in Michigan and Ohio. Indiana's mean claim severity between 1977 and 1988 was $404,832, while the means for Michigan and Ohio were $290,022 and $303,220, respectively, with the difference between these three means being highly significant. Although data on claim and claimant characteristics reveal considerable interstate variation, the results of regression analyses show that Indiana claim payment amounts are higher than Michigan or Ohio payments, independent of the effect of factors such as sex, age, severity of injury, allegations of negligence, and year of settlement.
Sources of Countervailing Power in Medicine
Authors: Mechanic David
Published: January 2008

In recent years a substantial literature has emerged on the alleged deprofessionalization and proletarianization of physicians. The contention is that corporatization is transforming the practice of medicine, divesting physicians of control over many features of their work, consistent with the needs of advanced capitalism. I examine the hypothesis skeptically, differentiating between the cultural role of medicine, the political and social legitimacy of medical concepts, and the personal autonomy of the individual physician. I suggest that while physicians are less autonomous than they used to be, the constraints imposed on them fall within a medical paradigm. From a cultural or social perspective, medicine is more central to the economy and more powerful than ever before. As its centrality and importance increase, there is more at stake, and interests compete more aggressively. I conclude that there is little evidence in support of the hypothesis.
Capture and Culture: Organizational Identity in New York Blue Cross
Authors: Brown Lawrence D.
Published: January 2008

This article explores the changing corporate culture of New York's Blue Cross and Blue Shield plan in its first fifty years. As the plan grew, corporate culture evolved over four sequential phases: the plan first had the character of an experiment, then that of a movement, a business, and, most recently, a corporate agglomerate. Accompanying this evolution has been an identity crisis, as the need to adapt to a turbulent environment has challenged the plan's settled understanding of its core values, namely, voluntarism, community, and cooperation.
The Effects of Tort Reform on Medical Malpractice Insurance Markets: An Empirical Analysis
Authors: Barker Drucilla K.
Published: January 2008

I use statewide loss ratio data to assess empirically the manner in which tort reforms have affected relative prices and profitability, and underwriting risk in the medical malpractice insurance industry. The empirical evidence suggests that the imposition of statutory ceilings on recoveries both decreased risk and improved relative profitability. Reforms that codified the required standard of care appeared to have a beneficial effect on relative profitability in certain cases.
Physicians' Perceptions of the Risk of Being Sued
Authors: Lawthers Ann G. , Localio A. Russell , Laird Nan M. , Lipsitz Stuart , Hebert Liesi , Brennan Troyen A.
Published: January 2008

We explore the deterrent effect of the tort system by assessing physician perceptions of the risk of being sued and the impact of those perceptions on their own practice. The data are from a mailed survey conducted in 1989 of a random sample of physicians who were practicing in New York State in 1984. The survey results were compared to the actual risk of suit using the between-group (Wald) test and logistic regression methods. We also surveyed physicians about practice changes undertaken in the last ten years, factors influencing practice standards, and the costs of being sued and included these in the analysis. On average, physicians estimate that 19.5 out of one hundred of their colleagues will be sued in a given year, approximately three times the actual rate, with significant differences by specialty, location, and suit history. Perceived risk is associated with self-reported changes in test-ordering frequency and reduction in practice scope. The median number of days lost from practice to defend a malpractice suit was three to five, and 6 percent of the physicians surveyed incurred some out-of-pocket expenses. These findings suggest that physicians respond to the messages sent by litigation in a manner consistent with the deterrent theory of tort litigation.
On Being Old and Sick: The Burden of Health Care for the Elderly in Canada and the United States
Authors: Barer Morris L. , Hertzman Clyde , Miller Robert , Pascali Marina V.
Published: January 2008

The debate over health care reform in the United States has drawn Canada under the microscope. Canada's health care system is frequently offered as a model for American national health insurance. Curiously absent from this policy discussion is any talk about the relative out-of-pocket costs of alternative models. In this paper, we provide data on these costs for American and Canadian elderly for medical, hospital, and ambulatory pharmaceutical use. Despite the fact that the elderly in America are generally viewed as facing fewer problems with access and out-of-pocket costs than younger Americans, their direct costs far exceed those of their Canadian counterparts. We also present data suggesting that, despite these greater costs, rates of growth in use of these services by American elderly have followed roughly the same pattern as those found in Canada. If Uncle Sam retired north of the border, being old and sick would also mean being wealthier and happier.
Home Care in Old Age: A Lost Cause?
Authors: Jamieson Anne
Published: January 2008

I consider policy trends and the provision of home care for frail elderly people in four countries: Denmark, the United Kingdom, Germany, and the United States. The differing natures of the health and social services systems of each country and the welfare ideologies that underlie them have affected the expansion of home care for this group of people. Hence, Denmarkand to a lesser extent Britainhas relatively well developed networks of home care services, in contrast to Germany and the United States. However, any significant shift away from predominantly medical and institutional care to more home-based, social care is highly unlikely.
The Importance of Public Health for Twenty-First-Century Health Care: Lessons from Tuberculosis
Authors: Bovbjerg Randall R.
Published: January 2008

Once epidemic, tuberculosis has reemerged, often in newly drug-resistant forms. This public health threat calls for strong public action as well as improved private care. Action has been hampered by failures in public health infrastructure and legal-philosophical support for government intervention. Josephine Girder's accompanying article usefully suggests rebuilding public-health agencies and adapting traditional authority and controls from the age of epidemics to take account of today's circumstances and sensibilities.