bluuebunny/crossref_metadata_2025_split huggingface dataset:
Changes in Hospital Competitive Strategy: A New Medical Arms Race?
Authors: Devers Kelly J. , Brewster Linda R. , Casalino Lawrence P. 
Published: March 2003

Objective To describe changes in hospitals' competitive strategies, specifically the relative emphasis placed on strategies for competing along price and nonprice (i.e., service, amenities, perceived quality) dimensions, and the reasons for any observed shifts.Methods This study uses data gathered through the Community Tracking Study site visits, a longitudinal study of a nationally representative sample of 12 U.S. communities. Research teams visited each of these communities every two years since 1996 and conducted between 50 to 90 semistructured interviews. Additional information on hospital competition and strategy was gathered from secondary data.Principal Findings We found that hospitals' strategic emphasis changed significantly between 1996–1997 and 2000–2001. In the mid‐1990s, hospitals primarily competed on price through “wholesale” strategies (i.e., providing services attractive to managed care plans). By 2000–2001, nonprice competition was becoming increasingly important and hospitals were reviving “retail” strategies (i.e., providing services attractive to individual physicians and the patients they serve). Three major factors explain this shift in hospital strategy: less than anticipated selective contracting and capitated payment; the freeing up of hospital resources previously devoted to horizontal and vertical integration strategies; and, the emergence and growth of new competitors.Conclusion Renewed emphasis on nonprice competition and retail strategies, and the service mimicking and one‐upmanship that result, suggest that a new medical arms race is emerging. However, there are important differences between the medical arms race today and the one that occurred in the 1970s and early 1980s: the hospital market is more concentrated and price competition remains relatively important. The development of a new medical arms race has significant research and policy implications.
Expanding the Andersen Model: The Role of Psychosocial Factors in Long‐Term Care Use
Authors: Bradley Elizabeth H , McGraw Sarah A , Curry Leslie , Buckser Alison , King Kinda L , Kasl Stanislav V , Andersen Ronald 
Published: March 2003

Objective. To examine a prevailing conceptual model of health services use (Andersen 1995) and to suggest modifications that may enhance its explanatory power when applied to empirical studies of race/ethnicity and long‐term care.Study Setting. Twelve focus groups of African‐American (five groups) and white (seven groups) individuals, aged 65 and older, residing in Connecticut during 2000.Study Design. Using qualitative analysis, data were coded and analyzed in NUD‐IST 4 software to facilitate the reporting of recurrent themes, supporting quotations, and links among the themes for developing the conceptual framework. Specific analysis was conducted to assess distinctions in common themes between African‐American and white focus groups.Data Collection. Data were collected using a standardized discussion guide, augmented by prompts for clarification. Audio taped sessions were transcribed and independently coded by investigators and crosschecked to enhance coding validity. An audit trail was maintained to document analytic decisions during data analysis and interpretation.Principal Findings. Psychosocial factors (e.g., attitudes and knowledge, social norms, and perceived control) are identified as determinants of service use, thereby expanding the Andersen model (1995). African‐American and white focus group members differed in their reported accessibility of information about long‐term care, social norms concerning caregiving expectations and burden, and concerns of privacy and self‐determination.Conclusions. More comprehensive identification of psychosocial factors may enhance our understanding of the complex role of race/ethnicity in long‐term care use as well as the effectiveness of policies and programs designed to address disparities in long‐term care service use among minority and nonminority groups.
Trust in the Medical Profession: Conceptual and Measurement Issues
Authors: Hall Mark A , Camacho Fabian , Dugan Elizabeth , Balkrishnan Rajesh 
Published: March 2003

Objective. To develop and test a multi‐item measure for general trust in physicians, in contrast with trust in a specific physician.Data Sources. Random national telephone survey of 502 adult subjects with a regular physician and source of payment.Study Design. Based on a multidimensional conceptual model, a large pool of candidate items was generated, tested, and revised using focus groups, expert reviewers, and pilot testing. The scale was analyzed for its factor structure, internal consistency, construct validity, and other psychometric properties.Principal Findings. The resulting 11‐item scale measuring trust in physicians generally is consistent with most aspects of the conceptual model except that it does not include the dimension of confidentiality. This scale has a single‐factor structure, good internal consistency (alpha=.89), and good response variability (range=11–54; mean=33.5; SD=6.9). This scale is related to satisfaction with care, trust in one's physician, following doctors' recommendations, having no prior disputes with physicians, not having sought second opinions, and not having changed doctors. No association was found with race/ethnicity. While general trust and interpersonal trust are qualitatively similar, they are only moderately correlated with each other and general trust is substantially lower.Conclusions. Emerging research on patients' trust has focused on interpersonal trust in a specific, known physician. Trust in physicians in general is also important and differs significantly from interpersonal physician trust. General physician trust potentially has a strong influence on important behaviors and attitudes, and on the formation of interpersonal physician trust.
An Approach to Forecasting Health Expenditures, with Application to the U.S. Medicare System
Authors: Lee Ronald , Miller Timothy 
Published: March 2003

Objective. To quantify uncertainty in forecasts of health expenditures.Study Design. Stochastic time series models are estimated for historical variations in fertility, mortality, and health spending per capita in the United States, and used to generate stochastic simulations of the growth of Medicare expenditures. Individual health spending is modeled to depend on the number of years until death.Data Sources/Study Setting. A simple accounting model is developed for forecasting health expenditures, using the U.S. Medicare system as an example.Principal Findings. Medicare expenditures are projected to rise from 2.2 percent of GDP (gross domestic product) to about 8 percent of GDP by 2075. This increase is due in equal measure to increasing health spending per beneficiary and to population aging. The traditional projection method constructs high, medium, and low scenarios to assess uncertainty, an approach that has many problems. Using stochastic forecasting, we find a 95 percent probability that Medicare spending in 2075 will fall between 4 percent and 18 percent of GDP, indicating a wide band of uncertainty. Although there is substantial uncertainty about future mortality decline, it contributed little to uncertainty about future Medicare spending, since lower mortality both raises the number of elderly, tending to raise spending, and is associated with improved health of the elderly, tending to reduce spending. Uncertainty about fertility, by contrast, leads to great uncertainty about the future size of the labor force, and therefore adds importantly to uncertainty about the health‐share of GDP. In the shorter term, the major source of uncertainty is health spending per capita.Conclusions. History is a valuable guide for quantifying our uncertainty about future health expenditures. The probabilistic model we present has several advantages over the high–low scenario approach to forecasting. It indicates great uncertainty about future Medicare expenditures relative to GDP.
Plan Characteristics and SSI Enrollees' Access to and Quality of Care in Four TennCare MCOs
Authors: Hill Steven C , Wooldridge Judith 
Published: March 2003

Objective. To assess hypotheses about which managed care organization (MCO) characteristics affect access to care and quality of care—including access to specialists, providers' knowledge about disability, and coordination of care—for people with disabilities.Data Sources/Study Setting. Survey of blind/disabled Supplemental Security Income (SSI) enrollees in four MCOs serving TennCare, Tennessee's Medicaid managed care program, in Memphis, conducted from 1998 through spring 1999.Study Design. We compared enrollee reports of access and quality across the four MCOs using regression methods, and we use case study methods to assess whether patterns both within and across MCOs are consistent with the hypotheses.Data Collection. We conducted computer‐assisted telephone surveys and used regression analysis to compare access and quality controlling for enrollee characteristics.Principal Findings. Although the four MCOs' characteristics varied, access to providers, coordination of care, and access to some services were generally similar across MCOs. Enrollees in one plan, the only MCO with a larger provider network and that paid physicians on a fee‐for‐service basis, reported their providers were more knowledgeable, and they had more secondary preventive care visits. Differences found in access to specialists and delays in approving care appear to be unrelated to characteristics reported by the MCOs, but instead may be related to how tightly utilization is reviewed.Conclusions. Plan networks, financial incentives, utilization management methods, and state requirements are important areas for further study, and, in the meantime, ongoing monitoring of SSI enrollees in each MCO may be important for detecting problems and successes.
Using Medicare Data to Estimate the Prevalence of Breast Cancer Screening in Older Women: Comparison of Different Methods to Identify Screening Mammograms
Authors: Randolph Whitney M , Mahnken Jonathan D , Goodwin James S , Freeman Jean L 
Published: March 2003

Objectives. To compare different methods for defining screening mammograms with Medicare claims and their impact on estimates of breast cancer screening rates.Methods. Medicare outpatient facility and physician claims for 61,962 women in 1993 and 59,652 women in 1998 were reviewed for evidence of receipt of screening mammography. We compared the estimates of screening mammography use derived from CPT (Current Procedure Terminology) codes to categorize mammograms as screening or diagnostic versus using an algorithm that uses CPT codes plus breast‐related diagnoses in the prior two years. We also compared estimates obtained from review of physician claims alone, facility claims alone, or the combination of the two sources of claims.Results. Use of physician claims alone produced estimates of screening rates similar to rates calculated from use of both physician and outpatient (facility) claims. In 1993, the CPT code for screening mammography underestimated the rate of screening compared to estimates generated by using the algorithm (8.3 percent versus 18.0 percent prevalence, p<0.001). By 1998, the screening prevalence rate generated from using the CPT code for screening mammography more closely approximated the rate generated by the algorithm (23.0 percent versus 25.1 percent). By all methods of estimating screening mammography with Medicare claims, its prevalence increased substantially between 1993 and 1998.Conclusion. Providers increased their use of the screening mammography code in their charges to Medicare during the 1990s. This has improved the claims' ability to distinguish screening from diagnostic mammograms, but screening rates computed with claims continue to fall below those generated from self‐reports of mammography use among general populations of older women.
Canadian consumption and portfolio shares
Authors: Normandin Michel , St–Amour Pascal 
Published: March 2003

In this paper we gauge consumption and portfolio shares, rather than the traditional pricing implications. We study both aggregated (financial, tangible, and human) and disaggregated (deposits, stocks, insurance, and pensions) assets. The empirical shares are computed from recent aggregate Canadian data. The theoretical shares are constructed from a flexible specification of both investors’ preferences and investment opportunities. Our results reveal that the theoretical shares statistically match observed consumption and aggregated assets, but not disaggregated assets. Also, our findings for corporate stocks are consistent with the empirical asset returns literature. Finally, our findings for other assets highlight several new striking features. JEL classification: G11 Consommation et parts de porte feuille au Canada. Cette recherche analyse la consommation et les parts de portefeuille, plutôt que les prix des actifs. Nous étudions les actifs agrégés (i.e., financiers, tangibles et humains) ainsi que désagrégés (i.e., dépôts, actions et caisses de retraite et assurance). Les parts empiriques sont calculées pour des données agrégées canadiennes récentes. Les parts théoriques sont construites à partir d’un modèle flexible en ce qui a trait aux préférences et aux possibilités d’investissement. Nos résultats démontrent que les parts théoriques reproduisent la consommation et les parts agrégées, mais pas les parts désagrégées. Aussi, nos résultats sont cohérents avec ceux de la littérature empirique sur les rendements. Nos résultats concernant les autres actifs identifient d’autres aspects caractéristiques.
Uncertainty, arbitrage and intra–industry trade
Authors: Dasgupta Sudipto , Ray Tridip , Wong Kit Pong 
Published: March 2003

When firms in the same industry located in different regions or countries experience shocks to production costs in their respective industries that are imperfectly correlated, arbitrage opportunities automatically lead to trade. Trade can either stabilize or destabilize the price faced by producers in a given country. Producers’ surplus is affected, owing to the ‘variance–covariance’ effect, while consumers’ surplus is more directly affected through the variance of the product price. We examine how consumers’ surplus, producers’ surplus, and social welfare are affected when the regions switch from autarky to free trade in the presence of industry and region–specific cost shocks. JEL Classification: F10, D80 Incertitude, arbitrage et commerce intra–industrie. Quand les entreprises d’une même industrie localisées dans diverses régions ou différents pays font face à des chocs, qui ne sont pas parfaitement co–reliés, dans leurs coûts de production, les possibilités d’arbitrage entraînent automatiquement un accroissement du commerce. Ce commerce inter–régional ou international peut soit stabiliser ou déstabiliser les prix auxquels les producteurs font face dans un pays donné. Le surplus aux producteurs est directement affecté via l’effet de «variance–covariance», alors que le surplus aux consommateurs est plus directement affecté via la variance du prix du produit. Ce mémoire examine comment le surplus aux producteurs, le surplus aux consommateurs, et le niveau de bien–être social sont affectés quand les régions passent de l’autarcie au libre échange dans le cas où existent des chocs dans les coûts qui sont spécifiques à l’industrie et à la région.
Relationship between mite, cat, and dog allergens in reservoir dust and ambient air
Authors: Custovic A , Simpson B , Simpson A , Hallam C , Craven M , Woodcock A 
Published: March 2003

Background: Standardized methods to measure allergen exposure are essential to assess the relationship between exposure, sensitization, and asthma. Most studies have measured allergen levels in reservoir dust, although air samples may be more representative as a measure of inhaled allergen. The aim of this study was to define the relationship between mite, cat, and dog allergen content in the reservoir dust and the levels in the ambient air. Methods: Dust samples from the living‐room floor (LF) and sofa (S) were collected in 127 homes: 62 without and 65 with pets (31 dogs, 34 cats). Air samples were taken in the same room, with a high‐volume pump for 1 h (flow 60 l/min). Der p 1, Fel d 1, and Can f 1 were determined by mAb‐based ELISA. Results: Airborne Der p 1 was below the detection limit (0.8 ng/m3) in all homes, with reservoir levels (GM and range) being 1.14 μg/g (0.2–66) and 1.15 μg/g (0.2–127) in LF and S, respectively. Airborne Can f 1 was detected in 40/62 homes without pets (range 0.6–12.4 ng/m3) and in all homes with dogs (range 0.5–99 ng/m3). In the multiple linear regression analysis, Can f 1 level in the LF was an independent correlate of the airborne Can f 1 (P=0.01, homes with dogs; P=0.04, homes without dogs). Fel d 1 was detected in the air in 16/62 homes without pets (range 0.16–1.8 ng/m3) and in all homes with cats (range 0.4–22.3 ng/m3). Fel d 1 level in the LF was an independent correlate of the airborne Fel d 1 in homes without cats (P=0.008), but airborne levels in homes with cats did not correlate with reservoir levels. Conclusions: The aerodynamics of each allergen must be taken into account when assessing exposure: while levels in reservoir dust are the best available index for mite allergens, airborne levels might be more suitable for defining exposure to pets. If air samples are difficult to obtain, levels of Can f 1 and Fel d 1 in the LF samples should be used as a surrogate measure of personal exposure.
Experimental common cold increases mucosal output of eotaxin in atopic individuals
Authors: Greiff Lennart , Andersson Morgan , Svensson Christer , Andersson Eva , Linden Margareta , Myint Steven , Persson Carl G.A. 
Published: March 2003

Background: In view of recent observations demonstrating that rhinovirus infections are associated with increased local activity of eosinophils, we hypothesized that eotaxin, a selective eosinophil chemoattractant, may be involved in eosinophil recruitment/activation in common cold infections. Methods: Twenty‐three patients with seasonal allergic rhinitis were inoculated with human rhinovirus 16 (HRV 16) outside the pollen season. Sequential diluent and allergen (103 SQ‐U) challenges, each followed by nasal lavage, were carried out about 3 months before and 4 days after virus inoculation. Results: Seventeen patients developed common cold and were further analyzed. Lavage fluid levels of eotaxin were increased at the height of active common cold (day 4 after inoculation) both at baseline (after diluent challenge) (P<0.01) and acutely after allergen challenge (P<0.05). Conclusions: Common cold symptoms after nasal HRV 16 inoculation are associated with increased nasal mucosal output of eotaxin, suggesting that this chemokine is partly responsible for recruitment/activation of airway mucosal eosinophils in common cold infections.
Effect of pre‐ and postnatal tobacco smoke exposure on specific sensitization to food and inhalant allergens during the first 3 years of life
Authors: Kulig M , Luck W , Lau S , Niggemann B , Bergmann R , Klettke U , Guggenmoos‐Holzmann† I , Wahn U ,   Multicenter Allergy and Study Group, Germany
Published: March 2003

Background: The study aimed to assess the effect of pre‐ and postnatal tobacco smoke exposure on specific sensitization to food allergens and inhalant allergens during the first 3 years of life. Methods: A total of 342 children of a prospective and observational birth cohort study on atopy (MAS) were included on the basis of a complete follow‐up of specific IgE measurements at the ages of 1, 2, and 3 years with available questionnaire information about the parental smoking habit at birth, 18 months, and 3 years of age. Study children were grouped into four exposure categories representing in utero and postnatal environmental tobacco smoke (ETS) exposure, and according to the number of cigarettes smoked by the parents. The effect on the development of allergic sensitization to food, outdoor, and indoor allergens by 3 years of age was determined by multiple logistic regression analyses. Results: At the age of 3, children who were pre‐ and postnatally exposed to tobacco smoke had a significantly higher risk of sensitization to food allergens (odds ratio: 2.3, 95% C.I.: 1.1–4.6) than unexposed children. Children who were only postnatally exposed by a smoking mother also had a 2.2 times higher risk (95% C.I.: 0.9–5.9) of sensitization than unexposed children. These two categories (pre‐ and/or postnatal exposure) contribute to the significant overall effect of the tobacco smoke exposure (P≤0.02). No significant association between tobacco smoke exposure and specific sensitization to inhalant allergens was observed. The determining risk factors for this type of sensitization were atopic family history and mite‐ and cat‐allergen exposure levels. Conclusions: During the first 3 years of life, both prenatal and postnatal tobacco smoke exposure has an adjuvant effect on allergic sensitization which seems to be restricted to allergens to which children are mainly exposed, in combination with the peak of the ETS exposure around the first birthday.
Suppressive activity of bronchial macrophages recovered by induced sputum
Authors: Fireman E , Onn A , Levo Y , Bugolovov E , Kivity S 
Published: March 2003

Background: The immunomodulatory activity of macrophages was shown to be a crucial mechanism in the pathogenesis of asthma. Methods: Induced sputum (IS) and methacholine challenge (MC) were carried out in 21 atopic subjects. Suppressive activity (SA) of sputum macrophages (SMO) was investigated on autologous peripheral lymphocytes (APL) proliferation in 12 of these patients and compared to the MC. Results: In 10 of the 21 patients, the FEV1 was >80%; five of these had a nonreactive MC. Eosinophils and metachromatic cells correlated well (r=0.6442; P=0.0029), but not with the MC. The SA of SMO correlated (P=0.0152) with the MC: SMO enhanced APL proliferation in five patients with a positive MC, while SMO showed SA in five with a negative MC. Only two patients with suppressive SMO had a positive MC. Cytokine profiles from five patients showed that two patients with a negative MC had interleukin (IL)‐1α and β, IL‐6, and transforming growth factor (TGF)‐β transcripts, while two patients with a positive MC transcripted IL‐4 and IL‐5. One patient with a borderline MC transcripted IL‐5, but not IL‐4. Conclusions: These data support the theory that patients with reduced suppressive bronchial macrophages display clinical bronchial hyperreactivity.