Showing papers by "RAND Corporation published in 1998"

How Good Is the Quality of Health Care in the United States

Abstract: Studies over the past decade show that some people are receiving more care than they need, and some are receiving less. Simple averages from a number of studies indicate that 50 percent of people received recommended preventive care; 70 percent, recommended acute care; 30 percent, contraindicated acute care; 60 percent, recommended chronic care; and 20 percent, contraindicated chronic care. These studies strongly suggest that the care delivered in the United States often does not meet professional standards. Efforts to measure quality and report routinely on the results to the public at large would allow more definitive assessments of the status of the nation's health care and would enable us to single out the areas in need of improvement.

Evidence for a subsurface ocean on Europa

Abstract: Ground-based spectroscopy of Jupiter's moon Europa, combined with gravity data, suggests that the satellite has an icy crust roughly 150 km thick and a rocky interior In addition, images obtained by the Voyager spacecraft revealed that Europa's surface is crossed by numerous intersecting ridges and dark bands (called lineae) and is sparsely cratered, indicating that the terrain is probably significantly younger than that of Ganymede and Callisto It has been suggested that Europa's thin outer ice shell might be separated from the moon's silicate interior by a liquid water layer, delayed or prevented from freezing by tidal heating; in this model, the lineae could be explained by repetitive tidal deformation of the outer ice shell However, observational confirmation of a subsurface ocean was largely frustrated by the low resolution (>2 km per pixel) of the Voyager images Here we present high-resolution (54 m per pixel) Galileo spacecraft images of Europa, in which we find evidence for mobile 'icebergs' The detailed morphology of the terrain strongly supports the presence of liquid water at shallow depths below the surface, either today or at some time in the past Moreover, lower-resolution observations of much larger regions suggest that the phenomena reported here are widespread

The Care of HIV-Infected Adults in the United States

Abstract: Background and Methods In order to elucidate the medical care of patients with human immunodeficiency virus (HIV) infection in the United States, we randomly sampled HIV-infected adults receiving medical care in the contiguous United States at a facility other than a military, prison, or emergency department facility during the first two months of 1996. We interviewed 76 percent of 4042 patients selected from among the patients receiving care from 145 providers in 28 metropolitan areas and 51 providers in 25 rural areas. Results During the first two months of 1996, an estimated 231,400 HIV-infected adults (95 percent confidence interval, 162,800 to 300,000) received care. Fifty-nine percent had the acquired immunodeficiency syndrome according to the case definition of the Centers for Disease Control and Prevention, and 91 percent had CD4+ cell counts of less than 500 per cubic millimeter. Eleven percent were 50 years of age or older, 23 percent were women, 33 percent were black, and 49 percent were men wh...

Influence of emotional engagement and habituation on exposure therapy for PTSD

Abstract: This study examined 2 process variables, emotional engagement and habituation, and outcome of exposure therapy for posttraumatic stress disorder. Thirty-seven female assault victims received treatment that involved repeated imaginal reliving of their trauma, and rated their distress at 10-min intervals. The average distress levels during each of 6 exposure sessions were submitted to a cluster analysis. Three distinct groups of clients with different patterns of distress were found: high initial engagement and gradual habituation between sessions, high initial engagement without habituation, and moderate initial engagement without habituation. Clients with the 1st distress pattern improved more in treatment than the other clients. The results are discussed within the framework of emotional processing theory, emphasizing the crucial role of emotional engagement and habituation in exposure therapy.

Identifying the content area for the 51-item National Eye Institute Visual Function Questionnaire: results from focus groups with visually impaired persons.

Abstract: Objective To identify the content area for a questionnaire designed to measure vision-targeted health-related quality of life and to determine whether problems with vision-related functioning are qualitatively similar across different common eye diseases. Design Twenty-six condition-specific focus groups were conducted with 246 patients from 5 geographic regions to identify the content area for a questionnaire for use among persons with diabetic retinopathy, glaucoma, macular degeneration, cytomegalovirus retinitis, and cataract. A standard protocol was used to structure each focus group discussion. Sessions were audiotaped, transcribed, and coded in preparation for a content analysis. Settings Five university-based ophthalmology practices and 1 nonprofit eye care foundation. Participants Eligible participants had to have 1 of the following eye conditions: age-related cataracts, age-related macular degeneration, diabetic retinopathy, primary open angle glaucoma, cytomegalovirus retinitis, or low vision from any cause. All eligible persons were older than 21 years, spoke English, and had sufficient cognitive function to provide informed consent. Results Among the 246 participants, 2623 problems with vision-related functioning were mentioned. The mean number of problems per person ranged from 13.5 for those with diabetic retinopathy to 7.9 for persons with glaucoma. For the sample overall, reading problems were mentioned most frequently, followed by driving, general problems with seeing clearly, and mental health complaints caused by vision. Although the proportion of persons who reported each problem varied by condition, at least some persons with each eye disease reported each problem. The 3 most common descriptors associated with each problem were difficulty or ease of performance (13%), psychological distress associated with performance of the activity (11%), and complete inability to participate in a visual activity (11%). Conclusion An item-generation strategy for a new questionnaire using a standardized focus group method identified content areas and aspects of visual disability that are not included in currently available vision-specific instruments that assess the impact of common eye diseases on visual functioning in everyday life. Although participants mentioned problems that were unique to their disease, across conditions the problems mentioned were similar. These findings provide empirical evidence of content validity for a vision-targeted, health-related quality-of-life survey designed for use across conditions.

Understanding the Impact of Parent School Involvement on Children's Educational Outcomes

Abstract: Parent school involvement in children's education is associated with positive educational outcomes. This association has prompted efforts to increase such involvement through formal programs. However, among the few programs that have been rigorously evaluated, most do not appear to improve child outcomes. Using data from a study of 193 Los Angeles area 2nd- and 5th-grade children and their mothers, the authors attempted to confirm the relationship between parent involvement and child outcomes and understand what underlies it. The findings indicate that parent school involvement contributes to positive child outcomes. However, such involvement appears to be a manifestation of parental enthusiasm and positive parenting style. Parent-involvement programs might be more effective if they focused on such underlying constructs.

The Reproducibility of a Method to Identify the Overuse and Underuse of Medical Procedures

Abstract: Background To assess the overuse and underuse of medical procedures, various methods have been developed, but their reproducibility has not been evaluated. This study estimates the reproducibility of one commonly used method. Methods We performed a parallel, three-way replication of the RAND–University of California at Los Angeles appropriateness method as applied to two medical procedures, coronary revascularization and hysterectomy. Three nine-member multidisciplinary panels of experts were composed for each procedure by stratified random sampling from a list of experts nominated by the relevant specialty societies. Each panel independently rated the same set of clinical scenarios in terms of the appropriateness of the relevant procedure on a risk–benefit scale ranging from 1 to 9. Final ratings were used to classify the procedure in each scenario as necessary or not necessary (to evaluate underuse) and inappropriate or not inappropriate (to evaluate overuse). Reproducibility was measured by overall agr...

Understanding trends in functional limitations among older Americans.

Abstract: OBJECTIVES: This report documents trends in functional limitations among older Americans from 1984 to 1993 and investigates reasons for such trends. METHODS: We applied logistic regression to data for noninstitutionalized Americans aged 50 years and older from the Survey of Income and Program Participation. We focused on 4 functional limitation measures unlikely to be affected by changes in role expectations and living environments: reported difficulty seeing words in a newspaper, lifting and carrying 10 pounds, climbing a flight of stairs, and walking a quarter of a mile. RESULTS: We found large declines in the crude prevalence of functional limitations, especially for those 80 years and older. Generally, changes in population composition explained only a small portion of the downward trends. Once changes in population composition and mobility-related device use were considered for difficulty walking, significant improvements in functioning remained for the 65- to 79-year-old group. CONCLUSIONS: Changes ...

Perceived Efficacy in Patient-Physician Interactions (PEPPI): Validation of an Instrument in Older Persons

Abstract: OBJECTIVE: To develop and validate a brief instrument – the Perceived Efficacy in Patient-Physician Interactions Questionnaire (PEPPI) – to measure older patients' self-efficacy in obtaining medical information and attention to their medical concerns from physicians. DESIGN: Two consecutive validation surveys. SETTING: Eleven senior multipurpose centers in Los Angeles County California. POPULATION: A convenience sample of 163 community-dwelling older persons (Survey 1: n = 59, mean age = 77.1 years, 76.3% female; Survey 2: n = 104, mean age = 77.4 years, 57.7% female). MEASURES: The 10-item PEPPI, subscales of the Patient Satisfaction Questionnaire, the Medical Outcomes Study (MOS) Coping Scale, the Mastery Scale, and global self-reported health and restricted activity days items. RESULTS: The full 10-item and a 5-item short form of PEFPI demonstrated Cronbach's alphas of 0.91 and 0.83, respectively. PEPPI demonstrated discriminant and convergent validity as hypothesized, correlating negatively with avoidant coping (r = -.27, P =.001) and positively with active coping (r =.17, P =.03) and with patient satisfaction with physician interpersonal manner (r =.49, P <.0001) and communication (r =.51, P <.0001) (values from the overall sample). Further, in the second survey, PEPPI correlated positively with self-reported health (r =.42, P <.0001), education (r =.24, P =.01) and self-mastery (r =.29, P =.01) and negatively with restricted activity days (r = -.25, P =.01). PEPPI-5 demonstrated correlations similar in magnitude, direction, and statistical significance. CONCLUSION: In either the 5- or 10-item version, PEPPI is a valid and reliable measure of older patients' perceived self-efficacy in interacting with physicians. This instrument may be useful in measuring the impact of empowerment interventions to increase older patients' personal sense of effectiveness in obtaining needed health care.

The Persistence of Race and Ethnicity in the use of Long-Term Care

Abstract: We examine the use of nursing homes, formal personal care, informal Activities of Daily Living (ADL) assistance, and no care to identify racial differences in their use. Using the 1987 National Medical Expenditure Survey of both nursing homes and the community, multinominal logistic regressions controlled for predisposing, enabling, and need variables as well as other types of service use. Additional state-level variables make few changes in race/ethnicity parameters, indicating that race/ethnicity are not simply proxies for state-level variables. Older African Americans are less likely to use nursing homes than similar whites, with the lower institutionalization replaced by a higher use of paid home care, informal-only care, and no care. This suggests that formal in-home community care is not fully compensating for the racial differences in nursing home use. Persistent effects of race/ethnicity could be the result of culture, class, and/or discrimination that may impair equitable access to services.

Panel Attrition from the Panel Study of Income Dynamics Household Income, Marital Status, and Mortality

Abstract: This analysis is concerned with the determinants of panel attrition from the Panel Study of Income Dynamics and with its consequences for estimation of dynamic behavioral models which exploit the panel or longitudinal information-household income dynamics, marriage formation and dissolution, and adult mortality risk. We develop and estimate joint models of attrition and one or more of these substantive processes, and allow for correlation across the equations through random effects. Although we find evidence of significant selectivity in attrition behavior, the biases that are introduced by ignoring selective attrition are very mild.

Self-control and criminal opportunity: a prospective test of the general theory of crime

Abstract: The general theory of crime (Gottfredson and Hirschi 1990) proposes that self-control is the primary individual-level cause of crime and that its effect is contingent on criminal opportunity. This study conducted a prospective test of self-control and opportunity as predictors of property crime and personal crime among drug-using offenders. Each predictor had a main effect; property crimes and personal crimes were more frequent among offenders lower on self-control and those with higher opportunity. A significant interaction between these predictors was also detected. About four percent of the variance in each type of crime was explained by these predictors. Results support the proposition that self-control is a causal factor in criminal behavior and suggest that its effect is partially contingent on opportunity, but self-control and opportunity, as measured here, had very modest explanatory power.

Assessing the predictive validity of the RAND/UCLA appropriateness method criteria for performing carotid endarterectomy.

Abstract: We assessed the predictive validity of an expert panel's ratings of the appropriateness of carotid endarterectomy by comparing ratings to the results of subsequent randomized clinical trials. We found the trials confirmed the ratings for 44 indications (covering almost 30% of operations performed in 1981) and refuted the ratings for none.

Does Early Drug Use Increase the Risk of Dropping Out of High School

Abstract: This study examines the impact of early adolescent drug use on subsequent dropping out of high school in a sample of 4,390 adolescents from California and Oregon. Participants were initially surveyed in 7th grade in 1985 and again in 1990 when they should have completed 12th grade. Logistic regression analyses show that frequency of cigarette use during 7th grade predicts dropping out of high school, controlling for demographics, family structure, academic orientation, early deviance, and school environment. Separate analyses by race/ethnicity replicate this finding for Asians, Blacks, and whites, but not for Latinos. For Latinos, early marijuana use predicts dropping out. The results suggest that preventing or reducing the incidence of early smoking and marijuana use may help reduce the probability of dropping out of high school.

Self-Control and Criminal Opportunity Cross-Sectional Test of the General Theory of Crime

Abstract: In this study, the authors tested two hypotheses drawn from the general theory of crime The first hypothesis is that low self-control is a major individual-level cause of crime The second, that the effect of self-control is contingent on criminal opportunity The measure of self-control used was a 23-item self-report index To measure criminal opportunity, two proxy variables were used: gender and crime-involved friends Crime measures included number of criminal acts of force and number of criminal acts of fraud reported in a 6-month recall period by a sample of 522 criminal offenders Self-control was lower among offenders reporting more crimes of force and fraud, but the variance explained by self-control was low in each case The relationship between self-control and fraud crimes was contingent on criminal opportunity, but the relationship between self-control and force crimes was not Implications of these findings for the general theory of crime are reviewed

Remittance behavior among Salvadoran and Filipino immigrants in Los Angeles.

Abstract: This study examines the practice of sending money to family members in their home countries (remittance behavior) among Filipinos and Salvadorans living and working in the United States. These subpopulations are among the largest and fastest-growing groups of Asian and Latin American immigrants to the US. Data were obtained from the 1991 Los Angeles Community Survey of 238 Filipinos and 383 Salvadorans concentrated in specific tracts. Among this population 445 families sent remittances in the year preceding the survey. It is hypothesized that the decision to remit and the amount sent are influenced by individual and income characteristics the motivation to migrate personal investments in the US and family obligations in the US and the country of origin. Findings from logistic models indicate that there were no differences between Filipinos and Salvadorans in the decision to remit. There were significant differences in the amount of money sent. After controlling for individual characteristics findings indicate that Salvadorans sent significantly more money in remittances than Filipinos. Findings confirm that earnings effected remittance behavior. Motivations affected the amount of money sent. Greater investments in the US were related to reduced remittances. Family obligations affected remittance behavior. Households with younger or older respondents were more likely to send remittances. Amounts remitted followed an inverted U-shaped pattern that peaked at 38.8 years. Years of education in the home country and in the US and English language skills were unrelated to remittances. Hours worked on the previous job among unemployed immigrants affected the decision to remit and the amount remitted. Among those currently employed the number of hours of work was unrelated to remittances. Age family income having studied English in the US and living alone were stronger explanatory variables for Filipinos remittance behavior. Different factors explained the decision to remit and the amount remitted.

The logic of ethnic terrorism

Abstract: Ethnic terrorism differs considerably from violence carried out for ideological, religious, or financial motives. Ethnic terrorists often seek to influence their own constituencies more than the country as a whole. Ethnic terrorists frequently seek to foster communal identity, in contrast to an identity proposed by the state. Ethnic terrorists often target potential intermediaries, who might otherwise compromise on identity issues. A secondary goal of the attacks is to create a climate of fear among a rival group's population. Ethnic terrorism creates a difficult problem for the state: conventional countermeasures may engender broader support for an insurgency or a separatist movement even when they hamstring or defeat a specific terrorist group. Because state strategies often backfire, an ideal strategy is to compel “in group” policing—encouraging ethnic moderates through carrots as well as sticks to punish radical activity.

Dispenser with doses counter

Abstract: There is provided a dispenser suitable for dispensing medicament, particularly medicament for use in the treatment of respiratory disorders. The dispenser comprises a housing (1) having a support (5); a container (2), locatable within said housing (1), having an outlet (3), wherein said container (2) dispenses through said outlet (3) in response to movement of the container (2), relative to the housing (1); and an actuation indicator having an indexing mechanism (13, 43) actuatable by movement of the container (2) relative to the housing (1). A couple mechanism (13, 43) is provided which couples the indexing mechanism (13, 43) to the container (2) to compensate for any variation in pre-actuation positionings of the indexing mechanism and container.

Beyond single mothers: cohabitation and marriage in the AFDC program.

Abstract: We investigate the extent and implications of cohabitation and marriage among U.S. welfare recipients. An analysis of four data sets (the Current Population Survey, the National Survey of Families and Households, the Panel Study of Income Dynamics, and the National Longitudinal Survey of Youth) shows significant numbers of cohabitors among recipients of AFDC. An even more surprising finding is the large number of married women on welfare. We also report the results of a telephone survey of state AFDC agencies conducted to determine state rules governing cohabitation and marriage. The survey results indicate that, in a number of respects, AFDC rules encourage cohabitation. Finally, we conduct an analysis of the impact of AFDC rules on cohabitation, marriage, and single motherhood and find weak evidence in support of incentives to cohabit.

Demography and the environment.

Abstract: Demographers' interest in the environment has generally been enmeshed in broader issues of population growth and economic development. Empirical research by demographers on environmental issues other than natural-resource constraints is limited. In this paper, I briefly review past demographic thinking about population and the environment and suggest reasons for the limited scope of demographic research in this area. Next, I describe more recent demographic research on the environment and suggest several newer areas for demographic research. Finally, I consider the future of research on the environment in the field of demography.

Choosing and evaluating clinical performance measures.

Abstract: Article-at-a-Glance Background The importance and utility of routine externally reported assessments of the quality of health care delivered in managed care organizations and hospitals have become widely accepted. Because externally reported measures of quality are intended to inform or lead to action, proposers of such measures have a responsibility to ensure that the results of the measures are meaningful, scientifically sound, and interpretable. Criteria for selecting meaningful assessment areas In choosing clinical performance measures to distinguish among health plans, the condition should have a significant impact on morbidity and/or mortality; the link between the measured processes and outcomes of care should have been established empirically; quality in this area should be variable or substandard currently; and health plans and/or providers should be able to take clinically sensible actions to enhance performance on the measure. Criteria for assessing scientific soundness Scientific soundness—the likelihood that a clinical performance measure will produce consistent and credible results when implemented—involves precision of specifications, adaptability, and adequacy of risk adjustment. Interpretability of results Interpretability is affected by the content of the measure and the audience. Measures that are clinically detailed and specific may be presented more generally to a consumer audience and in full detail to a clinical audience, but measures that are general by nature cannot be made more clinically detailed. Interpretability entails statistical analysis, calibration of measures, modeling, and presentation of information. Conclusions Increased standardization of both the expectations for public release on measures of quality and the criteria by which such measures will be evaluated should contribute to improvements in the larger field of quality assessment.

Cost-effectiveness of care for very low birth weight infants.

Abstract: Objective . Very low birth weight (VLBW)infants (those with birth weights <1500 g) account for only 1.2% of births but 46% of infant deaths. Large improvements in neonatal technology in the last 2 decades have significantly improved survival prospects for infants with low birth weights, but at a high cost. Due largely to a lack of data, the costs of medical care during the period in which infant mortality is measured (the first year of life), as well as the cost-effectiveness of that care for VLBW infants, have not been quantified. Despite this fact, public policies both toward providing insurance coverage for their care, as well as denying payment for their treatment, have either been proposed or implemented on cost-effectiveness grounds. Patients . The study includes all VLBW single live births in the state of California during 1986 and 1987 that were continuously eligible (through traditional channels) for the state's Medicaid program. Main Outcome Measures . Treatment costs were measured for all medical care received during the first year of life, including all inpatient and outpatient care received. The cost-effectiveness of care is measured by aggregate treatment costs for all singleton VLBW liveborns divided by the number of first-year survivors. Results . Average treatment costs per first-year survivor for infants <1500 g was $93 800 (in 1987 constant dollars). Treatment costs per survivor were twice as high for infants <750 g ($273 900) as for the next highest birth weight group 750 to 999 g ($138 800) which was itself almost twice as high as for the 1000 to 1249 g group ($75 100). The gradient in cost-effectiveness with birth weight then drops off to $58 000 per survivor for infants with birth weights between 1250 and 1499 g. Conclusion . Public policies aimed at improving birth outcomes by providing insurance coverage for pregnant women and children, such as the recent Medicaid expansions, can potentially be very cost-effective. Although maternal interventions such as prenatal care are relatively inexpensive, each normal birth that results instead in a VLBW birth saves $59 700 in first year medical expenses. However, cost savings attributable to increased birth weights depend on where in the birth weight distribution the increase occurs as well as the size of the birth weight increase. For infants with birth weights >750 g, significant gains can accrue from even a small shift in the birth weight distribution. A shift of 250 g at birth saves an average of $12 000 to $16 000 in first year medical costs and a shift of 500 g generates $28 000 in savings. However, there is a threshold effect on birth weight. For infants <750 g, increases in birth weight may increase medical expenditures. For instance, a shift in birth weight to the 750 to 999 g range increases costs by $29 000.

Impact of a High School Condom Availability Program on Sexual Attitudes and Behaviors

Abstract: Context While making condoms available in high schools has provoked much debate, evidence on the actual effects of such programs on students' attitudes and behavior is sparse. Methods Prior to implementation of a condom availability program in a Los Angeles County high school, 1,945 students in grades 9-12 (98% of eligible students) completed a self-administered anonymous survey on their sexual behavior and on related knowledge and attitudes; one year later, 1,110 students (59% of eligible students) completed a follow-up survey. Results There was no significant change over time in the percentage of males or females who had ever had vaginal intercourse or who had had vaginal intercourse during the year prior to the survey. The percentage of males who reported using condoms every time they engaged in vaginal intercourse during the past year increased significantly, from 37% to 50%, and the percentage of males who reported condom use at recently initiated first vaginal intercourse increased from 65% to 80%. On the other hand, female respondents showed no significant change in their condom use. The self-reported likelihood of using a condom for vaginal intercourse during the following year did not change significantly for students who had had vaginal intercourse, but it increased dramatically for those who, had never had vaginal intercourse. The students' attitudes toward sex and condom use either remained the same between surveys or changed in a direction favoring less sexual behavior and greater risk prevention. Conclusions The condom availability program appears not to have produced an increase in sexual activity among high school students, and it appears to have led to improved condom use among males. The apparent strong effect on students' intention to use condoms and on males' use at first vaginal intercourse suggests that such programs may have a particular impact on the least sexually experienced adolescents.

Large‐scale Portfolio Assessments in the US: evidence pertaining to the quality of measurement

Abstract: Portfolio assessment, that is, the evaluation of performance by means of a cumulative collection of student work, has figured prominently in recent US debate about education reform. Proponents hope not only to broaden measurement of performance, but also to use portfolio assessment to encourage improved instruction. Although portfolio assessment has sparked considerable attention and enthusiasm, it has been incorporated into only a few of the nearly ubiquitous large‐scale external assessment programmes in the US. This paper evaluates the quality of the performance data produced by several large‐scale portfolio efforts. Evaluations of reliability, which have focused primarily on the consistency of scoring, have yielded highly variable results. While high levels of consistency have been reached in some cases, scoring has been quite inconsistent in others, to the point of severely limiting the utility of scores. Information about other aspects of validity is more limited and generally discouraging. ...

Increasing Immunization Rates Among Inner-City, African American Children A Randomized Trial of Case Management

Abstract: Context.— Immunization rates in the inner city remain lower than in the general US population, but efforts to raise immunization levels in inner-city areas have been largely untested. Objective.— To assess the effectiveness of case management in raising immunization levels among infants of inner-city, African American families. Design.—Randomized controlled trial with follow-up through 1 year of life.Setting.—Low-income areas of inner-city Los Angeles, Calif.Patients.—A representative sample of 419 African American infants and their families.Interventions.— In-depth assessment by case managers before infants were 6 weeks of age, with home visits 2 weeks prior to when immunizations were scheduled and additional follow-up visits as needed. Main Outcome Measures.— Percentage of children with up-to-date immunizations at age 1 year, characteristics associated with improved immunization rates, and cost-effectiveness of case management intervention. Results.— A total of 365 newborns were followed up to age 1 year. Overall, the immunization completion for the case management group was 13.2 percentage points higher than the control group (63.8% vs 50.6%; P=.01). In a logistic model, the case management effect was limited to the 25% of the sample who reported 3 or fewer well-child visits (odds ratio, 3.43; 95% confidence interval, 1.26-9.35); for them, immunization levels increased by 28 percentage points. Although for the case management group intervention was not cost-effective ($12022 per additional child immunized), it was better ($4546) for the 25% of the sample identified retrospectively to have inadequate utilization of preventive health visits. Conclusions.— A case management intervention in the first year of life was effective but not cost-effective at raising immunization levels in inner-city, African American infants. The intervention was demonstrated to be particularly effective for subpopulations that do not access well-child care; however, currently there are no means to identify these groups prospectively. For case management to be a useful tool to raise immunizations levels among high-risk populations, better methods of tracking and targeting, such as immunization registries, need to be developed.

Ensuring the Longevity of Digital Information

Abstract: Digital documents are replacing paper in the most dramatic record-keeping revolution since the invention of printing. Is the current generation of these documents doomed to be lost forever? Note: this paper is an expanded version of the article \" Ensuring the Longevity of Digital Documents \

Nonprofit Production and Competition

Abstract: Industries in which private nonprofit production is present and significant, such as health care and education, account for more than one-fifth of US economic activity. This paper argues that previous analysis of nonprofits has not separated profit-deviating preferences from the state-defined regulatory status of nonprofit production. We argue that this separation is crucial in providing predictions about the underlying forces which allow the coexistence of nonprofit and for-profit production in an industry, as well as predictions about such fundamental matters as the share of nonprofit activity. By separating choice of nonprofit status from profit-deviating preferences, the paper provides predictions about the forces which determine the share of nonprofit production in an industry. We argue that this share falls with the share of the demand that is publicly subsidized, rises with the total number of firms in the industry, and rises with growth in the pace or extent of cost-reductions resulting from learning-by-doing. These predictions stem from a basic aspect of regulatory nonprofit choice which links the degree of competition in a market with the share of nonprofits: the availability of economic profits under for-profit status raises the cost of choosing nonprofit status when such a status is associated with a distribution constraint. Empirical evidence using panel data on US states in the long-term care industry from 1989 to 1994 suggests the presence of the discussed predictions in this industry.