Showing papers by "RAND Corporation published in 1999"

Healthy Bodies and Thick Wallets: The Dual Relation Between Health and Economic Status

Abstract: The first section of this paper documents the size of the association between health and one prominent economic status measure--household wealth. The next section deals with how health influences economic status by sketching out reasons why health may alter household savings (and eventually wealth) and then providing estimates of the empirical magnitude of these effects. The third section shifts attention to the other pathway--the links between economic status and health--and summarizes major controversies and evidence surrounding these issues.

Variations in the Care of HIV-Infected Adults in the United States: Results From the HIV Cost and Services Utilization Study

Abstract: ContextStudies of selected populations suggest that not all persons infected with human immunodeficiency virus (HIV) receive adequate care.ObjectiveTo examine variations in the care received by a national sample representative of the adult US population infected with HIV.DesignCohort study that consisted of 3 interviews from January 1996 to January 1998 conducted by the HIV Cost and Services Utilization Consortium.Patients and SettingMultistage probability sample of 2864 respondents (68% of those targeted for sampling), who represent the 231,400 persons at least 18 years old, with known HIV infection receiving medical care in the 48 contiguous United States in early 1996 in facilities other than emergency departments, the military, or prisons. The first follow-up consisted of 2466 respondents and the second had 2267 (65% of all surviving sampled subjects).Main Outcome MeasuresService utilization (<2 ambulatory visits, at least 1 emergency department visit that did not lead to hospitalization, at least 1 hospitalization) and medication utilization (receipt of antiretroviral therapy and prophylaxis against Pneumocystis carinii pneumonia).ResultsInadequate HIV care was commonly reported at the time of interviews conducted from early 1996 to early 1997 but declined to varying degrees by late 1997. Twenty-three percent of patients initially and 15% of patients subsequently had emergency department visits that did not lead to hospitalization, 30% initially and 26% subsequently of those who had CD4 cell counts below 0.20,×109/L did not receive P carinii pneumonia prophylaxis, and 41% initially and 15% subsequently of those who had CD4 cell counts below 0.50×109/L did not receive antiretroviral therapy (protease inhibitor or nonnucleoside reverse transcriptase inhibitor). Inferior patterns of care were seen for many of these measures in blacks and Latinos compared with whites, the uninsured and Medicaid-insured compared with the privately insured, women compared with men, and other risk and/or exposure groups compared with men who had sex with men even after CD4 cell count adjustment. With multivariate adjustment, many differences remained statistically significant. Even by early 1998, fewer blacks, women, and uninsured and Medicaid-insured persons had started taking antiretroviral medication (CD4 cell count adjusted P values <.001 to <.005).ConclusionsAccess to care improved from 1996 to 1998 but remained suboptimal. Blacks, Latinos, women, the uninsured, and Medicaid-insured all had less desirable patterns of care. Strategies to ensure optimal care for patients with HIV requires identifying the causes of deficiency and addressing these important shortcomings in care.

The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior.

Abstract: Context. Despite growing concern over the escalating antimicrobial resistance problem, physicians continue to inappropriately prescribe. It has been suggested that a major determinant of pediatrician antimicrobial prescribing behavior is the parental expectation that a prescription will be provided. Objectives. To explore the extent to which parental previsit expectations and physician perceptions of those expectations are associated with inappropriate antimicrobial prescribing; and to explore the relationship between fulfillment of expectations and parental visit-specific satisfaction. Design. Previsit and postvisit survey of parents and postvisit survey of physicians. Setting. Two private pediatric practices, one community based and one university based. Participants. Ten physicians (response rate = 77%), and a consecutive sample of 306 eligible parents (response rate = 86%) who were attending sick visits for their children between October 1996 and March 1997. Parents were screened for eligibility in the waiting rooms of the two practices and were invited to participate if they spoke and read English and their child was 2 to 10 years old, had a presenting complaint of ear pain, throat pain, cough, or congestion, was off antimicrobial therapy for the past 2 weeks, and was seeing one of the participating physicians. Main Outcome Measures. Antimicrobial prescribing decision, probability of assigning a bacterial diagnosis, and parental visit-specific satisfaction. Results. Based on multivariate analysis, physicians9 perceptions of parental expectations for antimicrobials was the only significant predictor of prescribing antimicrobials for conditions of presumed viral etiology; when physicians thought a parent wanted an antimicrobial, they prescribed them 62% of the time versus 7% of the time when they did not think the parent wanted antimicrobials. However, physician antimicrobial prescribing behavior was not associated with actual parental expectations for receiving antimicrobials. In addition, when physicians thought the parent wanted an antimicrobial, they were also significantly more likely to give a bacterial diagnosis (70% of the time versus 31% of the time). Failure to meet parental expectations regarding communication events during the visit was the only significant predictor of parental satisfaction. Failure to provide expected antimicrobials did not affect satisfaction. Conclusions. The antibiotic resistance epidemic should lead to immediate replication of this study in a larger more generalizable population. If inaccurate physician perceptions of parent desires for antimicrobials for viral infections are confirmed, then an intervention to change the way physicians acquire this set of perceptions should be undertaken.

Are Latinos Less Satisfied with Communication by Health Care Providers

Abstract: OBJECTIVE: To examine associations of patient ratings of communication by health care providers with patient language (English vs Spanish) and ethnicity (Latino vs white).

Costs of medical injuries in Utah and Colorado

Abstract: Patient injuries are thought to have a substantial financial impact on the health care system, but recent studies have been limited to estimating the costs of adverse drug events in teaching hospitals. This analysis estimated the costs of all types of patient injuries from a representative sample of hospitals in Utah and Colorado. We detected 459 adverse events (of which 265 were preventable) by reviewing the medical records of 14,732 randomly selected 1992 discharges from 28 hospitals. The total costs (all results are discounted 1996 dollars) were $661,889,000 for adverse events, and $308,382,000 for preventable adverse events. Health care costs totaled $348,081,000 for all adverse events and $159,245,000 for the preventable adverse events. Fifty-seven percent of the adverse event health care costs, and 46% of the preventable adverse event costs were attributed to outpatient medical care. Surgical complications, adverse drug events, and delayed or incorrect diagnoses and therapies were the most expensive types of adverse events. The costs of adverse events were similar to the national costs of caring for people with HIV/AIDS, and totaled 4.8% of per capita health care expenditures in these states.

Coup-proofing: Its Practice and Consequences in the Middle East

Abstract: In the aftermath of the U.S.-led coalition’s defeat of Iraq in the Gulf War, many observers believed that Saddam Hussein would eventually be toppled in a military coup. After years of dashed hopes, however, few expect that the Iraqi military is likely to undertake such action. Many analysts claim that the Iraqi regime is, in fact, coup-proof. Saddam Hussein’s staying power should cause any similarly led U.S. coalition to rethink not just the possibilities of both coups and coupprooang but how it would aght and defeat a coup-proof regime. In this article, I analyze how states become coup-proof, focusing speciacally on the policies that Saudi Arabia, Iraq, and Syria have adopted to achieve this goal. These policies include reliance on groups with special loyalties to the regime and the creation of parallel military organizations and multiple internal security agencies. The United States has a particular interest in how these countries have made their regimes coup-proof. Saudi Arabia is an important U.S. ally, Iraq is a hostile state, and Syria is somewhere in between. Conoict between the United States and either Iraq or Syria, however, pits a superpower with a short attention span against regimes that have accepted serious constraints on their ability to exercise their full military potential. Both states have developed heavily politicized militaries that are incapable of realizing this potential as long as their leaderships continue to divert resources to protect their regimes. At the same time, they have created a militarized politics that is surprisingly resilient in the face of defeat. If a U.S-led coalition decides that it wants to overthrow a coup-proofed regime through military action, it will have to devote serious attention to the regime’s true underpinnings. Field commanders will need more extensive means of understanding their opponent’s political-military situation and greater insight into the coalition’s political intentions. Moreover, the coordination of political-military operations will require greater political involvement

The Impact of Competing Subsistence Needs and Barriers on Access to Medical Care for Persons with Human Immunodeficiency Virus Receiving Care in the United States

Abstract: Objectives.To examine whether competing subsistence needs and other barriers are associated with poorer access to medical care among persons infected with human immunodeficiency virus (HIV), using self-reported data.Design.Survey of a nationally representative sample of 2,864 adults receiving HIV ca

Diffusion in Homicide: Exploring a General Method for Detecting Spatial Diffusion Processes

Abstract: This article proposes a new method for examining dynamic changes in thespatial distribution of a phenomenon. Recently introduced exploratoryspatial data analysis (ESDA) techniques provide social scientists with anew set of tools for distinguishing between random and nonrandom spatialpatterns of events (Anselin, 1998). Existing ESDA measures, however, arestatic and do not permit comparisons of distributions of events in the samespace but across different time periods. One ESDA method—the Moranscatterplot—has special heuristic value because it visually displayslocal spatial relationships between each spatial unit and its neighbors. Weextend this static cross-sectional view of the spatial distribution ofevents to consider dynamic features of changes over time in spatialdependencies. The method distinguishes between contagious diffusion betweenadjoining units and hierarchical diffusion that spreads broadly throughcommonly shared influences. We apply the method to homicide data, lookingfor evidence of spatial diffusion of youth-gang homicides acrossneighborhoods in a city. Contagious diffusion between neighboring censustracts is evident only during the year of peak growth in total homicides,when high local rates of youth-gang homicides are followed by significantincreases in neighboring youth- nongang rates. This pattern is consistentwith a spread of homicides from gang youth to nongang youth. Otherwise, theincreases in both youth-gang and youth- nongang homicides generally occursimultaneously in nonneighboring tracts.

Functioning and Utility for Current Health of Patients With Depression or Chronic Medical Conditions in Managed, Primary Care Practices

Abstract: Background: Health utility is the recommended outcome metric for medical cost-effectiveness studies. We compared health utility and quality of life for primary care patients with depression or chronic medical conditions. Methods: Respondents were outpatients (N = 17 558) of primary care clinicians (N = 181) in 7 managed care organizations. Utility was assessed by time tradeoff, or the years of life that patients would exchange for perfect health, and standard gamble, or the required chance of success to accept a treatment that can cause immediate death or survival in perfect health. Probable 12-month depressive disorder and affective syndromes were assessed through self-report items from a diagnostic interview. Medical conditions were assessed with selfreport. Quality of life was assessed by the 12-Item ShortForm Health Survey. Regression models were used to compare quality of life and utility for patients with depression vs chronic medical conditions. Results: Patients with probable 12-month depressive disorder had worse mental health and role-emotional and social functioning and lower utility for their current health than patients with each chronic medical condition (for most comparisons, P,.001). Depressed patients had worse physical functioning than patients with 4 common chronic conditions but better physical functioning than patients with 4 other conditions (each P,.001). Patients with lifetime bipolar illness and 12-month double depression had the poorest quality of life and lowest utility. Conclusions: Primary care patients with depressive conditions have poorer mental, role-emotional, and social functioning than patients with common chronic medical conditions, and physical functioning in the midrange. The low utility of depressed patients relative to patients with chronic medical conditions suggests that recovery from depression should be a high practice priority. Arch Gen Psychiatry. 1999;56:897-904

A randomized clinical trial of outpatient comprehensive geriatric assessment coupled with an intervention to increase adherence to recommendations.

Abstract: BACKGROUND: Although comprehensive geriatric assessment (CGA) has been demonstrated to confer health benefits in some settings, its value in outpatient or office settings is uncertain. OBJECTIVE: To assess the effectiveness of outpatient CGA consultation coupled with an adherence intervention on 15-month health outcomes. DESIGN: A randomized controlled trial. SETTING: Community-based sites. PATIENTS: 363 community-dwelling older persons who had failed a screen for at least one of four conditions (falls, urinary incontinence, depressive symptoms, or functional impairment) INTERVENTION: A single outpatient CGA consultation coupled with an intervention to improve primary care physician and patient adherence with CGA recommendations. MEASUREMENTS: Medical Outcomes Study Short Form-36 (MOS SF-36), restricted activity and bed days, Physical Perfomance Test, NIA lower-extremity battery. RESULTS: In complete case analysis (excluding the five control group subjects who died during the follow-up period), the adjusted difference in change scores (4.69 points) for physical functioning between treatment and control groups indicated a significant benefit of treatment (P = .021). Similar benefits were demonstrated for number of restricted activity days and MOS SF-36 energy/fatigue, social functioning, and physical health summary scales. In analyses assigning scores of 0 to those who died, these benefits were greater, and significant benefits for the Physical Performance Test and MOS SF-36 emotional/well being, pain, and mental health summary scales were also demonstrated. CONCLUSIONS: A single outpatient comprehensive geriatric assessment coupled with an adherence intervention can prevent functional and health-related quality-of-life decline among community-dwelling older persons who have specific geriatric conditions.

The Geography of International Investment

Abstract: Multinationals have become increasingly important to the world economy. Overseas production by U.S. affiliates is three times U.S. exports, for example. Who is investing where, for sales where? Much foreign direct investment is between high-income countries, but investment in some developing and transition regions, while still modest, grew rapidly in the 1990s. Adjusting for market size, much investment stays close to home; adjusting for distance, much heads toward the countries with the biggest markets. Foreign direct investment is more geographically concentrated than either exports or production. Thus U.S. affiliate production in Europe is 7 times U.S. exports to Europe; that ratio drops to 4 for all industrial countries and to 1.6 for developing countries. Multinational activity in high-income countries is overwhelmingly horizontal, involving production for sale to the host country market. In developing countries, a greater proportion of multinational activity is vertical, involving manufacturing at intermediate stages of production. Thus only 4 percent of U.S. affiliate production in the European Union is sold back to the United States, whereas for developing countries the figure is 18 percent, rising to 40 percent for Mexico. Similarly, less than 10 percent of Japan's affiliate production in the EU is sold back to Japan, compared with more than 20 percent in developing countries. In models of horizontal activity, the decision to go multinational is a tradeoff between the additional fixed costs involved in setting up a new plant and the savings in variable costs (transport costs and tariffs) on exports. In models of vertical activity, direct investment is motivated by differences in factor costs. Tariffs and transport costs both encourage vertical multinational activity (by magnifying differences in factor prices) and discourage it (by making trade between headquarters and an affiliate more expensive). The major outward investors carry out much horizontal investment in large markets. For U.S. investors, this means Europe, especially the United Kingdom; for Japan and Europe, it means the United States. Most EU investments, however, stay within the EU. The major outward investors carry out much of their vertical investment closer to home: the United States, in Mexico; the EU, in Central and Eastern Europe; Japan, in Asia. This paper - a product of Trade, Development Research Group - is part of a larger effort in the group to study the location of economic activity. Anthony J. Venables may be contacted at a.j.venables@lse.ac.uk.

The role of education in explaining and forecasting trends in functional limitations among older Americans.

Abstract: Using the Survey of Income and Program Participation, we document the importance of education in accounting for declines in functional limitations among older Americans from 1984 to 1993. Of the eight demographic and socioeconomic variables considered, education is most important in accounting for recent trends. The relationship between educational attainment and functioning has not changed measurably, but educational attainment has increased greatly during this period. Our analysis suggests, all else being equal, that future changes in education will continue to contribute to improvements in functioning, although at a reduced rate.

Panic disorder in the primary care setting: comorbidity, disability, service utilization, and treatment.

Abstract: Background: Increased medical service utilization in patients with panic disorder has been described in epidemiologic studies, although service use in primary care panic patients relative to other primary care patients is less well characterized. Inadequate recognition of panic has been shown in several primary care studies, although the nature of usual care for panic in this setting has not been well documented. This study aimed to document increased service use in panic patients relative to other primary care patients and to characterize the nature of their usual care for panic and their outcome. Method: Using a waiting room screening questionnaire and follow-up telephone interview with the Composite International Diagnostic Interview, we identified a convenience sample of 81 patients with panic disorder (DSM-IV) and a control group of 183 psychiatrically healthy patients in 3 primary care settings on the West Coast and determined psychiatric diagnostic comorbidity, panic characteristics, disability, and medical and mental health service use, including medications. A subsample (N = 41) of panic patients was reinterviewed 4-10 months later to determine the persistence of panic and the adequacy of intervening treatment received using the Harvard/Brown Anxiety Disorders Research Program study criteria for cognitive-behavioral therapy (CBT) and an algorithm developed by the authors for medications. Results: Seventy percent of panic patients had a comorbid psychiatric diagnosis. Patients had more disability in the last month (days missed or cut down activities) (p <.01), more utilization of emergency room and medical provider visits (p <.01), and more mental health visits (p <.05). Despite the latter, only 42% received psychotropic medication, 36% psychotherapy, and 64% any treatment. On follow-up, 85% still met diagnostic criteria for panic, and only 22% had received adequate medication (type and/or dose) and 12% adequate (i.e., CBT) psychotherapy. Conclusion: These findings suggest a need for improved treatment interventions for panic disorder in the primary care setting to decrease disability and potentially inappropriate medical service utilization.

A Three-way Error Components Analysis of Educational Productivity

Abstract: Previous research on educational productivity has decomposed the variance in student test scores into school and class effects.In this paper, we extend this work to include differences attributable to teachers as well as to schools and classes. Using data drawn from the National Educational Longitudinal Study of 1988, we find that unobservable School, teacher, classroom characteristics are important factors in explaining 10th-grade mathematics achievement, and account for the majority of the variation that is explained by educational variables.

Sex and race differences in young people's responsiveness to price and tobacco control policies.

Abstract: OBJECTIVE—To determine if there are differences in young people's responsiveness to price and tobacco control policies for population subgroups and to examine whether or not these differences, if they exist, can explain sex and racial differences in trends in the prevalence of smoking in young people in the United States. DESIGN—Use cross-sectional and intertemporal variation in local and state tobacco control policies and prices to calculate demand responses to these policies using regression analysis techniques. SUBJECTS—A nationally representative sample of American eighth grade (ages 13-14 years), 10th grade (15-16 years) and 12th grade (17-18 years) students obtained from the 1992-1994 Monitoring the Future surveys. MAIN OUTCOME MEASURE—Thirty-day smoking prevalence. RESULTS—Young men are much more responsive to changes in the price of cigarettes than young women. The prevalence elasticity for young men is almost twice as large as that for young women. Smoking rates of young black men are significantly more responsive to changes in price than young white men. Significant differences in responsiveness to particular tobacco control policies also exist. These differences, however, explain relatively little of the differences in smoking prevalence among young population subgroups. CONCLUSIONS—Policymakers need to keep in mind that there is not a "one-size fits all" strategy for discouraging smoking among young people. Keywords: adolescents; tobacco control policies; price; sex differences; racial differences

Utilization of mental health and substance abuse services among homeless adults in los angeles

Abstract: Objectives.Even though psychiatric disorders are disproportionately present among the homeless, little is known about the extent to which homeless people receive treatment for those problems or the factors that are associated with receiving treatment. This article examines utilization and predictors

Underuse of Cardiac Procedures: Do Women, Ethnic Minorities, and the Uninsured Fail To Receive Needed Revascularization?

Abstract: Although revascularization procedures are substantially underused, the rate of use did not vary by sex, ethnic group, or payer status among patients treated in hospitals that provide coronary arter...

A Little Corner of Freedom: Russian Nature Protection from Stalin to Gorbachev

Abstract: Acknowledgements Introduction 1. Environmental Activism and Social Identity 2. Archipelago of Freedom 3. The Road to "Liquidation">: Conservation in the Postwar Years 4. Zapovedniki in Peril, 1948-1950 5. Liquidation: The Second Phase, 1950 6. The Deluge, 1951 7. In the Throes of Crisis: VOOP in Stalin's Last Years 8. Death and Purgatory 9. VOOP after Stalin: Survival and Decay 10. Resurrection 11. A Time to Build 12. A Time to Meet 13. More Trouble in Paradise: Crises of Zapovedniki in teh Krushchev Era 14. Student Movements: Catalysts for New Activism 15. Three Men in a Boat: VOOP in the early 1960s 16. Storm over Baikal 17. Science Doesn't Stand Still 18. Environmental Struggles in the Era of Stagnation 19. Enviromental Activism under Gorbachev

Grandparents Caring for Grandchildren What Do We Know

Abstract: Approximately 5% to 6% of grandchildren and 10% of grandparents live in grandparent-grandchild households at any point in time. The proportion of children living with grandparents appears to have remained relatively stable over time. In this article, the authors critically review previous research on the determinants of grandparent care for grandchildren. This research suggests that grandparent care generally is precipitated by need or problems experienced by parents. However, the determinants of custodial care (in which grandparents become sole caretakers) and of coresidence (three-generation households) are quite different. Custodial care generally occurs when parents are no longer able or willing to take care of their children. Coresidence more commonly is associated with the middle generation's problems with living independently or with transition among roles.

Services to families of adults with schizophrenia: from treatment recommendations to dissemination.

Abstract: OBJECTIVE: Data from the Schizophrenia Patient Outcomes Research Team project were examined to determine the extent to which families of adults with schizophrenia receive services and whether training staff in the provision of family services increases service availability. METHODS: For patients with a diagnosis of schizophrenia, paid claims for family therapy were identified in 1991 in a nationally representative sample of Medicare data and one state's Medicaid data. In a field study in two states, 530 patients were asked about services received by their families. A quasiexperimental dissemination of a family intervention was done at nine agencies; staff at four agencies received a standard didactic presentation, and staff at five received that standard presentation paired with intensive training. RESULTS: In the representative national Medicare sample of 15,425 persons with schizophrenia, .7 percent (N=108) had an outpatient claim for family therapy. This figure was 7.1 percent in the Medicaid sample of...

Explaining the Wealth Holdings of Different Cohorts: Productivity Growth and Social Security

Abstract: It is well-known that individuals born in different periods of time (cohorts or generations) exhibit different wealth accumulation paths. While previous studies have used cohort dummies to proxy for this fact, research in this area suffers from a serious identification problem, i.e., how to disentangle age, time, and cohort effects from a simple cross-section or a time series of cross-sections. Furthermore, the use of cohort dummies leaves unexplained the reasons for the differences across cohorts. In this paper, we go beyond the simple use of cohort dummies to capture the differences in wealth holdings across generations. We use basic economic theory to propose two indicators of the economic conditions under which households accumulate wealth. The first one represents productivity differences across cohorts: the aggregate level of gross national product per capita around the time the head of the household entered the labor market. The second measure summarizes the changes in Social Security during the head of household’s working life. Using panel data from the Dutch Socio-Economic Panel, we show that productivity growth can explain all the cohort effects present in income data, while productivity growth and the generosity of Social Security can explain all the cohort effects present in household net worth. Thus, cohort effects can be traced back to past economic conditions and we do not need to resort to differences in preferences or other reasons to explain the differences in wealth holdings across generations.

Treatment Alternatives to Street Crime: An Evaluation of Five Programs

Abstract: In response to the increasing numbers of criminal offenders involved with drugs, the criminal justice system has sought more effective means of intervening with these offenders. One intervention approach is Treatment Alternatives to Street Crime (TASC), an offender management model that has been implemented in various forms since the early 1970s. TASC facilitates treatment for drug-using offenders as part of an overall strategy to control drug use and associated criminal behaviors. This article reviews the evolution of TASC and reports findings from an evaluation of five TASC programs. The evaluation, experimental at two sites and quasi-experimental at three, found favorable effects of TASC programs on service delivery and offenders' drug use. Findings on criminal recidivism were mixed and difficult to interpret. This article concludes with specific recommendations for improving TASC and similar programs within the criminal justice system.

The Nursing Home at Night: Effects of an Intervention on Noise, Light, and Sleep

Abstract: OBJECTIVES: The sleep of nursing home residents is fragmented by frequent awakening episodes associated, at least in part, with environmental variables, including noise and light changes. The purpose of this study was to improve sleep by reducing the frequency of nighttime noise and light changes. PARTICIPANTS AND SETTING: Two hundred sixty-seven incontinent nursing home residents in eight nursing homes. DESIGN: A randomized control group design with a delayed intervention for the control group. MEASUREMENTS: Bedside noise and light monitors recorded the number of 2-minute intervals at night with peak sounds recorded above 50 dBs and the number of light changes of at least 10 lux between adjacent 2-minute intervals. Daytime behavioral observations measured sleep and in-bed time during the day, and wrist activity was used to estimate sleep at night. Awakening events associated with the environmental variables were derived from the wrist activity data. INTERVENTION: A behavioral intervention implemented between 7:00 p.m. and 6:00 a.m. that involved feedback to nursing home staff about noise levels and implementation by research staff of procedures to both abate noise (e.g., turn off unwatched television sets) and to individualize nighttime incontinence care routines to be less disruptive to sleep. RESULTS: Noise was reduced significantly, from an average of 83 intervals per night with peak noises recorded above 50 dBs to an average of 58 intervals per night in the group that received the initial intervention, whereas noise in the control group showed no change (MANOVA group X time P < .001). All 10-dB categories of noise from 50 to 90 + dBs were reduced, and light changes were reduced from an average of four per night per resident to two per night (P <. 001). Despite these significant changes in the environmental variables, there was a significant differential improvement in the intervention group on only two night sleep measures: awakening associated with a combination of noise plus light (P <. 001) and awakening associated with light (P <. 001). However, there was a significant correlation between change in noise and change in percent sleep from baseline to intervention (r = -.29, P <. 05), suggesting that the intervention did not reduce noise to low enough levels to produce a significant improvement in sleep. The intervention effects on all environmental variables were replicated in the delayed intervention group, who again showed significant improvement on the same sleep measures. Observations of day sleep and in-bed time did not change over the phases of the trial for either group. CONCLUSION: The significant reductions in noise and light events resulting from the intervention did not lead to significant improvements in the day sleep and most night sleep measures. An intervention that combines both behavioral and environmental strategies and that addresses daytime behavioral factors associated with poor sleep (e.g., excessive time in bed) would potentially be more effective in improving the night sleep and quality of life of nursing home residents.

Price competition and hospital cost growth in the United States (1989-1994).

Abstract: In recent years, most health care markets in the United States (US) have experienced rapid penetration by health maintenance organizations (HMOs) and preferred provider organizations (PPOs). During this same period, the US has also experienced slowing health care costs. Using a national database, we demonstrate that HMOs and PPOs have significantly restrained cost growth among hospitals located in competitive hospital markets, but not so in the case of hospitals located in relatively concentrated markets. In relative terms, we estimate that HMOs have contained cost growth more effectively than PPOs.