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Research on the effects of Vietnam military service suggests that Vietnam veterans experienced significantly higher mortality than the civilian population at large. These results, however, may be biased by nonrandom selection into the military if unobserved background differences between veterans and nonveterans affect mortality directly. To generate unbiased estimates of exposure to conscription on mortality, the present study compares the observed proportion of draft-eligible male decedents born 1950–1952 to the (1) expected proportion of draft-eligible male decedents given Vietnam draft-eligibility cutoffs; and (2) observed proportion of draft-eligible decedent women. The results demonstrate no effect of draft exposure on mortality, including for cause-specific death rates. When we examine population subgroups—including splits by race, educational attainment, nativity, and marital status—we find weak evidence for an interaction between education and draft eligibility. This interaction works in the opposite direction of putative education-enhancing, mortality-reducing effects of conscription that have, in the past, led to concern about a potential exclusion restriction violation in instrumental variable (IV) regression models. We suggest that previous research, which has shown that Vietnam-era veterans experienced significantly higher mortality than nonveterans, might be biased by nonrandom selection into the military and should be further investigated.

China's rapid industrialization has led to a severe deterioration in water quality in the country's lakes and rivers. By exploiting variation in pollution across China's river basins, I estimate that a deterioration of water quality by a single grade (on a six-grade scale) increases the digestive cancer death rate by 9.7%. The analysis rules out other potential explanations such as smoking rates, dietary patterns, and air pollution. I estimate that doubling China's levy rates for wastewater dumping would save roughly 17,000 lives per year but require an additional [dollar]500 million in annual spending on wastewater treatment.

Careers in health administration continue to grow despite an overall downturn in the economy. This is a field that offers tremendous job opportunities across the spectrum of healthcare delivery and payment organizations. 101 Careers in Healthcare Management is the only comprehensive guide to careers in health administration, ranging from entry-level management positions to the most senior executive opportunities. The guide clearly explains the responsibilities and duties of each of these careers and how they differ from other management jobs. It describes the integral role of healthcare administrators in creating and sustaining the systems that allow healthcare clinicians to do their best work.

The book covers educational requirements, opportunities, traditional and nontraditional career pathways, and helps students assess whether they are temperamentally and intellectually suited to a career in healthcare management. Based on the most current data from the U.S. Department of Labor and professional societies in healthcare management, the guide describes careers in 14 different healthcare and related settings. These include long-term care, physician practices, commercial insurance, consulting firms, pharmaceuticals, medical devices, information technology, and biotechnology. Additionally, the book offers numerous interviews with health administrators, from those in entry-level positions to CEOs, to more vividly portray potential careers.

Objectives: To investigate trends in official development assistance for health, HIV and non-HIV activities over time and to discuss the efficiency implications of these trends in the context of achieving universal access to treatment and health systems.

Methods: Official development assistance for health, HIV programmes and non-HIV programmes were tracked using data from 2000 to 2009. A review of the literature on efficiency, treatment and health systems was conducted. Findings The rate of growth of donor funding to HIV programmes has slowed in recent years at levels below those required to sustain programmes and to move towards universal access to treatment. These trends are likely due to increased pressure on foreign aid budgets and donor fatigue for HIV programmes.

Conclusions: There is great need to consider how the limited resources available can be used most efficiently to increase the number of lives saved and to ensure that these resources also benefit health systems. Improving efficiency is much more than just improving the productive efficiency and also about ensuring that resources are going to where they will be the most beneficial and making investments that are the most efficient over time. These choices may be essential to achieving the goal of universal access to treatment as well as the sustainability of these programmes. 

Donor funding for HIV programs has increased rapidly over the past decade, raising questions about whether other health services in recipient-country health systems are being crowded out or strengthened. This article—an investigation of the impacts of increased HIV donor funding on non-HIV health services in sub-Saharan Africa during 2003–10—provides evidence of both effects. HIV aid in some countries has crowded out the delivery of childhood immunizations, especially in countries with the lowest density of health care providers. At the same time, HIV aid may have positively affected some maternal health services, such as prenatal blood testing. These mixed results suggest that donors should be more attentive to domestic resource constraints, such as limited numbers of health workers; should integrate more fully with existing health systems; and should address these constraints up front to limit possible negative effects on the delivery of other health services.

Objectives:To examine the associations of antibiotic exposures during the first 2
years of life and the development of body mass over the first 7 years of
life.Design:Longitudinal birth cohort study.Subjects:A total of 11 532 children
born at 2500 g in the Avon Longitudinal Study of Parents and Children (ALSPAC), 
a population-based study of children born in Avon, UK in
1991-1992. Measurements:Exposures to antibiotics during three different early-life
time windows (<6 months, 6-14 months, 15-23 months), and indices of body mass at 
five time points (6 weeks, 10 months, 20 months, 38 months and 7
years).Results:Antibiotic exposure during the earliest time window (<6 months)
was consistently associated with increased body mass (+0.105 and +0.083 s.d.
unit, increase in weight-for-length Z-scores at 10 and 20 months, P<0.001 and
P=0.001, respectively; body mass index (BMI) Z-score at 38 months +0.067 s.d.
units, P=0.009; overweight OR 1.22 at 38 months, P=0.029) in multivariable,
mixed-effect models controlling for known social and behavioral obesity risk
factors. Exposure from 6 to 14 months showed no association with body mass, while
exposure from 15 to 23 months was significantly associated with increased BMI
Z-score at 7 years (+0.049 s.d. units, P=0.050). Exposures to non-antibiotic
medications were not associated with body mass.Conclusions:Exposure to
antibiotics during the first 6 months of life is associated with consistent
increases in body mass from 10 to 38 months. Exposures later in infancy (6-14
months, 15-23 months) are not consistently associated with increased body mass.
Although effects of early exposures are modest at the individual level, they
could have substantial consequences for population health. Given the prevalence
of antibiotic exposures in infants, and in light of the growing concerns about
childhood obesity, further studies are needed to isolate effects and define
life-course implications for body mass and cardiovascular risks

OBJECTIVE:
To assess the association of the severity of obesity with diagnosis and health education, and to identify any differences within demographic or other subgroups.
DESIGN:
Clinician visits for 2-18 year olds from the 2005-2008 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey were combined. Descriptive, bivariate and multivariate analyses were used to compare diagnosis of obesity and health education (nutrition, exercise and weight reduction) across elevated body mass index (BMI) groups (overweight, obese and extreme or very obese, defined as >120% of the 95th percentile for age and gender), patient socio-demographic characteristics, physician specialty and type of visit (well child visits (WCV) versus non-well child visits (non-WCV).
RESULTS:
A total of 17 808 visits had a calculated BMI, of which 5.8% were extremely obese, 13% were obese and 15.2% were overweight, with the highest percentages among older children, blacks and Hispanics. Diagnosis and weight reduction education were higher among children with an extreme BMI. Nutrition and exercise education were not correlated with severity of obesity. Race, ethnicity or gender biases were not identified. Severity of obesity was significantly associated with presentation to a non-WCV rather than a WCV.
CONCLUSION:
Extremely obese children have higher, but still insufficient, rates of diagnosis and health education. Nutrition and exercise education are not prevalent throughout all age groups. Providers may be relying inconsistently and insufficiently on visual cues to drive their obesity prevention practices. Furthermore, lower rates of diagnosis and education at non-WCV may result in a missed opportunity to prevent comorbidities. This is of particular concern as overweight children are less likely to be seen at WCV than non-WCV.International Journal of Obesity advance online publication, 24 January 2012; doi:10.1038/ijo.2012.1.

Clinical guidelines and quality measures are important new paradigms for conceptualizing and managing quality in the United States. Researchers have proposed that professional elites-including members of academic medicine-were an important cause of the shift to guidelines and measures. This paper draws on content analysis of abstracts focused on quality in major American medical journals between 1975 and 2009 to empirically assess whether and how paradigms for managing quality changed in academic medicine. The content analysis shows that guidelines- and measures-based approaches to quality increased in prominence. Individual expertise-based approaches to quality, however, remain important. Concurrent with changing paradigms in academic medicine, there was a reorientation of policy toward increased use of guidelines and measures the late 1980s and early 1990s in the United States. This policy reorientation was informed by earlier work by medical researchers proposing new approaches to quality. The policy reorientation was followed by an increase in the prominence of guidelines and measures in medical research.

Declining birth rates, increasing longevity and urbanization have created a new challenge for cities: how to respond to an ageing population. Although population ageing and urbanization are not new concerns for national governments around the world, the consequences of these trends for quality of life in cities has only recently started to receive attention from policy makers and researchers. Few comparative studies of world cities examine their health or long-term care systems; nor have comparisons of national systems for the provision of long-term care focused on cities, let alone world cities.

By extending the work of the CADENZA and World Cities Projects , this report investigates how three world cities -- Hong Kong, New York and London -- are coping with this challenge. These world cities are centers of finance, information, media, arts, education, specialized legal services and advanced business services, and contribute disproportionate shares of GDP to their national economies. But are these influential centers prepared to meet the challenge posed by the “revolution of longevity?” How will these world cities accommodate this revolutionary demographic change? Are they prepared to implement the health and social policy innovations that may be required to serve their residents, both old and young? Will they be able to identify the new opportunities that increased longevity may offer? Can they learn from one another as they seek to develop creative solutions to the myriad issues that arise? Finally, can other cities learn from the experience of these three cities as they confront this challenge?

To address these questions, we examine comparable data on the economic and health status of older persons, as well as the availability and use of health, social and long-term care across and within these cities. In the report “How Well Are Seniors in Hong Kong Doing? An International Comparison”, a first attempt was made to compare the situation in Hong Kong with five economically developed countries. This report extends this study by comparing the situation in Hong Kong with two other world cities—New York City and London, which are more comparable in terms of population size and economic characteristics.

"These 10 articles from leading scholars address federal government activism in such areas as health, education, transportation, and the arts. In some areas, federal involvement has been direct; for example, while school public systems are governed locally, Washington provides about 10% of k–12 funding. Similarly, antipoverty programs, such as the New Deal’s Social Security Act and Aid for Dependent Children, have played a major role in reducing the poverty rate from around 40% in 1900 to 11.2% in 1974. At other times, Washington has exerted influence more subtly, through regulations and research. Examples include the 1933 Glass-Steagall Act, which mandated the separation of investment and commercial banking and the WWII-era research that yielded compounds to prevent and cure malaria, syphilis, and tuberculosis. Further, as public policy scholar Paul C. Light points out in a fascinating concluding piece, more than two-thirds of leading governmental initiatives have been supported by both Democratic and Republican administrations. However, Light adds, the massive tax cut in 2001 “continue[s] to constrain federal investment in problem solving.” The scholars brought together by Ohio State historian Conn (History’s Shadow) persuasively demonstrate how the growth of “big government” throughout the 20th century has benefited ordinary Americans so comprehensively and unobtrusively that they have often taken it for granted."

Publishers Weekly

http://www.publishersweekly.com/978-0-19-985855-2

Without a governance structure, IT at many hospitals and healthcare systems is a haphazard endeavor that typically results in late, over-budget projects and, ultimately, disparate systems. IT Governance in Hospitals and Health Systems offers a practical “how to” in creating an information technology governance process that ensures the IT projects supporting a hospital or health systems’ strategy are completed on-time and on-budget. The authors define and describe IT governance as it is currently practiced in leading healthcare organizations, providing step-by-step guidance of the process so readers can replicate these best practices at their own hospital or health system. The book provides an overview of what IT governance is and why it is important to a healthcare organization. In addition, the book examines keys to IT governance success, as well as common mistakes to avoid; governance processes, workflows and project management; and the important roles that staff, a board of directors and committees play. Special features in the book include case studies from hospitals and health systems that have successfully developed an effective IT governance structure for their organization. 2012.

BACKGROUND:

The WHO Multiple Exposures Multiple Effects (MEME) framework identifies community contextual variables as central to the study of childhood health. Here we identify multiple domains of neighborhood context, and key variables describing the dimensions of these domains, for use in the National Children's Study (NCS) site in Queens. We test whether the neighborhoods selected for NCS recruitment, are representative of the whole of Queens County, and whether there is sufficient variability across neighborhoods for meaningful studies of contextual variables.

METHODS:

Nine domains (demographic, socioeconomic, households, birth rated, transit, playground/greenspace, safety and social disorder, land use, and pollution sources) and 53 indicator measures of the domains were identified. Geographic information systems were used to create community-level indicators for US Census tracts containing the 18 study neighborhoods in Queens selected for recruitment, using US Census, New York City Vital Statistics, and other sources of community-level information. Mean and inter-quartile range values for each indicator were compared for Tracts in recruitment and non-recruitment neighborhoods in Queens.

RESULTS:

Across the nine domains, except in a very few instances, the NCS segment-containing tracts (N = 43) were not statistically different from those 597 populated tracts in Queens not containing portions of NCS segments; variability in most indicators was comparable in tracts containing and not containing segments.

CONCLUSIONS:

In a diverse urban setting, the NCS segment selection process succeeded in identifying recruitment areas that are, as a whole, representative of Queens County, for a broad range of community-level variables.

Objective. The Medicare and Premier Inc. Hospital Quality Incentive Demonstration (HQID), a hospital-based pay-for-performance program, changed its incentive design from one rewarding only high performance (Phase 1) to another rewarding high performance, moderate performance, and improvement (Phase 2). We tested whetherthis design change reduced the gap in incentive payments among hospitals treating patients across the gradient of socioeconomic disadvantage.

Data. To estimate incentive payments in both phases, we used data from the Premier Inc. website and from Medicare Provider Analysis and Review Files.We used data from the American Hospital Association Annual Survey and Centers for Medicare and Medicaid Services Impact File to identify hospital characteristics.

Study Design. Hospitals were divided into quartiles based on their Disproportionate Share Index (DSH) , from lowest disadvantage (Quartile 1) to highest disadvantage (Quartile 4). In both phases of the HQID, we tested for differences across the DSH quartiles for three outcomes: (1) receipt of any incentive payments; (2) total incentive payments; and (3) incentive payments per discharge. For each of the study outcomes,we performed a hospital-level difference-in-differences analysis to test whether the gap between Quartile 1 and the other quartiles decreased from Phase 1 to Phase 2.

Principal Findings. In Phase 1, there were significant gaps across the DSH quartiles for the receipt of any payment and for payment per discharge. In Phase 2, the gap was not significant for the receipt of any payment, but remained significant for payment perdischarge. For the receipt of any incentive payment, difference-in-difference estimates showed significant reductions in the gap between Quartile 1 and the other quartiles (Quartile 2, 17.5 percentage points [p < .05]; Quartile 3, 18.1 percentage points [p < .01]; Quartile 4, 28.3 percentage points [p < .01]). For payments per discharge, the gap was also signi_cantly reduced between Quartile 1 and the other quartiles (Quartile 2, $14.92 per discharge [p < .10]; Quartile 3, $17.34 per discharge [p < .05]; Quartile 4, $21.31 per discharge [p < .01]). There were no significant reductions in the gap for total payments.

Conclusions. The design change in the HQID reduced the disparity in the receipt of any incentive payment and for incentive payments per discharge between hospitals caring for the most and least socioeconomically disadvantaged patient populations. 

Medicare’s flagship hospital pay-for-performance program, the Premier Hospital Quality Incentive Demonstration, began in 2003 but changed its incentive design in late 2006. The goals were to encourage greater quality improvement, particularly among lower-performing hospitals. However, we found no evidence that the change achieved these goals. Although the program changes were intended to provide strong incentives for improvement to the lowest-performing hospitals, we found that in practice the new incentive design resulted in the strongest incentives for hospitals that had already achieved quality performance ratings just above the median for the entire group of participating hospitals. Yet during the course of the program, these hospitals improved no more than others. Our findings raise questions about whether pay-for-performance strategies that reward improvement can generate greater improvement among lower performing providers. They also cast some doubt on the extent to which hospitals respond to the specific structure of economic incentives in pay-for-performance programs.

Health care policymakers have cited transportation
barriers as key obstacles to providing health care to
low-income suburbanites, particularly because suburbs have
become home to a growing number of recent immigrants
who are less likely to own cars than their neighbors. In a
suburb of New York City,we conducted a pilot survey of low
income, largely immigrant clients in four public clinics, to
find out how much transportation difficulties limit their
access to primary care. Clients were receptive to the opportunity
to participate in the survey (response rate = 94%).
Nearly one-quarter reported having transportation problems
that had caused them to miss or reschedule a clinic
appointment in the past. Difficulties included limited and
unreliable local bus service, and a tenuous connection to a
car. Our pilot work suggests that this population is willing to
participate in a survey on this topic. Further, since even
among those attending clinic there was significant evidence
of past transportation problems, it suggests that a populationbased
survey would yield information about substantial
transportation barriers to health care.

At A Time When Health Care Organizations Face Unprecedented Financial Challenges, Understanding Financial Accounting Is Important For All Health Care Professionals, Especially Those Who Manage A Department And A Budget. Designed For Both Students And Professionals, Accounting Fundamentals For Health Care Management, Second Edition Clearly Explains Accounting Principles And Applies Them To The Health Care Environment.Critical Topics Such As Recording And Reporting Financial Information, Depreciation, And Financial Statement Analysis Are All Thoroughly Covered The Second Edition Offers: New Co-Author, Thad Calabrese New Chapter (Chapter 2) Provides An Excel Tutorial. New Discussion Of The Impact Of Health Care Reform In Chapter 3 Updated Throughout With Information On IFRS Coverage Of Cash Basis Vs. Accrual Basis New Discussion Of Fair Value Simplified Discussion Of MACRS New Discussion Of Sarbanes-Oxley Act Many General Updates

Objective:To determine clinical characteristics, demographics and short-term outcomes of neonates diagnosed with fetomaternal haemorrhage (FMH).

Design:The authors analysed the Nationwide Inpatient Sample, 1993 to 2008. Singleton births diagnosed with FMH were identified by International Classification of Diseases (ICD-9) code 762.3. Descriptive, univariate and multivariable regression analyses were performed to determine the national annual incidence of FMH over time as well as demographics and clinical characteristics of neonates with FMH.ResultsFMH was identified in 12 116 singleton births. Newborns with FMH required high intensity of care: 26.3% received mechanical ventilation, 22.4% received blood product transfusion and 27.8% underwent central line placement. Preterm birth (OR 3.7), placental abruption (OR 9.8) and umbilical cord anomaly (OR 11.4) were risk factors for FMH. Higher patient income was associated with increased likelihood of FMH diagnosis (OR 1.2), and Whites were more likely to be diagnosed than ethnic minorities (OR 1.9). There was reduced frequency of diagnosis in the Southern USA (OR 0.8 vs the Northeastern USA).

Conclusions: Diagnosis of FMH is associated with significant morbidity as well as regional, socioeconomic and racial disparity. Further study is needed to distinguish between diagnostic coding bias and true epidemiology of the disease. This is the first report of socioeconomic and racial/ethnic disparities in FMH, which may represent disparities in detection that require national attention. 

The obesity epidemic has transformed children's healthcare, such that diabetes, hypertension and the metabolic syndrome are phrases more commonly used by child health providers than ever before. This article reviews the economic consequences of this epidemic for healthcare delivery systems, both in the short term when obesity has been associated with increased utilization, and in the long term where increased likelihood of adult obesity and cardiovascular disease is well documented. Large investments through research and prevention are needed and are likely to provide strong returns in cost savings, and would optimally emerge through a cooperative effort between private and government payers alike. 

Objectives:

To examine the associations of antibiotic exposures during the first 2 years of life and the development of body mass over the first 7 years of life.

Design:

Longitudinal birth cohort study.

Subjects:
A total of 11 532 children born at 2500 g in the Avon Longitudinal Study of Parents and Children (ALSPAC), a population-based study of children born in Avon, UK in 1991–1992.

Measurements:

Exposures to antibiotics during three different early-life time windows (

Results:

Antibiotic exposure during the earliest time window (

Conclusions:

Exposure to antibiotics during the first 6 months of life is associated with consistent increases in body mass from 10 to 38 months. Exposures later in infancy (6–14 months, 15–23 months) are not consistently associated with increased body mass. Although effects of early exposures are modest at the individual level, they could have substantial consequences for population health. Given the prevalence of antibiotic exposures in infants, and in light of the growing concerns about childhood obesity, further studies are needed to isolate effects and define life-course implications for body mass and cardiovascular risks.

Context  Bisphenol A (BPA), a manufactured chemical, is found in canned food, polycarbonate-bottled liquids, and other consumer products. In adults, elevated urinary BPA concentrations are associated with obesity and incident coronary artery disease. BPA exposure is plausibly linked to childhood obesity, but evidence is lacking to date.

Objective  To examine associations between urinary BPA concentration and body mass outcomes in children.

Design, Setting, and Participants  Cross-sectional analysis of a nationally representative subsample of 2838 participants aged 6 through 19 years randomly selected for measurement of urinary BPA concentration in the 2003-2008 National Health and Nutrition Examination Surveys.

Main Outcome Measures  Body mass index (BMI), converted to sex- and age-standardized z scores and used to classify participants as overweight (BMI ≥85th percentile for age/sex) or obese (BMI ≥95th percentile).

Results  Median urinary BPA concentration was 2.8 ng/mL (interquartile range, 1.5-5.6). Of the participants, 1047 (34.1% [SE, 1.5%]) were overweight and 590 (17.8% [SE, 1.3%]) were obese. Controlling for race/ethnicity, age, caregiver education, poverty to income ratio, sex, serum cotinine level, caloric intake, television watching, and urinary creatinine level, children in the lowest urinary BPA quartile had a lower estimated prevalence of obesity (10.3% [95% CI, 7.5%-13.1%]) than those in quartiles 2 (20.1% [95% CI, 14.5%-25.6%]), 3 (19.0% [95% CI, 13.7%-24.2%]), and 4 (22.3% [95% CI, 16.6%-27.9%]). Similar patterns of association were found in multivariable analyses examining the association between quartiled urinary BPA concentration and BMI z score and in analyses that examined the logarithm of urinary BPA concentration and the prevalence of obesity. Obesity was not associated with exposure to other environmental phenols commonly used in other consumer products, such as sunscreens and soaps. In stratified analysis, significant associations between urinary BPA concentrations and obesity were found among whites (P < .001) but not among blacks or Hispanics.

Conclusions  Urinary BPA concentration was significantly associated with obesity in this cross-sectional study of children and adolescents. Explanations of the association cannot rule out the possibility that obese children ingest food with higher BPA content or have greater adipose stores of BPA.

CONTEXT:

Bisphenol A (BPA), a manufactured chemical, is found in canned food, polycarbonate-bottled liquids, and other consumer products. In adults, elevated urinary BPA concentrations are associated with obesity and incident coronary artery disease. BPA exposure is plausibly linked to childhood obesity, but evidence is lacking to date.

OBJECTIVE:

To examine associations between urinary BPA concentration and body mass outcomes in children.

DESIGN, SETTING, AND PARTICIPANTS:

Cross-sectional analysis of a nationally representative subsample of 2838 participants aged 6 through 19 years randomly selected for measurement of urinary BPA concentration in the 2003-2008 National Health and Nutrition Examination Surveys.

MAIN OUTCOME MEASURES:

Body mass index (BMI), converted to sex- and age-standardized z scores and used to classify participants as overweight (BMI ≥85th percentile for age/sex) or obese (BMI ≥95th percentile).

RESULTS:

Median urinary BPA concentration was 2.8 ng/mL (interquartile range, 1.5-5.6). Of the participants, 1047 (34.1% [SE, 1.5%]) were overweight and 590 (17.8% [SE, 1.3%]) were obese. Controlling for race/ethnicity, age, caregiver education, poverty to income ratio, sex, serum cotinine level, caloric intake, television watching, and urinary creatinine level, children in the lowest urinary BPA quartile had a lower estimated prevalence of obesity (10.3% [95% CI, 7.5%-13.1%]) than those in quartiles 2 (20.1% [95% CI, 14.5%-25.6%]), 3 (19.0% [95% CI, 13.7%-24.2%]), and 4 (22.3% [95% CI, 16.6%-27.9%]). Similar patterns of association were found in multivariable analyses examining the association between quartiled urinary BPA concentration and BMI z score and in analyses that examined the logarithm of urinary BPA concentration and the prevalence of obesity. Obesity was not associated with exposure to other environmental phenols commonly used in other consumer products, such as sunscreens and soaps. In stratified analysis, significant associations between urinary BPA concentrations and obesity were found among whites (P < .001) but not among blacks or Hispanics.

CONCLUSIONS:

Urinary BPA concentration was significantly associated with obesity in this cross-sectional study of children and adolescents. Explanations of the association cannot rule out the possibility that obese children ingest food with higher BPA content or have greater adipose stores of BPA.

Children's trauma-related mental health problems are widespread, largely untreated and constitute significant barriers to academic achievement and attainment. Translational research has begun to identify school-based interventions to prevent violence, trauma and psychopathology. We describe in detail the findings to date on research evaluating one such intervention, the Reading, Writing, Respect, and Resolution (4Rs) Program. The 4Rs Program has led to modest positive impacts on both classrooms and children after 1 year that appear to cascade to more impacts in other domains of children's development after 2 years. This research strives not only to translate research into practice but also translate practice into research. However, considerable challenges must be met for such research to inform prevention strategies at population scale.

The Institute of Medicaid has identified equity as a key dimension of quality. Recently, Massachusetts’ Medicaid program (MassHealth) took the unusual step of linking pay-for-performance (P4P) to the reduction of racial/ethnic disparities for hospital care.  We report on early experience with the program, describing the challenges of implementing an ambitious program in a short time frame, with limited resources.  Our findings raise questions about whether P4P as currently constituted is a suitable tool for addressing disparities in hospital care.

Background: In the United States, registered nurses [RNs] are trained through one of three educational pathways: a diploma course; an associate's degree, or a baccalaureate degree in nursing (the BSN). A national consensus has emerged that the proportion of RNs that are baccalaureate-trained should be substantially increased. Yet achieving that goal may be difficult in areas where college graduates are unlikely to reside.

Objectives: To determine whether the level of training of the hospital registered nurse [RN] workforce varies geographically, along with the education of the local general workforce.

Research design: Cross sectional, ecological study.

Subjects: Hospital nurses who participated in the National Sample Survey of Registered Nurses [NSSRN] in 2004 (n = 16,567).

Measures. Registered Nurse training was measured as Diploma, Associates degree, or Baccalaureate degree or above. County-level general workforce quality was assessed as the adult college graduation rate. Counties were divided into US population quartiles, with the highest quartile (Q4) having more than 29.3% college graduates, and the lowest quartile (Q1) having fewer than 16.93% college graduates.

Results: Hospital RNs have a higher level of training in counties where the general population is better
educated. For example, in Q4, 55.2% of hospital RNs are baccalaureate-trained, in Q3, 50.2%; in Q2,45.2%; and in Q1, 34.9% (p < .001 for all pairwise comparisons). The association between RN training and general workforce education is found in cities, towns and rural areas.

Conclusions: Nationwide, there are substantial geographic variations in the training of hospital RNs. Educational segregation (the tendency for educated people to cluster geographically) may make it more difficult to achieve a BSN-rich nursing workforce in some areas of the US. Further work is needed to assess whether educational segregation similarly influences the distribution of other health care professionals, and whether it leads to variations in the local quality of care.

Lake Chapala is a major source of water for crop irrigation and subsistence fishing for a population of 300,000 people in central Mexico. Economic activities have created increasing pollution and pressure on the whole watershed resources. Previous reports of mercury concentrations detected in fish caught in Lake Chapala have raised concerns about health risks to local families who rely on fish for both their livelihood and traditional diet. Our own data has indicated that 27% of women of childbearing age have elevated hair mercury levels, and multivariable analysis indicated that frequent consumption of carp (i.e., once a week or more) was associated with significantly higher hair mercury concentrations. In this paper we describe a range of environmental health research projects. Our main priorities are to build the necessary capacities to identify sources of water pollution, enhance early detection of environmental hazardous exposures, and deliver feasible health protection measures targeting children and pregnant women. Our projects are led by the Children's Environmental Health Specialty Unit nested in the University of Guadalajara, in collaboration with the Department of Environmental Health of Harvard School of Public Health and Department of Pediatrics of the New York School of Medicine. Our partnership focuses on translation of knowledge, building capacity, advocacy and accountability. Communication will be enhanced among women's advocacy coalitions and the Ministries of Environment and Health. We see this initiative as an important pilot program with potential to be strengthened and replicated regionally and internationally.

Lake Chapala is a major source of water for crop irrigation and subsistence fishing for a population of 300,000 people in central Mexico. Economic activities have created increasing pollution and pressure on the whole watershed resources. Previous reports of mercury concentrations detected in fish caught in Lake Chapala have raised concerns about health risks to local families who rely on fish for both their livelihood and traditional diet. Our own data has indicated that 27% of women of childbearing age have elevated hair mercury levels, and multivariable analysis indicated that frequent consumption of carp (i.e., once a week or more) was associated with significantly higher hair mercury concentrations. In this paper we describe a range of environmental health research projects. Our main priorities are to build the necessary capacities to identify sources of water pollution, enhance early detection of environmental hazardous exposures, and deliver feasible health protection measures targeting children and pregnant women. Our projects are led by the Children's Environmental Health Specialty Unit nested in the University of Guadalajara, in collaboration with the Department of Environmental Health of Harvard School of Public Health and Department of Pediatrics of the New York School of Medicine. Our partnership focuses on translation of knowledge, building capacity, advocacy and accountability. Communication will be enhanced among women's advocacy coalitions and the Ministries of Environment and Health. We see this initiative as an important pilot program with potential to be strengthened and replicated regionally and internationally.

Prior researchers have deployed the Vietnam-era draft lottery as an instrument to estimate causal effects of military service on health and earnings. However, household and residential outcomes may be more sensitive to the psychological effects of military service. Using 2SLS analyses of the 2000 Census and the 2005 American Community Survey, we find mixed results for residential stability, housing tenure, and extended family residence. While in the ACS white veterans are less mobile, veteran status has no effect on homeownership. Veteran status reduces extended family living for whites in the Census but increases it for ACS veterans of "other" races.

Patient safety, and more broadly the quality of care, is typically discussed with reference to the reduction of preventable adverse events within hospitals and adherence to practice guidelines on care processes. We call it the ‘care-centered approach’ and recognize that the United States is a leader in the field. Another face of patient safety and care quality may be defined as the ‘system-centered approach’. It focuses on access to a timely and effective continuum of health-care services – clinical prevention, primary care and appropriate referral to and receipt of specialty care. Although France's efforts to pursue a care-centered approach to patient safety are limited, its system-centered approach yields some benefits. Based on the evidence we have reviewed for access to primary care (hospital discharges for avoidable hospital conditions), mortality amenable to medical intervention and consumer satisfaction, in the United States and France, there appear to be good grounds for bolstering the system-centered approach in the United States.

Objective:Obesity is an enormous public health problem and children have been particularly highlighted for intervention. Of notable concern is the fast-food consumption of children. However, we know very little about how children or their parents make fast-food choices, including how they respond to mandatory calorie labeling. We examined children's and adolescents' fast-food choice and the influence of calorie labels in low-income communities in New York City (NYC) and in a comparison city (Newark, NJ).
Design:Natural experiment: Survey and receipt data were collected from low-income areas in NYC, and Newark, NJ (as a comparison city), before and after mandatory labeling began in NYC. Study restaurants included four of the largest chains located in NYC and Newark: McDonald's, Burger King, Wendy's and Kentucky Fried Chicken.Subjects:A total of 349 children and adolescents aged 1-17 years who visited the restaurants with their parents (69%) or alone (31%) before or after labeling was introduced. In total, 90% were from racial or ethnic minority groups.
Results:We found no statistically significant differences in calories purchased before and after labeling; many adolescents reported noticing calorie labels after their introduction (57% in NYC) and a few considered the information when ordering (9%). Approximately 35% of adolescents ate fast food six or more times per week and 72% of adolescents reported that taste was the most important factor in their meal selection. Adolescents in our sample reported that parents have some influence on their meal selection.
Conclusions:Adolescents in low-income communities notice calorie information at similar rates as adults, although they report being slightly less responsive to it than adults. We did not find evidence that labeling influenced adolescent food choice or parental food choices for children in this population.

Objective To examine variations in health service expenditures and social services expenditures across Organisation for Economic Co-operation and Development (OECD) countries and assess their association with five population-level health outcomes.

Design A pooled, cross-sectional analysis using data from the 2009 release of the OECD Health Data 2009 Statistics and Indicators and OECD Social Expenditure Database.

Setting OECD countries (n=30) from 1995 to 2005.

Main outcomes Life expectancy at birth, infant mortality, low birth weight, maternal mortality and potential years of life lost.

Results Health services expenditures adjusted for gross domestic product (GDP) per capita were significantly associated with better health outcomes in only two of five health indicators; social services expenditures adjusted for GDP were significantly associated with better health outcomes in three of five indicators. The ratio of social expenditures to health expenditures was significantly associated with better outcomes in infant mortality, life expectancy and increased potential life years lost, after adjusting for the level of health expenditures and GDP.

Conclusion Attention to broader domains of social policy may be helpful in accomplishing improvements in health envisioned by advocates of healthcare reform.

Over the past decade, HIV programs have been successfully scaled up in many developing countries, leading some to wonder how the investments made into HIV infrastructure could be leveraged to deliver additional health services. Although the concept is appealing from many perspectives, integrating additional health services into existing vertical HIV infrastructure may not mitigate some of the challenges these programs have introduced in implementing countries. In addition, this approach to integration may countervail parallel efforts of the global health community to strengthen health systems and improve aid effectiveness. It might also undermine the HIV programs themselves. International donors and health system planners should carefully consider whether the benefits outweigh the potential costs of these well-intentioned integration efforts.

While the growth of urbanization, worldwide, has improved the lives of migrants from the hinterland, it also raises health risks related to population density, concentrated poverty and the transmission of infectious disease. Will megacity regions evolve into socially infected breeding grounds for the rapid transmission of disease, or can they become critical spatial entities for the protection and promotion of population health? We address this question for the Pearl River Delta Region (PRD) based on recent data from Chinese sources, and on the experience of how New York, Greater London, Tokyo and Paris have grappled with the challenges of protecting population health and providing their populations with access to health care services. In some respects, there are some important lessons from comparative experience for PRD, notably the importance of covering the entire population for health care services and targeting special programs for those at highest risk for disease. In other respects, PRD's growth rate and sheer scale make it a unique megacity region that already faces new challenges and will require new solutions.

The increasing need to educate healthcare IT leaders will require the use of other educational methods in addition to classroom instruction, seminars at conferences and webinars. The author has 12 years experience offering a "blended" course on healthcare IT for managers and clinicians in an MBA program. The course combines face-to-face classroom instruction with on-line discussion. This reduces the time away from work and travel required. But it has far greater benefits, including the development of a capacity to analyze situations and develop and defen solutions. Participants share knowledge and begin to grasp the differences in their environments that require attention. This method is compared with other teaching methods and its advantages are explained.

Strong property tax growth and proactive policies - including beginning the recession with a substantial surplus of $5.3 billion (9 percent of revenues) - offset a severe contraction in income tax receipts, protecting the City's budget such that it never contracted in absolute terms during or immediately following the Great Recession. Policymakers increased property and sales tax rates, utilized fund balances, cut agency budgets repeatedly, and re-appropriated retiree health benefits in response to the fiscal challenges brought about by the Great Recession. Whether one attributes it to compliance with a strong, state-mandated, balanced budget rule or adept leadership, New York City certainly appears to be dealing effectively with the Great Recession's impact on its budget. However, City leaders have asked lower income residents to bear a substantial portion of the burden by favoring more regressive tax policies and by cutting the social service agency's budget substantially. With forecast budget gaps of $3 billion and $4 billion in FY 2012 and FY 2013, the long-term impact of the Great Recession on New York City's budget remains an open question.

Transportation planners, policymakers, urban designers, and activists have expended considerable effort over the past few decades promoting walking as one of several alternatives to driving.  More recently, the public health benefit of a physically active population, including a population that walks more often, has become another reason to encourage walking.  Amongst all of this excitement about walking, there has so far been little exploration of the role walking plays in people’s lives and cities’ welfare.  One little understood aspect of walking is its appeal beyond simple “derived demand” travel choice frameworks.  Though we might intuitively know that people walk for more than just to get from A to B, there’s been little to explain what people gain from walking beyond its potential health benefit.  An investigation of pedestrian behavior using the 2009 National Household Travel Survey suggests that the reasons that people choose to walk vary considerably across place and class, and that walking in urban areas may best be explained by a dual conceptualization of walking as the mode of last resort and a highly-prized urban amenity.  This seemingly self-contradictory dual role suggests that policies that want to encourage walking across a broad swath of the population will need to overcome barriers rooted in everyday lifestyles just as much as in the quality of the built environment.

Nonprofit organizations are a critical part of society as well as a growing sector of the economy. For funders there is an increasing and pressing need to ensure that society reaps the most social benefit for their money while also developing the nonprofit sector as a whole. By routinely scrutinizing nonprofit reports in an effort to deduce whether a nonprofit organization is efficient, funders may believe that they are, in fact, giving responsibly. However, we find that these nonprofit reports are unreliable, supporting a myriad of empirical research and revealing that report-based funding methods do not facilitate efficient allocation of funds. In response, we develop audit contracts that put funders in a position to enact change. Auditing, perhaps obviously, supports funders; however, we find that it also benefits the population of nonprofits. Moreover, auditing results in improved efficiency for the nonprofit sector overall. Indeed, our conclusions indicate that nonprofits may want to work with funders to increase the use of auditing, consequently increasing efficiency for the sector overall and impacting society as a whole.

This paper examines the impact of institutional change on patient care. Using panel data on obstetric deliveries from the state of California in the United States between 1983 and 2001, it develops and tests hypotheses predicting impacts of three features of institutional change-managed care insurance, changing professional controls and public attention to cost-control practices-on cesarean use and geographic variation in cesarean deliveries. It finds that managed care insurance promotes the diffusion of cost-effective patient care practices, reducing cesarean use and increasing variation. I found that over time, managed care patients experience continued lower use and reduced geographic variation as new practices become established. The combined effects of changing professional controls-the growing importance of clinical guidelines-and public attention to cost-control practices also diffuses cost-effective practices, increasing variation and decreasing cesarean use. Cesarean use increases and geographic variation declines in a period of managed care retreat in the late 1990s. The analysis extends prior research by documenting the impact of institutional change on health services use and variation and by suggesting that geographic variation is caused, in part, by the diffusion of new patient care practices

Objective. To test the effect of Massachusetts Medicaid's (MassHealth) hospital-based pay-for-performance (P4P) program, implemented in 2008, on quality of care for pneumonia and surgical infection prevention (SIP). Data. Hospital Compare process of care quality data from 2004 to 2009 for acute care hospitals in Massachusetts (N=62) and other states (N=3,676) and American Hospital Association data on hospital characteristics from 2005. Study Design. Panel data models with hospital fixed effects and hospital-specific trends are estimated to test the effect of P4P on composite quality for pneumonia and SIP. This base model is extended to control for the completeness of measure reporting. Further sensitivity checks include estimation with propensity-score matched control hospitals, excluding hospitals in other P4P programs, varying the time period during which the program was assumed to have an effect, and testing the program effect across hospital characteristics. Principal Findings. Estimates from our preferred specification, including hospital fixed effects, trends, and the control for measure completeness, indicate small and nonsignificant program effects for pneumonia (-0.67 percentage points, p>.10) and SIP (-0.12 percentage points, p>.10). Sensitivity checks indicate a similar pattern of findings across specifications. Conclusions. Despite offering substantial financial incentives, the MassHealth P4P program did not improve quality in the first years of implementation.

There has been little research to date on the linkages between air pollution and infectious respiratory illness in children, and the resulting health care costs. In this study we used data on air pollutants and national hospitalizations to study the relationship between fine particulate air pollution and health care charges and costs for the treatment of bronchiolitis, an acute viral infection of the lungs. We found that as the average exposure to fine particulate matter over the lifetime of an infant increased, so did costs for the child's health care. If the United States were to reduce levels of fine particulate matter to 7 percent below the current annual standard, the nation could save $15 million annually in reduced health care costs from hospitalizations of children with bronchiolitis living in urban areas. These findings reinforce the need for ongoing efforts to reduce levels of air pollutants. They should trigger additional investigation to determine if the current standards for fine-particulate matter are sufficiently protective of children's health.

There has been little research to date on the linkages between air pollution and infectious respiratory illness in children, and the resulting health care costs. In this study we used data on air pollutants and national hospitalizations to study the relationship between fine particulate air pollution and health care charges and costs for the treatment of bronchiolitis, an acute viral infection of the lungs. We found that as the average exposure to fine particulate matter over the lifetime of an infant increased, so did costs for the child's health care. If the United States were to reduce levels of fine particulate matter to 7 percent below the current annual standard, the nation could save $15 million annually in reduced health care costs from hospitalizations of children with bronchiolitis living in urban areas. These findings reinforce the need for ongoing efforts to reduce levels of air pollutants. They should trigger additional investigation to determine if the current standards for fine-particulate matter are sufficiently protective of children's health.

Economic analyses are increasingly appearing in the children's environmental-health literature. In this review, an illustrative selection of articles that represent cost analyses, cost-effectiveness analyses, and cost-benefit analyses is analyzed for the relative merits of each approach. Cost analyses remain the dominant approach due to lack of available data. Cost-effectiveness and cost-benefit analyses in this area face challenges presented by estimation of costs of environmental interventions, whose costs are likely to decrease with further technological innovation. Benefits are also more difficult to quantify economically and can only be partially alleviated through willingness-to-pay approaches. Nevertheless, economic analyses in children's environmental health are highly informative and important informants to public-health and policy practice. Further attention and training in their appropriate use are needed.

A 2002 analysis documented $54.9 billion in annual costs of environmentally mediated diseases in US children. However, few important changes in federal policy have been implemented to prevent exposures to toxic chemicals. We therefore updated and expanded the previous analysis and found that the costs of lead poisoning, prenatal methylmercury exposure, childhood cancer, asthma, intellectual disability, autism, and attention deficit hyperactivity disorder were $76.6 billion in 2008. To prevent further increases in these costs, efforts are needed to institute premarket testing of new chemicals; conduct toxicity testing on chemicals already in use; reduce lead-based paint hazards; and curb mercury emissions from coal-fired power plants.

The article under evaluation analyzed healthcare utilization data from the German Interview and Examination Survey for Children and Adolescents, a representative cross-sectional survey that quantifies healthcare services and costs by category. The author used widely accepted health economic methods to quantify incremental costs and utilization attributable to elevated BMI in children. There are important limits to consider for policy makers, clinicians and others who may use these data in isolation to quantify economic savings and other benefits to quantify cost-effectiveness and cost-benefit profiles of environmental, dietary, physical activity and/or pharmaceutical interventions to prevent or treat obesity in childhood. Longer term benefits of preventing obesity in childhood must be considered.

A 2002 analysis documented $54.9 billion in annual costs of environmentally mediated diseases in US children. However, few important changes in federal policy have been implemented to prevent exposures to toxic chemicals. We therefore updated and expanded the previous analysis and found that the costs of lead poisoning, prenatal methylmercury exposure, childhood cancer, asthma, intellectual disability, autism, and attention deficit hyperactivity disorder were $76.6 billion in 2008. To prevent further increases in these costs, efforts are needed to institute premarket testing of new chemicals; conduct toxicity testing on chemicals already in use; reduce lead-based paint hazards; and curb mercury emissions from coal-fired power plants.

As state sessions draw to a close, this brief examines legislative activity in the first half of 2011 in three main areas—economic security, immigration reform, and reproductive rights—and highlights what state-level legislative wins and losses mean for women of color and their families. Clear trends emerge in this summary: an unprecedented number of attacks on workers, immigrant rights, and women’s reproductive health represent challenges ahead for women of color. At the same time, many setbacks were accompanied with signs of promise, including notable rejections of anti-immigrant measures and legal challenges to legislation restricting women’s access to reproductive health services.

This month, Chairman of the House Budget Committee Representative Paul Ryan, the Congressional Progressive Caucus (CPC) and President Obama shared three very different FY 2012 budget proposals and deficit reduction strategies. The CPC's People's Budget calls for investments in job creation and deficit elimination by increasing tax revenues from the wealthy. President Obama's deficit reduction plan combines spending cuts, tax reform and enhancing the Affordable Care Act to reduce growth in health care spending. Representative Ryan's proposal extends tax cuts to wealthy individuals and corporations, while cutting social safety net programs such as food stamps, housing assistance, and Pell Grants. This policy brief evaluates each proposal's impact on people of color and recommends investing in job creation and infrastructure to strengthen communities in times of hardship and prosperity.

Children and youth vary in their developmental health due to differences in family economic security and exposure to toxic stress. The economic downturn has increased the challenges facing low-income children. The ARRA and the President's first budget made significant down-payments on investments in protecting and promoting the well-being of these children. But some of those investments are temporary and must be built into baselines going forward. Many other promising avenues for policy change could be implemented through reauthorization of PRWORA and ESEA. Further, a new era of experimentation in innovative program and policies is recommended for when the economy recovers.

Substance use (SU) disorders adversely impact health status and contribute to inappropriate health services use. This qualitative study sought to determine SU-related factors contributing to repeated hospitalizations and to identify opportunities for preventive interventions. Fifty Medicaid-insured inpatients identified by a validated statistical algorithm as being at high-risk for frequent hospitalizations were interviewed at an urban public hospital. Patient drug/alcohol history, experiences with medical, psychiatric and addiction treatment, and social factors contributing to readmission were evaluated. Three themes related to SU and frequent hospitalizations emerged: (a) barriers during hospitalization to planning long-term treatment and follow-up, (b) use of the hospital as a temporary solution to housing/family problems, and (c) unsuccessful SU aftercare following discharge. These data indicate that homelessness, brief lengths of stay complicating discharge planning, patient ambivalence regarding long-term treatment, and inadequate detox-to-rehab transfer resources compromise substance-using patients' likelihood of avoiding repeat hospitalization. Intervention targets included supportive housing, detox-to-rehab transportation, and postdischarge patient support.

Abstract

Background: Pay-for-performance is an increasingly popular approach to improving health care quality, and the US government will soon implement pay-for-performance in hospitals nationwide. Yet hospital capacity to perform (and

improve performance) likely depends on local resources. In this study, we quantify the association between hospital performance and local economic and human resources, and describe possible implications of pay-for-performance for socioeconomic equity.

Methods and Findings: We applied county-level measures of local economic and workforce resources to a national sample of US hospitals (n = 2,705), during the period 2004–2007. We analyzed performance for two common cardiac conditions (acute myocardial infarction [AMI] and heart failure [HF]), using process-of-care measures from the Hospital Quality Alliance [HQA], and isolated temporal trends and the contributions of individual resource dimensions on performance, using multivariable mixed models. Performance scores were translated into net scores for hospitals using the Performance Assessment Model, which has been suggested as a basis for reimbursement under Medicare’s ‘‘Value-Based Purchasing’’ program. Our analyses showed that hospital performance is substantially associated with local economic and workforce resources. For example, for HF in 2004, hospitals located in counties with longstanding poverty had mean HQA composite scores of 73.0, compared with a mean of 84.1 for hospitals in counties without longstanding poverty (p,0.001). Hospitals located in counties in the lowest quartile with respect to college graduates in the workforce had mean HQA composite scores of 76.7, compared with a mean of 86.2 for hospitals in the highest quartile (p,0.001). Performance on AMI measures showed similar patterns. Performance improved generally over the study period. Nevertheless, by 2007—4 years after public reporting began—hospitals in locationally disadvantaged areas still lagged behind their locationally advantaged counterparts. This lag translated into substantially lower net scores under the Performance Assessment Model for hospital reimbursement.

Conclusions: Hospital performance on clinical process measures is associated with the quantity and quality of local economic and human resources. Medicare’s hospital pay-for-performance program may exacerbate inequalities across regions, if implemented as currently proposed. Policymakers in the US and beyond may need to take into consideration the balance between greater efficiency through pay-for-performance and socioeconomic equity.

Please see later in the article for the Editors’ Summary.

BACKGROUND:

Since Mexico's joining the North American Free Trade Agreement (NAFTA) and the Organization for Economic Cooperation and Development (OECD) in 1994, it has witnessed rapid industrialization. A byproduct of this industrialization is increasing population exposure to environmental pollutants, of which some have been associated with childhood disease. We therefore identified and assessed the adequacy of existing international and Mexican governance instruments and policy tools to protect children from environmental hazards.

METHODS:

We first systematically reviewed PubMed, the Mexican legal code and the websites of the United Nations, World Health Organization, NAFTA and OECD as of July 2007 to identify the relevant governance instruments, and analyzed the approach these instruments took to preventing childhood diseases of environmental origin. Secondly, we interviewed a purposive sample of high-level government officials, researchers and non-governmental organization representatives, to identify their opinions and attitudes towards children's environmental health and potential barriers to child-specific protective legislation and implementation.

RESULTS:

We identified only one policy tool describing specific measures to reduce developmental neurotoxicity and other children's health effects from lead. Other governance instruments mention children's unique vulnerability to ozone, particulate matter and carbon monoxide, but do not provide further details. Most interviewees were aware of Mexican environmental policy tools addressing children's health needs, but agreed that, with few exceptions, environmental policies do not address the specific health needs of children and pregnant women. Interviewees also cited state centralization of power, communication barriers and political resistance as reasons for the absence of a strong regulatory platform.

CONCLUSIONS:

The Mexican government has not sufficiently accounted for children's unique vulnerability to environmental contaminants. If regulation and legislation are not updated and implemented to protect children, increases in preventable exposures to toxic chemicals in the environment may ensue.

Cassandra Shaylor and Cynthia Chandler founded Justice Now in 2000. They push hard for prison abolition while advocating for better health care and conditions for prisoners in California's two largest women's prisons. They prioritize the leadership of prisoners, and offer interns the opportunity to work and meet with women inside prisons to learn firsthand about prisoners' human struggles as well as the policy implications of state sponsored violence. Their strategies include the following:

• Conduct Legal Visits Inside Prisons to Expose and Challenge Human Rights Abuses: Shaylor, Chandler and the Justice Now interns spend as much time as possible inside prisons to uncover human rights abuses and organize to challenge them. They build relationships with women inside and become the eyes and ears to the outside.
• Build Leadership Among Prisoners: Justice Now engages people in prison in the organization's work at every level. They also assist women who are already working as activists within the prisons.
• Push the Prison Abolition Frontier: While Justice Now helps to improve health care and other conditions, they oppose prison reformation efforts. Instead they push for prison abolition.
• Spread a Vision of a World Without Prisons: Through plays, music, oral histories and toolkits, the organization helps envision and promote a new approach to building lives, not locking people away.

In this leadership story Shaylor and Chandler, along with Justice Now interns and activists, describe their experiences in this case example.

The enduring impact of exposure to the 9/11 terrorist attacks on mental health and sociopolitical attitudes was examined in a sample of 427 adolescents (M = 16.20 years) and their mothers residing in New York City. Direct exposure to the terrorist attack was associated with youth depression symptoms and with mothers’ posttraumatic stress disorder symptoms. There was no evidence of reciprocal effects of mother exposure on youth or of youth exposure on mothers. Although mothers reported engaging in more emotional processing coping assistance with their children, coping assistance was not associated with youth’s symptomatology. Media exposure was found to be a strong predictor of youth’s and mothers’ sociopolitical attitudes about issues such as prejudice toward immigrants, social mistrust, and current events.

BACKGROUND:

Tetraethyl lead was phased out of gasoline in Uganda in 2005. Recent mitigation of an important source of lead exposure suggests examination and re-evaluation of the prevalence of childhood lead poisoning in this country. Ongoing concerns persist about exposure from the Kiteezi landfill in Kampala, the country's capital.

OBJECTIVES:

We determined blood lead distributions among Kampala schoolchildren and identified risk factors for elevated blood lead levels (EBLLs; >or= 10 microg/dL). Analytical approach: Using a stratified, cross-sectional design, we obtained blood samples, questionnaire data, and soil and dust samples from the homes and schools of 163 4- to 8-year-old children representing communities with different risks of exposure.

RESULTS:

The mean blood lead level (BLL) was 7.15 microg/dL; 20.5% of the children were found to have EBLL. Multivariable analysis found participants whose families owned fewer household items, ate canned food, or used the community water supply as their primary water source to have higher BLLs and likelihood of EBLLs. Distance < 0.5 mi from the landfill was the factor most strongly associated with increments in BLL (5.51 microg/dL, p < 0.0001) and likelihood of EBLL (OR = 4.71, p = 0.0093). Dust/soil lead was not significantly predictive of BLL/EBLL.

CONCLUSIONS:

Lead poisoning remains highly prevalent among school-age children in Kampala. Confirmatory studies are needed, but further efforts are indicated to limit lead exposure from the landfill, whether through water contamination or through another mechanism. Although African nations are to be lauded for the removal of lead from gasoline, this study serves as a reminder that other sources of exposure to this potent neurotoxicant merit ongoing attention.

New York. London. Paris. Although these cities have similar sociodemographic characteristics, including income inequalities and ethic diversity, they have vastly different health systems and services. This book compares the three and considers lessons that can be applied to current and future debates about urban health care.

Highlighting the importance of a national policy for city health systems, the authors use well-established indicators and comparable data sources to shed light on urban health policy and practice. Their detailed comparison of the three city health systems and the national policy regimes in which they function provides information about access to health care in the developed world's largest cities.

The authors first review the current literature on comparative analysis of health systems and offer a brief overview of the public health infrastructure in each city. Later chapters illustrate how timely and appropriate disease prevention, primary care, and specialty health care services can help cities control such problems as premature mortality and heart disease.

In providing empirical comparisons of access to care in these three health systems, the authors refute inaccurate claims about health care outside of the United States.

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Context: The continuing rise in obesity rates across the United States has proved impervious to clinical treatment or public health exhortation, necessitating policy responses. Nearly a decade's worth of political debates may be hardening into an obesity issue regime, comprising established sets of cognitive frames, stakeholders, and policy options.

Methods: This article is a survey of reports on recently published studies.

Findings: Much of the political discussion regarding obesity is centered on two "frames," personal-responsibility and environmental, yielding very different sets of policy responses. While policy efforts at the federal level have resulted in little action to date, state and/or local solutions such as calorie menu labeling and the expansion of regulations to reduce unhealthy foods at school may have more impact.

Conclusions: Obesity politics is evolving toward a relatively stable state of equilibrium, which could make comprehensive reforms to limit rising obesity rates less feasible. Therefore, to achieve meaningful change, rapid-response research identifying a set of promising reforms, combined with concerted lobbying action, will be necessary.

Obesity burst onto the U.S. national policy agenda in 2000/2001, initially fuelled by a widely disseminated set of maps by the Centers for Disease Control and Prevention (CDC) depicting sharply rising obesity rates nationwide, followed by the surgeon general's warning that obesity had become a "new national epidemic" (Mokdad et al. 2003; Oliver 2006; Satcher 2001). A snapshot of responses since then would include alarmed reactions from medical, media, and policy actors alike. The health establishment has rushed to devise medical treatments, from surgical to pharmaceutical, for obesity and its manifold health effects. Surging media attention to obesity and overweight features reports ranging from dire health alarms ("the current generation may be the first to live shorter lives than their parents-and obesity is to blame"; Belluck 2005, p. A1; see also Daniels 2006; Olshansky et al. 2005) to economic warnings (over $120 billion lost annually to obesity-related illnesses; see e.g., Bhattacharya and Sood 2006) to "lifestyle" stories of coffins, airplane seats, and hospital beds all made larger to suit the "supersizing of America" (St. John 2003, p. A13). Public officials at all levels have decried the "epidemic," although statutory reforms have been concentrated in a few energetic local and state polities; the federal government has been noticeably slow to act. All the while obesity rates continue to rise, with thirty-seven states reporting significant year-to-year increases from 2007 to 2008, with none reporting a decrease (TFAH 2008).

This article explores obesity politics as it has evolved in recent years. First I discuss the sustained struggles over framing the topic now that public agendas have begun to solidify into an "issue regime" around obesity. Then I examine popular local and state policy options and review approaches that could have an impact on soaring obesity rates, along with an assessment of the likelihood of their widespread adoption. While promising policy approaches exist, the opportunity to take action may be closing fast. On most public health issues, policymaking features a bustle of activity followed by a period of quiescence as a regime coalesces-even when the underlying problems continue to mount. Antiobesity advocates who face declining interest from lawmakers will therefore need to devise creative ways to sustain a focus on this topic.

Understanding the complex factors contributing to the growing childhood obesity epidemic is vital not only for the improved health of the world's future generations, but for the healthcare system. The impact of childhood obesity reaches beyond the individual family and into the public arenas of social systems and government policy and programs. Global Perspectives on Childhood Obesity explores these with an approach that considers the current state of childhood obesity around the world as well as future projections, the most highly cited factors contributing to childhood obesity, what it means for the future both for children and society, and suggestions for steps to address and potentially prevent childhood obesity.

Whether newer pharmaceuticals justify their higher costs by reducing other health expenditures has generated significant debate. We replicate a frequently cited paper by Lichtenberg on drug “offsets” and find the results disappear using a more appropriate model or updated dataset. Further, we test the suitability of similar methods using newer hypertension drugs. We find our observational results run counter to well-established clinical evidence on comparative efficacy and conclude that our model, as well as other studies that do not adequately control for unobserved characteristics that jointly determine drug choice and health expenditures, are likely subject to significant bias.

Has the role of the social entrepreneur been glorified as the primary driver of social breakthrough? Have we neglected the important role that all change agents play? What must be done to create the networks that create so many breakthroughs? How does the breakthrough cycle actually work? How do we strengthen the infrastructure that supports social change organizations in their quest? Driving Social Change is the ultimate introduction to the many steps needed to challenge and replace the prevailing wisdom.

Based on the latest research from author, professor, and Washington Post online columnist Paul C. Light, Driving Social Change confronts head-on the seemingly eternal questions of solving tough, even intractable, social problems. Starting with the definition of social entrepreneurship as a powerful driver of social change, it goes well beyond the concept to a more detailed assessment of the "breakthrough" cycle with several other drivers. Along the way, the book focuses on the need to protect past social breakthroughs from complacency and counterattack.

If our purpose is to change the world, writes Light, we must concentrate on every driver possible, not just the ones we can see. To that end, the book highlights alternative paths to creating social breakthrough and provides actionable advice, exploring:

-Strategies to broaden the definition of social entrepreneurship

-Tactics to build strong social organizations and networks

-Dynamic methods to respond to constant economic and social change

-The journey from initial commitment to a world of justice and opportunity

As much as social entrepreneurship is a wondrous, inspirational act, even more extraordinary is the creation of durable social impact through whatever means necessary. Driving Social Change tells us that we should be less concerned about the tools of agitation and more concerned about the disruption and replacement of the status quo.

Holding old mindsets up to the light of day, this timely book unflinchingly addresses the change process and challenges us to question our beliefs about how it really works.

Although an increasing amount of community mental health research has investigated the deleterious effects of disasters and the targeting and efficacy of treatment in their aftermath, little research has sought to identify preexisting characteristics of the social environment that are predictive of post-disaster distress. A national US telephone survey fielded before and after September 11, 2001, was used to investigate the psychological distress among American adolescents related to the attacks, and to identify environmental and other characteristics that predisposed youth to experience higher or lower levels of post-disaster distress. The study found that widespread characteristics of children’s school environments—school disorder and physical threats—were at least as strongly associated with a proxy for psychological distress as exposure to the events of 9/11. Further, children exposed to physical threats at school appeared to be more vulnerable to the psychological effects of disasters than children in safer school environments.

We explore attention to Clinton's health care reform proposal, ongoing debates, and its political demise to develop theory that explains how events create opportunities for cognitive realignment and transformation in institutional logics. Our case analysis illustrates how a bottom-up process of environmental sensemaking led to the emergence and adoption of a logic of managed care, which provided new organizing principles in the hospitals' organizational field. In addition to theorization, highlighted by prior research, we propose a second mechanism of environmental sensemaking: representation of change through exemplars and environmental features. The interplay between theorization, representation, and ongoing event attention can lead to change in institutional logics over an event's life course. We found that the managed care logic did not emerge in a fully formed fashion, but that actors theorized individual dimensions of the logic consistent with changing representations of hospitals' relationships with other actors in the field. As the event unfolded, the individual dimensions came to be theorized as part of an overall managed care logic. The label "managed care," previously understood as a specific organizational form, took on a new meaning to symbolize the organizing principles for hospitals' relationships with a variety of institutional actors as alternative models not congruent with the changing organizational field were abandoned.

Objective
To determine whether a diabetes case management telemedicine intervention reduced healthcare expenditures, as measured by Medicare claims, and to assess the costs of developing and implementing the telemedicine intervention.
Design
We studied 1665 participants in the Informatics for Diabetes Education and Telemedicine (IDEATel), a randomized controlled trial comparing telemedicine case management of diabetes to usual care. Participants were aged 55 years or older, and resided in federally designated medically underserved areas of New York State.
Measurements
We analyzed Medicare claims payments for each participant for up to 60 study months from date of randomization, until their death, or until December 31, 2006 (whichever happened first). We also analyzed study expenditures for the telemedicine intervention over six budget years (February 28, 2000- February 27, 2006).
Results
Mean annual Medicare payments (SE) were similar in the usual care and telemedicine groups, $9040 ($386) and $9669 ($443) per participant, respectively (p>0.05). Sensitivity analyses, including stratification by censored status, adjustment by enrollment site, and semi-parametric weighting by probability of dropping-out, rendered similar results. Over six budget years 28 821 participant/months of telemedicine intervention were delivered, at an estimated cost of $622 per participant/month.
Conclusion
Telemedicine case management was not associated with a reduction in Medicare claims in this medically underserved population. The cost of implementing the telemedicine intervention was high, largely representing special purpose hardware and software costs required at the time. Lower implementation costs will need to be achieved using lower cost technology in order for telemedicine case management to be more widely used.

Slowing the rate of growth of health spending is as critical a goal at the state level as it is at the national level. Philanthropy can hardly address this issue alone, yet it has an obligation to take on big and seemingly intractable problems. The New York State Health Foundation is committed to stimulating innovative and replicable approaches to bending the cost curve.

This article describes how the foundation recently awarded six grants to support efforts related to payment reform, hospital re-admissions, medical malpractice reform, palliative care, and the quantification of other cost containment approaches that could be pursued atthe state level.

Health care policymakers have cited transportation barriers as key obstacles to providing health care to low-income suburbanites, particularly because suburbs have become home to a growing number of recent immigrants who are less likely to own cars than their neighbors. In a suburb of New York City, we conducted a pilot survey of low income, largely immigrant clients in four public clinics, to find out how much transportation difficulties limit their access to primary care. Clients were receptive to the opportunity to participate in the survey (response rate = 94%). Nearly one-quarter reported having transportation problems that had caused them to miss or reschedule a clinic appointment in the past. Difficulties included limited and unreliable local bus service, and a tenuous connection to a car. Our pilot work suggests that this population is willing to participate in a survey on this topic. Further, since even among those attending clinic there was significant evidence of past transportation problems, it suggests that a population based survey would yield information about substantial transportation barriers to health care.

OBJECTIVE:

To determine the trends in incidence of diagnosis of bronchopulmonary dysplasia (BPD) and associated health services use for the neonatal hospitalization of patients with BPD in an era of changing definitions and management.

PATIENTS AND METHODS:

All neonatal hospitalization records available through the Nationwide Inpatient Sample, 1993-2006, were analyzed. Multivariable regression analyses were performed for incidence of BPD diagnosis and associated hospital length of stay and charges. Multiple models were constructed to assess the roles of changes in diagnosis of very low birth weight (VLBW) neonates and different modalities of respiratory support used for treatment.

RESULTS:

The absolute incidence of diagnosis of BPD fell 3.3% annually (P = .0009) between 1993 and 2006 coincident with a 3.5-fold increase in the use of noninvasive respiratory support in patients with BPD. When data were controlled for demographic factors, this significant decrease in incidence persisted at a rate of 4.3% annually (P = .0002). All models demonstrated a rise in hospital length of stay and financial charges for the neonatal hospitalization of patients with BPD. The incidence of BPD adjusted for frequency of prolonged mechanical ventilation also decreased but only by 2.8% annually (P = .0075).

CONCLUSIONS:

The incidence of diagnosis of BPD decreased significantly between 1993 and 2006. In well-controlled models, birth hospitalization charges for these patients rose during the same period. Less invasive ventilatory support may improve respiratory outcomes of VLBW neonates.

Victor Rodwin, professor of health policy and management at NYU Wagner, and his colleague Didier Tabuteau, counselor of state and professor of health policy at the Institut d'Etudes Politiques and the University of Paris Descartes, have published a new book (published by Editions Jacob Duvernet) in which they challenge the conventional wisdom that the French health care system is a government-managed, public and collective enterprise and the American system a private, market-oriented and individualist system. Based on six months of debates in Paris while Professor Rodwin held the Fulbright-Toqueville Chair (spring semester, 2010), this book compares public health, health insurance, the power of physicians, health care reform, and the silent revolution that is transforming health care organization in both France and the United States.

Policy makers generally agree that childhood obesity is a national problem. However, it is not always clear whether enough is being spent to combat it. This paper presents nine scenarios that assume three different degrees of reduction in obesity/overweight rates among children in three age groups. A mathematical model was then used to project lifetime health and economic gains. Spending $2 billion a year would be cost-effective if it reduced obesity among twelve-year-olds by one percentage point. The analysis also found that childhood obesity has more profound economic consequences than previously documented. Large investments to reduce this major contributor to adult disability may thus be cost-effective by widely accepted criteria.

BACKGROUND:

Elevated concentrations of mercury have been documented in fish in Lake Chapala in central Mexico, an area that is home to a large subsistence fishing community. However, neither the extent of human mercury exposure nor its sources and routes have been elucidated.

METHODS:

Total mercury concentrations were measured in samples of fish from Lake Chapala; in sections of sediment cores from the delta of Rio Lerma, the major tributary to the lake; and in a series of suspended-particle samples collected at sites from the mouth of the Lerma to mid-Lake. A cross-sectional survey of 92 women ranging in age from 18-45 years was conducted in three communities along the Lake to investigate the relationship between fish consumption and hair mercury concentrations among women of child-bearing age.

RESULTS:

Highest concentrations of mercury in fish samples were found in carp (mean 0.87 ppm). Sediment data suggest a pattern of moderate ongoing contamination. Analyses of particles filtered from the water column showed highest concentrations of mercury near the mouth of the Lerma. In the human study, 27.2% of women had >1 ppm hair mercury. On multivariable analysis, carp consumption and consumption of fish purchased or captured from Lake Chapala were both associated with significantly higher mean hair mercury concentrations.

CONCLUSIONS:

Our preliminary data indicate that, despite a moderate level of contamination in recent sediments and suspended particulate matter, carp in Lake Chapala contain mercury concentrations of concern for local fish consumers. Consumption of carp appears to contribute significantly to body burden in this population. Further studies of the consequences of prenatal exposure for child neurodevelopment are being initiated.

Policy makers generally agree that childhood obesity is a national problem. However, it is not always clear whether enough is being spent to combat it. This paper presents nine scenarios that assume three different degrees of reduction in obesity/overweight rates among children in three age groups. A mathematical model was then used to project lifetime health and economic gains. Spending $2 billion a year would be cost-effective if it reduced obesity among twelve-year-olds by one percentage point. The analysis also found that childhood obesity has more profound economic consequences than previously documented. Large investments to reduce this major contributor to adult disability may thus be cost-effective by widely accepted criteria.

Too often in the fast-moving healthcare field, decision makers rely primarily on what has worked before. Evidence-Based Management in Healthcare explains how healthcare leaders can move from making educated guesses to using the best available information to make decisions.

Despite the extensive literature on the determinants of child labor, the evidence on the consequences of child labor on outcomes such as education, labor, and health is limited. We evaluate the causal effect of child labor participation among children in school on these outcomes using panel data from Vietnam and an instrumental variables strategy. Five years subsequent to the child labor experience we find significant negative impacts on education, and also find a higher probability of wage work for those young adults who worked as children while attending school. We find few significant effects on health.

Purpose

This study investigates the degree to which the racial composition of the school environment may influence the body mass index (BMI) of children aged 10 to 18 years. This research may be viewed as extending prior work that has found that the prevalence of risk behaviors among nonwhite adolescents is influenced by exposure to white adolescents.

Methods

This research used data from the Survey of Adults and Youth, which was conducted as part of the evaluation of the Robert Wood Johnson Foundation's Urban Health Initiative. The study population for this analysis is comprised of parent and child respondents in the 2004 to 2005 survey wave who lived in one of the five program cities: Baltimore, Detroit, Oakland, Philadelphia, and Richmond. We constructed two-level school random effects models and added school and census tract-level variables that describe the racial composition of the residential community and the school attended.

Results

Black and Hispanic adolescent girls who attend schools with a mostly nonwhite student body have higher BMIs than do their white counterparts. However, black girls in predominately white schools do not have higher BMIs than white girls. Further, black and Hispanic girls whose schoolmates are predominately white have significantly lower BMIs than black and Hispanic girls in schools where fewer than half the students are white. These associations are not found among boys, and are net of a broad variety of individual, household, and group level characteristics.

Conclusions

Our findings suggest that the BMI of minority adolescent girls is influenced by the norms of the social environment.

Physical inactivity is one of the most important public health issues in the U.S. and internationally. Increasingly, links are being identified between various elements of the physical—or built—environment and physical activity. To understand the impact of the built environment on physical activity, the development of high-quality measures is essential. Three categories of built environment data are being used: (1) perceived measures obtained by telephone interview or self-administered questionnaires; (2) observational measures obtained using systematic observational methods (audits); and (3) archival data sets that are often layered and analyzed with GIS. This review provides a critical assessment of these three types of built-environment measures relevant to the study of physical activity. Among perceived measures, 19 questionnaires were reviewed, ranging in length from 7 to 68 questions. Twenty audit tools were reviewed that cover community environments (i.e., neighborhoods, cities), parks, and trails. For GIS-derived measures, more than 50 studies were reviewed. A large degree of variability was found in the operationalization of common GIS measures, which include population density, land-use mix, access to recreational facilities, and street pattern. This first comprehensive examination of built-environment measures demonstrates considerable progress over the past decade, showing diverse environmental variables available that use multiple modes of assessment. Most can be considered first-generation measures, so further development is needed. In particular, further research is needed to improve the technical quality of measures, understand the relevance to various population groups, and understand the utility of measures for science and public health.

We examined the influence of menu calorie labels on fast food choices in the wake of New York City's labeling mandate. Receipts and survey responses were collected from 1,156 adults at fast-food restaurants in low-income, minority New York communities. These were compared to a sample in Newark, New Jersey, a city that had not introduced menu labeling. We found that 27.7 percent who saw calorie labeling in New York said the information influenced their choices. However, we did not detect a change in calories purchased after the introduction of calorie labeling. We encourage more research on menu labeling and greater attention to evaluating and implementing other obesity-related policies.

Patients with frequent hospitalizations generate a disproportionate share of hospital visits and costs. Accurate determination of patients who might benefit from interventions is challenging: most patients with frequent admissions in 1 year would not continue to have them in the next. Our objective was to employ a validated regression algorithm to case-find Medicaid patients at high-risk for hospitalization in the next 12 months and identify intervention-amenable characteristics to reduce hospitalization risk. We obtained encounter data for 36,457 Medicaid patients with any visit to an urban public hospital from 2001 to 2006 and generated an algorithm-based score for hospitalization risk in the subsequent 12 months for each patient (0 = lowest, 100 = highest). To determine medical and social contributors to the current admission, we conducted in-depth interviews with high-risk hospitalized patients (scores >50) and analyzed associated Medicaid claims data. An algorithm-based risk score >50 was attained in 2,618 (7.2%) patients. The algorithm’s positive predictive value was equal to 0.67. During the study period, 139 high-risk patients were admitted: 60 met inclusion criteria and 50 were interviewed. Fifty-six percent cited the Emergency Department as their usual source of care or had none. Sixty-eight percent had >1 chronic medical conditions, and 42% were admitted for conditions related to substance use. Sixty percent were homeless or precariously housed. Mean Medicaid expenditures for the interviewed patients were $39,188 and $84,040 per patient for the years immediately prior to and following study participation, respectively. Findings including high rates of substance use, homelessness, social isolation, and lack of a medical home will inform the design of interventions to improve community-based care and reduce hospitalizations and associated costs.

Key Messages

• Until recently researchers and policymakers paid little attention to the role of health workers in developing countries but a new generation of studies are providing a fuller understanding of these issues using more sophisticated data and research tools.
  
• Recent research highlights the value of viewing health workers as active agents in dynamic labour markets who are faced with many competing incentives and constraints.
  
• Newer studies have provided greater insights into human resource requirements in health, the motivations and behaviours of health workers, and health worker migration. We are encouraged by the progress but believe there is a need for even more, and higher quality, research on this topic.

The question posed in this paper is whether single-payer health care systems

are more likely to provide equal treatment for equal need (horizontal equity) than are multipayer systems. To address this question, we compare access to primary and specialty health care services across selected neighborhoods, grouped by average

household income, in a single-payer system (the English NHS), a multiple-payer system with universal coverage (French National Health Insurance), and the U.S. multiple-payer system characterized by large gaps in health insurance coverage. We find that Paris residents, including those with low incomes, have better access to health care than their counterparts in Inner London and Manhattan. This finding casts doubt on the notion that the number of payers influences the capacity of a health care system to provide equitable access to its residents. The lesson is to worry less about the number of payers and more about the system’s ability to assure access to primary and specialty care services.

The paper provides a mid-course assessment of the Bronx Health REACH faith-based initiative four years into its implementation.

The continuing rise in obesity rates across the United States has proved impervious to clinical treatment or public health exhortation, necessitating policy responses. Nearly a decade’s worth of political debates may be hardening into an obesity issue regime, comprising established sets of cognitive frames, stakeholders, and policy options.

OBJECTIVE:

The National Children's Study is a long-term epidemiologic study of 100,000 children from 105 locations across the United States. It will require information on a large number of environmental variables to address its core hypotheses. The resources available to collect actual home and personal exposure samples are limited, with most of the home sampling completed on periodic visits and the personal sampling generally limited to biomonitoring. To fill major data gaps, extant data will be required for each study location. The Queens Vanguard Center has examined the extent of those needs and the types of data that are generally and possibly locally available.

DATA:

In this review we identify three levels of data--national, state and county--and local data and information sets (levels 1-3, respectively), each with different degrees of availability and completeness, that can be used as a starting point for the extant data collection in each study location over time. We present an example on the use of this tiered approach, to tailor the data needs for Queens County and to provide general guidance for application to other NCS locations.

CONCLUSIONS:

Preexisting and continually evolving databases are available for use in the NCS to characterize exposure. The three levels of data we identified will be used to test a method for developing exposure indices for segments and homes during the pilot phase of NCS, as outlined in this article.

Background: Care coordination is essential to effective chronic care, but knowledge of processes by which health care professionals coordinate their activities when caring for chronically ill patients is limited. Electronic health records (EHRs) are expected to facilitate coordination of care, but whether they do so completely-and under what conditions-is not well understood.

Objectives: To identify processes by which providers worked together to provide care using an EHR and to examine factors supporting coordination of care.

Design: Qualitative multiple case study in 4 sites with diverse care delivery models, using semi-structured in-person interviews with 46 physicians and staff and telephone interviews with 65 adult patients with diabetes.

Setting: Four Kaiser Permanente medical centers.

Results: Across all care models, physicians and staff acted sequentially as loosely coupled links in a chain, relying on EHR-enabled informational continuity to coordinate care. Of providers, 94% were highly satisfied with the availability of patient information, and 89% of patients were satisfied or very satisfied with the coordination of their care. However, 6 of 65 patients described experiences of uncoordinated care, and 5 of 12 primary care providers identified coordination issues. These pertained to unreconciled differences of opinion, conflicting role expectations, and discipline-specific views of patient needs.

Conclusions: Diabetes care can be coordinated across providers, but some coordination issues persist despite the informational continuity provided by an EHR. Multidisciplinary care teams should be alert to potential coordination challenges, and possible solutions should be explored, including longitudinal care planning with structured communications at key points in care.

Six experiments investigate the hypothesis that social targets who display a greater action orientation are perceived as having more power (i.e., more control, less dependence, and more influence) than less action-oriented targets. I find evidence that this inference pattern is based on the pervasive belief that individuals with more power experience less constraint and have a greater capacity to act according to their own volition. Observers infer that targets have more power and influence when they exhibit more implementation than deliberation in the process of making decisions in their personal lives (Study 1a), in a public policy context (Study 1b), and in small groups (Study 2). In an organizational context, observers infer that a target who votes for a policy to change from the status quo has more power than a target who votes not to change from the status quo (Study 3). People also infer greater intra-organizational power and higher hierarchical rank in targets who take physical action toward a personal goal than in those who do not (Studies 4–5).

About forty percent of the world's people live on incomes of two dollars a day or less. If you've never had to survive on an income so small, it is hard to imagine. How would you put food on the table, afford a home, and educate your children? How would you handle emergencies and old age? Every day, more than a billion people around the world must answer these questions. Portfolios of the Poor is the first book to explain systematically how the poor find solutions.

The authors report on the yearlong "financial diaries" of villagers and slum dwellers in Bangladesh, India, and South Africa--records that track penny by penny how specific households manage their money. The stories of these families are often surprising and inspiring. Most poor households do not live hand to mouth, spending what they earn in a desperate bid to keep afloat. Instead, they employ financial tools, many linked to informal networks and family ties. They push money into savings for reserves, squeeze money out of creditors whenever possible, run sophisticated savings clubs, and use microfinancing wherever available. Their experiences reveal new methods to fight poverty and ways to envision the next generation of banks for the "bottom billion."

The U.S. health care system faces well-known problems: 47 million people without health insurance, rapidly rising costs that consume 16 percent of the country'e economic output, and widely uneven quality of care. Even many people with coverage are experiencing serious problems paying for the rapidly rising costs of health care and insurance.

This book--a joint product of the National Academy of Public Administration and the National Academy of Social Insurance--undertakes a sweeping analysis of the management and administrative issues that arise in expanding health care coverage. The book identifies the core administrative functions that need to be performed in assuring access to health coverage, describes how these functions are performed at present and under proposed alternatives, draws lessons from experience in the U.S. and abroad, and assesses suggested administrative approaches designed to facilitate the improvement and expansion of health care coverage.

Adequate health care is one of today's most crucial domestic policy concerns. Expanding Access to Health Care is designed to bring together in one place some of the best thinking on the subject, not as an exercise in advocacy, but rather to lay out the issues in a balanced way so that policymakers, researchers, and citizens can better understand the complex details of health care reform.

Victor G. Rodwin, qui tiendra une conférence à Marseille le 22 janvier prochain, explique en quoi la réforme
du système de santé est si difficile à mettre en oeuvre aux États-Unis. Si le Président Obama a surmonté
les premières difficultés, la course d'obstacles n'est pas pour autant terminée. Rodwin reconnaît l'excellence
du système médical français tout en contestant la première place attribuée par l'OMS à notre pays.

In Assessing Corruption in Ethiopia, forthcoming from the World Bank (ed. Janelle Plummer)

A comprehensive and concise guide to performance improvement in healthcare, Performance Improvement in Hospitals and Health Systems describes the management engineering principles focused on designing optimal management and information systems and processes. The book covers topics such as:

• Key terminology and concepts in PI
• Scope, value and management of performance improvement projects
• Developing and leading performance improvement departments
• Simulation methods in patient flow
• Understanding cost and quality relationships
• Six Sigma and Lean in healthcare
• Data mining methods for process improvment
• Integrating nursing/clinical staff with performance improvement
• Evaluation and selection criteria for projects
• Decision support systems

Written for management engineers, performance improvement professionals, quality managers and internal consultants who use a combination of methods to improve systems and processes, this book has timely, practical and actionable information and valuable insights into improving the healthcare environment.

Most studies of the economic costs of childhood obesity have focused upon hospitalization for comorbidities of obesity, whereas increased expenditures may also be the result of additional outpatient/emergency room visits or prescription drug expenditures. To quantify the magnitude of increased health-care utilization and expenditures among overweight and obese children, we performed descriptive, bivariate, and multivariable analyses on data from 6- to 19-year olds in the 2002-2005 Medical Expenditure Panel Survey (MEPS), a national probability survey of the noninstitutionalized civilian population in the United States. Compared with normal/underweight children, we found that children who were obese during both years of the MEPS had USD194 higher outpatient visit expenditures, USD114 higher prescription drug expenditures, and USD12 higher emergency room expenditures. Children who were overweight during both years, or overweight in one year and obese in the other had USD79 higher outpatient visit expenditures, USD64 higher prescription drug expenditures, and USD25 higher emergency room expenditures than normal/underweight children. Significantly, increased utilization was noted for outpatient visits, prescription drug use, and emergency room visits. Increased costs and utilization were concentrated among adolescents, though 6-11-year-old children who were obese in both years did have more outpatient visits and expenditures than other children. Extrapolated to the nation, elevated BMI in childhood was associated with USD14.1 billion in additional prescription drug, emergency room, and outpatient visit costs annually. Although further research is needed to identify effective interventions, the immediate economic consequences of childhood obesity are much greater than previously realized, and further reinforce efforts to prevent this major comorbidity are needed.

OBJECTIVE:

In this review we describe the approach taken by the National Children's Study (NCS), a 21-year prospective study of 100,000 American children, to understanding the role of environmental factors in the development of obesity.

DATA SOURCES AND EXTRACTION:

We review the literature with regard to the two core hypotheses in the NCS that relate to environmental origins of obesity and describe strategies that will be used to test each hypothesis.

DATA SYNTHESIS:

Although it is clear that obesity in an individual results from an imbalance between energy intake and expenditure, control of the obesity epidemic will require understanding of factors in the modern built environment and chemical exposures that may have the capacity to disrupt the link between energy intake and expenditure. The NCS is the largest prospective birth cohort study ever undertaken in the United States that is explicitly designed to seek information on the environmental causes of pediatric disease.

CONCLUSIONS:

Through its embrace of the life-course approach to epidemiology, the NCS will be able to study the origins of obesity from preconception through late adolescence, including factors ranging from genetic inheritance to individual behaviors to the social, built, and natural environment and chemical exposures. It will have sufficient statistical power to examine interactions among these multiple influences, including gene-environment and gene-obesity interactions. A major secondary benefit will derive from the banking of specimens for future analysis.

Childhood obesity is increasingly recognized as an epidemic, but the economic consequences have not been well quantified. We evaluated trends in obesity-associated hospitalizations, charges, and costs using 1999-2005 data from a nationally representative sample of admissions to U.S. hospitals. We detected a near-doubling in hospitalizations with a diagnosis of obesity between 1999 and 2005 and an increase in costs from $125.9 million to 237.6 million (in 2005 dollars) between 2001 and 2005. Medicaid appears to bear a large burden of hospitalizations for conditions that occur along with obesity, while private payers pay a greater portion of hospitalization costs to treat obesity itself.

Most studies of the economic costs of childhood obesity have focused upon hospitalization for comorbidities of obesity, whereas increased expenditures may also be the result of additional outpatient/emergency room visits or prescription drug expenditures. To quantify the magnitude of increased health-care utilization and expenditures among overweight and obese children, we performed descriptive, bivariate, and multivariable analyses on data from 6- to 19-year olds in the 2002-2005 Medical Expenditure Panel Survey (MEPS), a national probability survey of the noninstitutionalized civilian population in the United States. Compared with normal/underweight children, we found that children who were obese during both years of the MEPS had USD194 higher outpatient visit expenditures, USD114 higher prescription drug expenditures, and USD12 higher emergency room expenditures. Children who were overweight during both years, or overweight in one year and obese in the other had USD79 higher outpatient visit expenditures, USD64 higher prescription drug expenditures, and USD25 higher emergency room expenditures than normal/underweight children. Significantly, increased utilization was noted for outpatient visits, prescription drug use, and emergency room visits. Increased costs and utilization were concentrated among adolescents, though 6-11-year-old children who were obese in both years did have more outpatient visits and expenditures than other children. Extrapolated to the nation, elevated BMI in childhood was associated with USD14.1 billion in additional prescription drug, emergency room, and outpatient visit costs annually. Although further research is needed to identify effective interventions, the immediate economic consequences of childhood obesity are much greater than previously realized, and further reinforce efforts to prevent this major comorbidity are needed.

Childhood obesity is increasingly recognized as an epidemic, but the economic consequences have not been well quantified. We evaluated trends in obesity-associated hospitalizations, charges, and costs using 1999-2005 data from a nationally representative sample of admissions to U.S. hospitals. We detected a near-doubling in hospitalizations with a diagnosis of obesity between 1999 and 2005 and an increase in costs from $125.9 million to 237.6 million (in 2005 dollars) between 2001 and 2005. Medicaid appears to bear a large burden of hospitalizations for conditions that occur along with obesity, while private payers pay a greater portion of hospitalization costs to treat obesity itself.

This article uses the evaluation of the Robert Wood Johnson Foundation’s (RWJF) Urban Health Initiative (UHI), a 10-year effort to improve health and safety outcomes in distressed cities, to demonstrate the strength of an evaluation design that integrates theory of change and quasiexperimental
approaches, including the use of comparison cities. This paper focuses on the later stages of implementation and, especially, our methods for estimating program impacts. While the theory of change was used to make preliminary identification of intended outcomes, we used the sites’ plans and early implementation to refine this list and revisit our strategy for estimating impacts. Using our integrated design, differences between program and comparison cities are considered impacts only if they were predicted by program theory, local plans for action, and early implementation. We find small, measurable changes in areas of greatest programmatic effort. We discuss the importance of the integrated design in identifying impacts.

BACKGROUND:

While much attention is focused on national policies intended to protect human health from environmental hazards, states can also prevent environmentally mediated disease through legislation and regulation. However, relatively few analyses have examined the extent to which states protect children from chemical factors in the environment.

METHODS:

Using Lexis Nexis and other secondary sources, we systematically reviewed environmental regulation and legislation in the fifty states and the District of Columbia as of July 2007 intended to protect children against neurodevelopmental disabilities and asthma.

RESULTS:

States rarely address children specifically in environmental regulation and legislation, though many state regulations go far to limit children's exposures to environmental hazards. Northeast and Midwest states have implemented model regulation of mercury emissions, and regulations in five states set exposure limits to volatile organic compound emissions that are more stringent than US Environmental Protection Agency standards.

DISCUSSION:

Differences in state environmental regulation and legislation are likely to lead to differences in exposure, and thus to impacts on children's health. The need for further study should not inhibit other states and the federal government from pursuing the model regulation and legislation we identified to prevent diseases of environmental origin in children.

Many policy problems require governmental leaders to forge vast networks beyond their own hierarchical institutions. This essay explores the challenges of implementation in a networked institutional setting and incentives to induce coordination between agencies and promote quality implementation. It describes the national evaluation of the Assuring Better Child Health and Development program, a state-based program intended to increase and enhance the delivery of child development services for low-income children through the health care sector, using Medicaid as its primary vehicle. Using qualitative evaluation methods, the authors found that all states implemented programs that addressed their stated goals and made changes in Medicaid policies, regulations, or reimbursement mechanisms. The program catalyzed interagency cooperation and coordination. The authors conclude that even a modest level of external support and technical assistance can stimulate significant programmatic change and interorganizational linkages within public agencies to enhance provision of child development services.

Racial disparities are a ubiquitous feature of the US medical landscape, with health care delivery substantially segregated by race/ethnicity. Recent evidence from hospitals,1-3 nursing homes,4-5 and physicians' offices6 suggests that those caring for minority patients do not perform as well as those who care for nonminority patients, on average. This evidence is troubling but hardly surprising because the limited resources of those who care for the poor have helped to create and sustain racial disparities. As the United States enters an era of accountability in health care, it is time to consider these familiar circumstances from a new perspective.

Structural equation modeling was used to compare 6 competing theoretically based psychosocial models of the longitudinal association between life stressors and depressive symptoms in a sample of early adolescents (N= 907; 40% Hispanic, 32% Black, and 19% White; mean age at Time 1 = 11.4 years). Only two models fit the data, both of which included paths modeling the effect of depressive symptoms on stressors recall: The mood-congruent cognitive bias model included only depressive symptoms to life stressors paths (DS→S), whereas the fully transactional model included paths representing both the DS→S and stressors to depressive symptoms (S→DS) effects. Social causation models and the stress generation model did not fit the data. Findings demonstrate the importance of accounting for mood-congruent cognitive bias in stressors–depressive symptoms investigations.

Yellow-dust storms (YDSs) have attracted increasing attention worldwide in the past decade. They can extensively disrupt socioeconomic activities and pose hazards to ecosystems, as well as human health.  In recent years, China has invested multi-billions of dollars to mitigate the impact of YDSs.  However, the effectiveness of such YDS-control programs has rarely been evaluated. This research develops a causal model to quantify the environmental benefits of YDS-control programs in China, and further employs regional economic models to evaluate the ensuing economic impacts. The economic benefits generated from the YDS-control programs have remained stable across the years, primarily because of the multiplier effect of the investments, while the environmental benefits tend to decline over time.  Our results suggest that YDS-control programs should consider stimulating local economic activities in addition to environmental goals in order to be cost-effective and sustainable in the long term.

The fourth edition of Health Politics and Policy examines the political arena in which United States health care policies are made, and provides a framework for understanding how the process works. This book conveys the excitement of health care politics and covers the issues facing the American health care system. Factors that shape health policy are discussed in detail, including values, private players, and government, as well as the resulting dynamic of these forces. A comparison of the U.S. system to others offers a foundation for understanding our system within an international context.

Research on childhood obesity has primarily been conducted by experts in nutrition, psychology, and medicine. Only recently have public policy scholars devoted serious work to this burgeoning public health crisis. Here the authors advance that research by surveying national experts in health/nutrition and health policy on the public health impact and the political feasibility of fifty-one federal policy options for addressing childhood obesity. Policies that were viewed as politically infeasible but having a great impact on childhood obesity emphasized outright bans on certain activities. In contrast, education and information dissemination policies were viewed as having the potential to receive a favorable hearing from national policy makers but little potential public health impact. Both nutrition and policy experts believed that increasing funding for research would be beneficial and politically feasible. A central need for the field is to develop the means to make high-impact policies more politically feasible.

Der Aufruf des Surgeon Generals 2 beginnt dramatisch: „Übergewicht und Adipositas haben epidemische Ausmaße erreicht...." (Satcher zit. nach Mokdad 2001). Wissenschaftler, Regierungssprecher, Medienexperten, Journalisten und Lobbygruppen stimmen zunehmend lauter in diesen alarmistischen Chor ein. Im Gegensatz aber zu vielen anderen Public-Health-Problemen ist Adipositas zu großen Teilen individuellen Verhaltensweisen wie Essen und Trinken geschuldet. In den Vereinigten Staaten mit ihrer starken Kultur des Individualismus wird Privates oft als Tabuzone für staatliche Interventionen betrachtet: „Die Regierung sollte sich aus den persönlichen Entscheidungen, die ich treffe, heraushalten", schreibt der Washingtoner Universitätsprofessor Robert Rüssel, „meine bzw. deine Essgewohnheiten rechtfertigen nicht, dass mir die Regierung in den Kochtopf guckt" (zit. nach St. Louis Dispatch: 21.03.2002).

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? These core issues regarding our health policy are answered in this text.This is a textbook for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? Health Care Delivery in the United States, 8 th Edition discusses these and other core issues in the field. Under the editorship of Dr. Kovner and with the addition of Dr. James Knickman, Senior VP of Evaluation, Robert Wood Johnson Foundation, leading thinkers and practitioners in the field examine how medical knowledge creates new healthcare services. Emerging and recurrent issues from wide perspectives of health policy and public health are also discussed. With an easy to understand format and a focus on the major core challenges of the delivery of health care, this is the textbook of choice for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? These core issues regarding our health policy are answered in this text.This is a textbook for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs

Thoroughly presents today's health care system, its administration and its dissemination.

The past two years have been unsettled at best for Congress. Public approval toward Congress remains low, legislative debates have been contentious, polarization remains high, and Congress has a mixed record in dealing with major long-term issues such as Social Security and Medicare. The State Children's Health Insurance program has been delayed awaiting a compromise that might expand coverage, immigration reform has been waylaid by the intensity of opposition across the party lines, energy reform was diluted by ongoing disputes about how to reduce the nation's dependence on foreign oil, and the war in Iraq continues to dictate the pace of major legislative debates.

In two studies, we investigate the effects of individuals’ power motivation on decision-making. We distinguish between two types of power motivation [McClelland, D. C. (1970). The two faces of power. Journal of International Affairs, 24, 29–47; Winter, D. G. (1973). The power motive. New York: The Free Press] and demonstrate that both types of power motivation facilitate influential decision-making but that each type plays a different role in different contexts. In a conflict context (Study 1), individuals’ personalized (self-serving) power motivation was associated with antisocial decisions, and in a healthcare context (Study 2), individuals socialized (other-serving) power motivation was associated with prosocial decisions. Furthermore, the type of power motivation elicited in each context was associated with less perceived need to deliberate over the relevant policy decision. In separating out the independent effects of each type of power motivation, we are able to explain more variance in decision-making behavior across various contexts than in models using aggregate power motivation (personalized plus socialized).

In two studies, we investigate the effects of individuals' power motivation on decisionmaking. We distinguish between two types of power motivation [McClelland, D. C. (1970). The two faces of power. Journal of International Affairs, 24, 29-47; Winter, D. G. (1973). The power motive. New York: The Free Press] and demonstrate that both types of power motivation facilitate influential decision-making but that each type plays a different role in different contexts. In a conflict context (Study 1), individuals' personalized (selfserving) power motivation was associated with antisocial decisions, and in a healthcare context (Study 2), individuals socialized (other-serving) power motivation was associated with prosocial decisions. Furthermore, the type of power motivation elicited in each context was associated with less perceived need to deliberate over the relevant policy decision. In separating out the independent effects of each type of power motivation, we are able to explain more variance in decision-making behavior across various contexts than in models using aggregate power motivation (personalized plus socialized).

Developing community capacity to improve health is a cornerstone of community-based public health. The concept of community capacity reflects numerous facets and dimensions of community life and can have different meanings in different contexts. This paper explores how members of one community identify and interpret key aspects of their community's capacity to limit the availability and use of tobacco products. Particular attention is given to examining the interrelationship between various dimensions of community capacity in order to better understand the processes by which communities are able to mobilize for social change. The study is based on qualitative analysis of 19 in-depth interviews with key informants representing a variety of community sectors in Harlem, New York City. Findings indicate that the community is viewed as rich in human and social resources. A strong sense of community identity and connectedness underlies this reserve and serves as a catalyst for action.

Abstract Survival among perinatally infected children and youth with HIV has been greatly extended since the advent of highly active antiretroviral therapies. Yet, adherence to HIV medication regimens is suboptimal and decreases as children reach adolescence. This paper reports on a qualitative study examining psychosocial factors associated with adherence among perinatally infected youth ages 10-16 years. The study was based on in-depth interviews with a sample of 30 caregivers participating in a comprehensive health care program in New York City serving families with HIV. A subsample comprising 14 caregivers of children ages 10 and above is the focus of this paper. The analysis identified a number of themes associated with the psychosocial context of managing adherence among older children. Maintaining adherence was an ongoing challenge and strategies evolved as children matured. Regimen fatigue and resistance to taking the medications were major challenges to maintaining adherence among the oldest children. In other cases, caregivers developed a kind of partnership with their child for administering the medications. Disclosure to the child of his or her HIV status was used as a strategy to promote adherence but seemed to be effective only under certain circumstances. Social support appeared to have an indirect influence on adherence, primarily by providing caregivers with temporary help when needed. Health care professionals were an important source of disclosure and adherence support for parents. The study illustrates the interplay of maturational issues with other contextual psychosocial factors as influences on adherence among older children and adolescents.

The South Bronx, New York, has one of the highest asthma rates among school-age children in the United States. Since children spend significant parts of their day at school, an understanding of where schools are located in relation to environmental health hazards that can potentially affect asthma can provide important information for making
decisions related to urban land-use planning and environmental policy. GIS provides communities with an important tool for leveraging data for policymaking efforts and improving policy makers' understanding of how different land uses might affect public health.

Quantitative risk assessment is a growing, important component of the larger field of risk assessment. The need to understand the risks of an activity, be it economic, environmental, public health/biomedical, or even based on terrorist or other hazardous impacts, has led to a number of methods of analysis for many different application scenarios. Indeed, all major areas of the larger endeavor - hazard identification, dose-response assessment, exposure assessment, and risk characterization - rely on and benefit from quantitative operations. Within these contexts, enhanced understanding of both the variability and the uncertainty inherent in the risk identification process is critically dependent upon proper implementation of appropriate statistical methodologies.

A collection of writings by leading experts and newer researchers on the SARS outbreak and its relation to infectious disease management in progressively global and urban societies.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? These core issues regarding our health policy are answered in this text.This is a textbook for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

General editor Haider-Markel (U. of Kansas) presents a two-volume encyclopedia intended to serve as a first-stop reference on state politics in the United States, which also includes some coverage of US overseas territories and Puerto Rico. The encyclopedia opens with four broad topical essays on the evolution and impact of state constitutions, the impact of direct democracy (voter initiatives and the like), cooperation between the states, and states as policy testing grounds. It then presents individual state profiles, about ten pages each, that are uniformly structured to allow comparison of state history, the political environment, elections and voting behavior, the legislative branch, the executive branch, the judicial branch, intergovernmental relations, state-tribal relations (where applicable), and long-term issues and policy trends. The state entries also include bibliographies; charts showing partisan distribution of presidential elections from 1988 to 2004; and data tables on political history, political environment, elections and voting behavior, the legislative branch, the executive branch, and the judicial branch. Also included are some 175 A-to-Z topical entries discussing general concepts related to governmental functions and procedures, government structures and bodies, political theory, and political behavior. Examples of specific topics would include gerrymandering, impeachment, public health, auditor, bicameralism, legislative leadership, common law, judicial review, and social welfare. Finally, statistical data on populations, economics, finance, the environment, government spending, voting, and campaign fundraising is presented for all 50 states, followed by a comprehensive index.

To analyze long-term consequences of homelessness, the authors compared 388 formerly homeless children 55 months after shelter entry with 382 housed peers, birth to 17, using mother- and child-reported health, mental health, community involvement, cognitive performance, and educational records. Both groups scored below cognitive and achievement norms. Small group differences favored housed 4- to 6-year-olds on cognition and 4- to 10-year-olds on mental health only. Child care and recent stressful events, which were high, were as or more important than prior homelessness. Only children living with mothers were included, potentially biasing results. Policy implications are discussed.

To analyze long-term consequences of homelessness, the authors compared 388 formerly homeless children 55 months after shelter entry with 382 housed peers, birth to 17, using mother- and child-reported health, mental health, community involvement, cognitive performance, and educational records. Both groups scored below cognitive and achievement norms. Small group differences favored housed 4- to 6-year-olds on cognition and 4- to 10-year-olds on mental health only. Child care and recent stressful events, which were high, were as or more important than prior homelessness. Only children living with mothers were included, potentially biasing results. Policy implications are discussed.

Pediatricians can help limit children's exposures to environmental hazards, but few studies have assessed their comfort with discussing and dealing with environmental health issues. We surveyed the membership of the Minnesota Chapter of the American Academy of Pediatrics to assess pediatricians' attitudes and beliefs about the effect the environment can have on children's health, and to assess their practices in regard to screening for, diagnosing, and treating illnesses related to environmental exposures. Results showed that Minnesota pediatricians agree that children are suffering from preventable illnesses of environmental origin but feel ill-equipped to educate parents about many common exposures and their consequences. Responses also indicated significant demand for education on the subject and for a referral center that can evaluate patients who may be suffering from environmental exposures.

This paper offers some reflections on the grant-making process from a former foundation executive. Some of the opportunities, challenges, and pitfalls inherent in the foundation world are described, and one approach to grant making, the "call for proposals," is examined as an example of the need for greater attention to and investment in the science of grant making itself, to maximize the potential return from philanthropy.

The article discusses the improvement of care management for high-cost Medicaid patients. It explores on Medicaid budgets which have prompted policymakers to redouble efforts to explore ways of boosting efficiency in care delivery, particularly for people with high-cost and chronic conditions. It also illustrates John Billings and Tod Mijanovich's article which examines the cost-effectiveness of care management for chronic disease patients treated in fee-for-service practice. The authors present an algorithm that identifies patients at high risk of future hospitalizations and offer a business-case analysis about the rate of reduction in future hospitalization and the cost of the intervention.

Objective. To identify strategies that facilitate readiness for local Institutional Review Board (IRB) review, in multicenter studies.

Study Setting. Eleven acute care hospitals, as they applied to participate in a foundation-sponsored quality improvement collaborative.

Study Design. Case series.

Data Collection/Extraction. Participant observation, supplemented with review of written and oral communications.

Principal Findings. Applicant hospitals responded positively to efforts to engage them in early planning for the IRB review process. Strategies that were particularly effective were the provisions of application templates, a modular approach to study description, and reliance on conference calls to collectively engage prospective investigators, local IRB members, and the evaluation/national program office teams. Together, these strategies allowed early identification of problems, clarification of intent, and relatively timely completion of the local IRB review process, once hospitals were selected to participate in the learning collaborative.

Conclusions. Engaging potential collaborators in planning for IRB review may help expedite and facilitate review, without compromising the fairness of the grant-making process or the integrity of human subjects protection.

We find that estimates of the prevalence of teenage smoking and drinking in “urban,” “suburban,” and “rural” areas vary with different definitions of these types of geographic units. Given the salience of youth risk behavior to the public debate, we urge researchers to purposefully choose their definitions of geographic areas and to be explicit about those choices.

The President's proposal to replace the current exclusion of employer-paid health insurance premiums with a standard deduction for qualifying health insurance would level the playing field for employment-based coverage and private plans but would risk the loss of insurance for many workers, threaten existing risk- sharing pools, and unfairly favor the wealthy. This paper evaluates the President's plan, suggests changes that would improve it, and assesses alternatives that would address the plan's shortcomings and improve its likelihood of expanding coverage to many families who now lack insurance.

Climate change and human health are intertwined.  The heat waves in Chicago, in 1995, and in Paris, in 2003, followed by Hurricane Katrina_s destruction of New Orleans, raised awareness of the risks faced by vulnerable older people. Many cities have responded by announcing emergency preparedness plans; some of these plans have already been tested. Last summer, from July 27 to August 5, New York City suffered a mild heat wave with temperatures reaching 100-F. Paris, as well, was hit by another heat wave from July 17 to July 29, with maximum temperatures reaching 104-F, which was considerably milder than in 2003 when they often exceeded 110-F. In New York, there were 100 "excess deaths," an increase of 8% over past trends. In Paris, the number of excess deaths in 2006 (42), also an increase of 8%, was considerably lower than the 1,294 deaths registered in 2003-an increase of 190% compared to the preceding three-year average. Given existing surveillance capacity, it is impossible to know whether the reduction in excess deaths in Paris was due, partly, to its enhanced preparedness or whether it reflects no more than the effects of a far milder heat wave. Nevertheless, the milder heat wave of 2006 does provide an opportunity to examine the actual implementation of the heat wave preparedness plan. In light of ongoing efforts to develop such plans in cities worldwide and completed studies on the effects of the 2003 heat wave in Paris, what may be learned to promote urban health and improve understanding of the factors that put vulnerable older people at greatest risk?

This paper provides evidence suggesting that gun control measures have been effective in reducing the toll of violence on population health in Brazil. In 2004, for the first time in more than a decade, firearm-related mortality declined 8 percent from the previous year. Firearm-related hospitalizations also reversed a historical trend that year by decreasing 4.6 percent from 2003 levels. These changes corresponded with anti-gun legislation passed in late 2003 and disarmament campaigns undertaken throughout the country since mid-2004. The estimated impact of these measures, if they prove causal, could be as much as 5,563 firearm-related deaths averted in 2004 alone.

PURPOSE:
Focusing on guidelines governing medication use in nursing homes, in this study we explore the ways in which clinical professionals perceive and apply treatment guidelines, and how interprofessional interactions shape the delivery of pharmacotherapies to residents.

DESIGN AND METHODS:
Seventeen semistructured interviews were conducted with physicians, nursing staff, and consultant pharmacists in 4 purposefully selected nursing homes in Michigan.

RESULTS:
Perceptions of guidelines varied by clinical groups, with physicians perceiving them as reference tools, whereas nurses and consultant pharmacists saw them as rules to which clinical practices should adhere. Key external factors including resident and family demands, economic constraints, limited face-to-face contact, and the organizational hierarchy further drove clinical personnel to use guidelines differently and induced interprofessional conflicts. These negative interactions make facility-wide guideline adherence challenging by undermining the regulatory role of consultant pharmacists.

IMPLICATIONS:
This study provides important insight on work-related factors that hinder the implementation of treatment guidelines in nursing homes.

This book helps nurses develop and refine good budgeting skills - a necessity in today's economy-driven health care system. Clearly written and thoroughly understandable, this new edition shows first-line nurse managers and their immediate supervisors how to work effectively with financial staff and management, and how to develop, monitor, and maintain departmental and institutional budgets. It is written at a level that assumes no previous financial management experience or expertise on the part of the reader.

Covering the financial topics all nurse managers need to know and use, this book explains how financial management fits into the healthcare organization. You'll study accounting principles, cost analysis, planning and control management of the organization's financial resources, and the use of management tools. In addition to current issues, this edition also addresses future directions in financial management.

Essentials of Cost Accounting for Health Care Organizations, Third Edition is a comprehensive text that applies the tool and techniques of cost accounting to the health services field. It is an essential tools for all professionals who need to deal with the challenges of managing health facilities in a difficult economic environment.

Developing countries that were early, enthusiastic adopters of Primary Health Care often developed an extensive – but eventually dilapidated and under-utilized – network of public clinics at the grassroots. As paradigms and investment patterns of health sector reform have shifted, the question of what role these public clinics can meaningfully play, and how best to revitalize them, has become important in a number of countries. This paper evaluates the strategy taken by, and outcomes of, a major attempt in Vietnam to revitalize the grassroots infrastructure of primary health care against the backdrop of the country’s economic transition. The project’s substantial supply-side investments in infrastructure led to marginal increases in utilization and the quality of preventive health services  provided by the centers. But because the project failed to take adequate stock of broader, public sector-wide trends and reforms over the transition, the investments had little impact on the incentives, accountability patterns and capacities of clinic staff and the local authorities. Such institutional factors are heavily implicated, in Vietnam as elsewhere, in the substantial and often increasing disparities in service access and quality that continue to afflict transitional health sectors.

The study of the health workforce has gained in prominence in recent years, as the dynamic interconnections between human resource issues and health system effectiveness have come into sharper focus. This paper reviews lessons relating to strategic management challenges emerging from the growing literature in this area. Workforce issues are strategic: they affect overall system performance as well as the feasibility and sustainability of health reforms. Viewing workforce issues strategically forces health authorities to confront the yawning gaps between policy and implementation in many developing countries.

Lessons emerge in four areas. Once concerns imbalances in workforce structure, whether from a functional specialization, geographical or facility lens. These imbalances pose a strategic challenge in that authorities must attempt to steer workforce distribution over time using a limited range of policy tools. A second group of lessons concerns the difficulties of central-level steering of the health workforce, often critically weak due to the lack of proper information systems and the complexities of public sector decentralization and service commercialization trends affecting the grassroots. A third cluster examines worker capacity and motivation, often shaped in developing countries as much by the informal norms and incentives as by formal attempts to support workers or to hold them accountable. Finally, a range of reforms centering on service contracting and improvements to human resource management are emerging. Since these have as a necessary (but not sufficient) condition some flexibility in personnel practices, recent trends towards the sharing of such functions with local authorities are promising. The paper identifies a number of current lines of productive research, focusing on the relationship between health policy reforms and the local institutional environments in which the workforce, both public and private, is deployed.

An interdisciplinary examination of rates of avoidable hospitalizations in France and England to evaluate access to primary care and identify the extent to which these countries may be able to reduce hospital costs by investing in disease management and primary care. The policy brief was published under the Alliance for Health & the Future, a partnership between ILC-USA, ILC-UK and ILC-France.

Cross-national comparisons that assess dimensions of health system performance indicate that the US provides higher rates of revascularization procedures than France and other developed nations, but we believe these findings are misleading. In this paper, we compare the use of these procedures in the US, France and their two world cities, Manhattan and Paris. In doing so, we address a number of limitations associated with existing cross-national comparisons of heart disease treatment. After adjusting for the prevalence of disease in these nations and cities, we found that residents of France aged 45�64 years receive more revascularization procedures than residents of the US and that Parisians receive more revascularizations than residents of Manhattan. Older residents 65 years and over (65+) in the US receive more of these procedures than their French counterparts, but the differences are not nearly as great as previous studies suggest. Moreover, our data on Manhattan and Paris where the population and level of health resources are more comparable, indicate that older Parisians obtain more revascularization procedures than older Manhattanites. Finally, we found that the use of revascularization procedures is significantly lower in Manhattan among persons without private health insurance and among racial and ethnic minorities.

Every family has its own unique dynamics and conversations. Philanthropy adds a new dimension to these conversations which are often taking place both within and between generations. This is why 21/64 partnered with New York University's Robert F. Wagner Graduate School of Public Service to create a case study about multigenerational issues in family foundations. By exploring the issues of a hypothetical family in this case study, and utilizing questions in the accompanying Facilitator's Guide, families and professional advisors can begin to develop a healthy family process and productive philanthropic enterprise.

A book for senior executives, managers and clinicians that covers the "before, during and after" stages of a health care information technology (IT) project and provides guidance on how projects can be successfully managed. It shows readers how to assess IT project value before approval, monitor whether projects are on-time and ­on-budget, and measure performance after implementation. Case studies and effective project management tools and techniques help readers maximize project benefits.

To ensure that an information technology project is a success, health care leaders must first define the benefits, then manage the project and realize its benefits.

When health care executives complain that information technology projects are late, over budget or fail to deliver the expected benefits, the underlying cause is likely to be the absence of a defined, uniform and enforced project management process implemented by staff trained in project management. A complex construction project wouldn't proceed without a qualified, experienced construction manager, but multimillion-dollar health IT projects often are implemented by staff without project management expertise. It also is common for CIOs to be responsible for dozens of current projects yet never receive comprehensive reports on their statuses. As a result, controlling staff resources and making tough decisions on changes in the timeline, scope and budget of projects becomes impossible. The need for accessible project status reports and an inventory of projects in order for the CIO to maintain control is obvious.

We sought to determine whether low acculturation among Mexican American caregivers protects their children against asthma. Methods. Data were obtained from an observational study of urban pediatric asthma. Dependent variables were children's diagnosed asthma and total (diagnosed plus possible) asthma. Regression models were controlled for caregivers' level of acculturation, education, marital status, depression, life stress, and social support and children's insurance. Results. Caregivers' level of acculturation was associated with children's diagnosed asthma (P=.025) and total asthma (P=.078) in bivariate analyses. In multivariate models, protective effects of caregivers' level of acculturation were mediated by the other covariates. Independent predictors of increased diagnosed asthma included caregivers' life stress (odds ratio [OR]= 1.12, P=.005) and children's insurance, both public (OR=4.71, P=.009) and private (OR = 2.87, P=.071). Only caregiver's life stress predicted increased total asthma (OR = 1.21, P=.001). Conclusions. The protective effect of caregivers' level of acculturation on diagnosed and total asthma for Mexican American children was mediated by social factors, especially caregivers' life stress. Among acculturation measures, foreign birth was more predictive of disease status than was language use or years in country. Increased acculturation among immigrant groups does not appear to lead to greater asthma risk.

From everyday support requests to large capital projects, the IT department's ability to meet demand is limited. Organizational and IT leaders need to proactively address this issue and do a better job of predicting when services will be needed and whether appropriate resources will be available. This article describes the common issues that healthcare IT departments face in the efficient delivery of services as a result of factors such as budget constraints, skill sets and project dependencies. Best practices for controlling demand are discussed, including resource allocation, governance processes and a graphical analysis of forecasted vs. actual thresholds. Using specific healthcare provider examples, the article intends to provide IT management with an approach to predicting and controlling resource demand.

This paper proposes a framework for examining the process by which
government consideration and adoption of new vaccines takes place, with specific reference to developing country settings. The cases of early hepatitis B vaccine adoption in Taiwan and Thailand are used to explore the relevance of explanatory factors identified in the literature as well as the need to go beyond a variablecentric focus by highlighting the role of policy context and process in determining the pace and extent of  adoption. The cases suggest the feasibility and importance of modeling ‘causal diversity’ – the complex set of necessary and sufficient conditions leading to particular decisional outcomes – in a broad range of country contexts. A better understanding of the lenses through which government decision makers filter information, and of the arenas in which critical decisions are shaped and taken, may assist both analysts (in predicting institutionalization of new vaccines) and advocates (in crafting targeted strategies to accelerate their diffusion).

Purpose: Focusing on guidelines governing medication use in nursing homes, in this study we explore the ways in which clinical professionals perceive and apply treatment guidelines, and how interprofessional interactions shape the delivery of pharmacotherapies to residents.

Design and Methods: Seventeen semistructured interviews were conducted with physicians, nursing staff, and consultant pharmacists in 4 purposefully selected nursing homes in Michigan.

Results: Perceptions of guidelines varied by clinical groups, with physicians perceiving them as reference tools, whereas nurses and consultant pharmacists saw them as rules to which clinical practices should adhere. Key external factors including resident and family demands, economic constraints, limited face-to-face contact, and the organizational hierarchy further drove clinical personnel to use guidelines differently and induced interprofessional conflicts. These negative interactions make facility-wide guideline adherence challenging by undermining the regulatory role of consultant pharmacists.

Implications: This study provides important insight on work-related factors that hinder the implementation of treatment guidelines in nursing homes.

OBJECTIVES:

We examined the mechanisms by which living in a disadvantaged minority community influences smoking and illegal cigarette sale and purchasing behaviors after a large cigarette tax increase.

METHODS:

Data were collected from 14 focus groups (n=104) that were conducted during the spring of 2003 among Blacks aged 18 years and older living in New York City.

RESULTS:

A large tax increase led to what focus group participants described as a pervasive illegal cigarette market in a low-income minority community. Perceived pro-smoking community norms, a stressful social and economic environment, and the availability of illegal cigarettes worked together to reinforce smoking and undermine cessation.

CONCLUSIONS:

Although interest in quitting was high, bootleggers created an environment in which reduced-price cigarettes were easier to access than cessation services. This activity continues to undermine the public health goals of the tax increase.

Aims To assess the relative cost-effectiveness of lower versus higher cost prize-based contingency management (CM) treatments for cocaine abuse.

Design Cost-effectiveness analyses based on resource utilization, unit costs and outcomes from a previous CM efficacy trial.

Setting Two community-based treatment centers.

Participants Patients (n = 120) enrolled in out-patient treatment for cocaine abuse.

Intervention Random assignment to one of three 12-week treatment conditions: standard treatment (STD) alone or two variants of STD combined with prize based CM. In CM, drawing for prizes was available to those submitting drug-free urine samples and completing goal-related activities. There were two levels of pay-out (referred to as $80 versus $240) based on the potential value of prizes won.

Measurements Costs per participant associated with counseling utilization, urine and breathalyzer testing, and operation of the prize-drawing procedure were derived from a survey conducted at 16 clinics that had participated in CM studies. The three measures of effectiveness were: (1) longest duration of consecutive abstinence; (2) percentage completing treatment; and (3) percentage of samples drug-free.

Findings The higher magnitude CM produced outcomes at a lower per unit cost than did the lower magnitude prize CM treatment. This was the case for all three outcome measures examined and held across various assumptions in the sensitivity analysis.

Conclusions Cost-effectiveness analyses can inform policy decisions regarding selection of one treatment model over another. Decisions on adoption of new evidence-based treatments would be aided by more information on society's willingness to pay for incremental gains in effectiveness.

Background: Access to timely and effective medical services can reduce rates of premature mortality attributed to certain conditions. We investigate rates of total and avoidable mortality (AM) and the percentage of avoidable deaths in France, England and Wales and the United States, three wealthy nations with different health systems, and in the urban cores of their world cities, Paris, Inner London and Manhattan. We examine the association between AM and an income-related variable among neighbourhoods of the three cities. Methods: We obtained mortality data from vital statistics sources for each geographic area. For two time-periods, 1988–90 and 1998–2000, we assess the correlation between area of residence and age- and gender-adjusted total and AM rates. In our comparison of world cities, regression models are employed to analyse the association of a neighbourhood income-related variable with AM. Results: France has the lowest mortality rates. The US exhibits higher total, but similar AM rates compared to England and Wales. Rates of AM are lowest in Paris and highest in London. Avoidable mortality rates are higher in poor neighbourhoods of all three cities; only in Manhattan is there a correlation between the percentage of deaths that are avoidable and an income related variable. Conclusions: Beyond the well-known association of income and mortality, persistent disparities in AM exist, particularly in Manhattan and Inner London. These disparities are disturbing and should receive greater attention from policy makers.

Released in partnership with the Human Rights Project of the Urban Justice Center, this shadow report highlights the persistent discrimination experienced by people of color and immigrants in NYC and brings attention to the failure of the City to meet its full obligations under CERD.

Increasing the representation of Spanish-speaking study participants requires development and dissemination of reliable and valid translated scales. In the current study the construct validity was assessed of the Spanish version of the Crisis in Family Systems-Revised, a measure of contemporary life stressors, with a convenience sample of 377 parents interviewed in a study of childhood asthma, although over half of the respondents did not have children with asthma. Most respondents were foreign-born women between 20 to 60 years old (M = 35, SD = 7). 52% had not completed high school or its equivalent, and 55% reported a household income of $15,000 or less. For a subsample of 25 respondents test-retest reliability was .86 over 2 wk. Reporting more life stressors was associated with greater depressive symptomatology, poorer physical and mental health function, and lower household income. These relationships support the construct validity of the test in Spanish. This study provided strong evidence that this version is a valid and reliable measure of life stressors for a Spanish-speaking population living in the United States.

Context The Centers for Medicare & Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) measure and report quality process measures for acute myocardial infarction (AMI), but little is known about how these measures are correlated with each other and the degree to which inferences about a hospital's outcomes can be made from its performance on publicly reported processes.

Objective To determine correlations among AMI core process measures and the degree to which they explain the variation in hospital-specific, risk-standardized, 30-day mortality rates.

Design, Setting, and Participants We assessed hospital performance in the CMS/JCAHO AMI core process measures using 2002-2003 data from 962 hospitals participating in the National Registry of Myocardial Infarction (NRMI) and correlated these measures with each other and with hospital-level, risk-standardized, 30-day mortality rates derived from Medicare claims data.

Main Outcome Measures Hospital performance on AMI core measures; hospital-specific, risk-standardized, 30-day mortality rates for AMI patients aged 66 years or older.

Results We found moderately strong correlations (correlation coefficients ≥0.40; P values <.001) for all pairwise comparisons between beta-blocker use at admission and discharge, aspirin use at admission and discharge, and angiotensin-converting enzyme inhibitor use, and weaker, but statistically significant, correlations between these medication measures and smoking cessation counseling and time to reperfusion therapy measures (correlation coefficients <0.40; P values <.001). Some process measures were significantly correlated with risk-standardized, 30-day mortality rates (P values <.001) but together explained only 6.0% of hospital-level variation in risk-standardized, 30-day mortality rates for patients with AMI.

Conclusions The publicly reported AMI process measures capture a small proportion of the variation in hospitals' risk-standardized short-term mortality rates. Multiple measures that reflect a variety of processes and also outcomes, such as risk-standardized mortality rates, are needed to more fully characterize hospital performance.

We find that estimates of the prevalence of teenage smoking and drinking in "urban," "suburban," and "rural" areas vary with different definitions of these types of geographic units. Given the salience of youth risk behavior to the public debate, we urge researchers to purposefully choose their definitions of geographic areas and to be explicit about those choices.

Public authorities play a major role in delivering public services. They supplement direct government agencies in three ways:

• Provide a business-like organizational structure for public services that are financed primarily by user fees and whose capital investments are self-financed through bonds supported by user fees.
• Provide a stewardship for major capital assets and make long-run investment decisions with some isolation from pressures of the electoral cycle.
• Provide a mechanism for taking advantage of federal tax benefits for economic development and other purposes that otherwise would be treated as private activities.

Authorities are intended to strike a balance between political accountability and political independence. Unlike heads of direct government agencies, governing boards of authorities are expected to be more independent of those who appoint them, to make difficult and unpopular decisions outside the arena of elected politics, and to be accountable to the public indirectly through reporting, transparency in decision-making and long-run performance. New York State makes extensive use of public authorities.

This report makes the case that it is possible to lower Medicaid expenditures by about $5.8 billion annually, without reducing the program's effectiveness in helping low-income New Yorkers obtain needed care. These significant savings are feasible by addressing the three main areas where New York's program differs drastically from those of other states:

 New York extends Medicaid eligibility to the non-poor or middle class for longterm
care.
 New York pays some institutional providers, specifically hospitals, nursing homes
and institutions for the disabled, at rates above competitive costs.
 New York allows excessive use of some types of services, specifically personal care
and inpatient hospital care.

This report describes these differences and makes three recommendations to bring New York's program more in line with national norms:

 Limit Medicaid eligibility to the poor.
 Reduce payment rates to competitive levels.
 Reduce excessive use of personal care and hospital inpatient care.

Most government workers are paid more than their private sector counterparts, so more generous and expensive
retirement benefits are no longer justified.

Bronx Health REACH, a coalition of community- and faith-based groups, health care providers, and an academic institution, recently examined the causes of racial and ethnic health disparities in the southwest Bronx and identified separate systems of care for uninsured and publicly insured patients, who are predominantly people of color, and those with private insurance. We found evidence that patients are sorted into segregated pathways of care, a system of medical apartheid in which differential care contributes to disparities in health care and health outcomes.

Substantial national attention is being directed at enhancing the competency levels of early careerists in healthcare management. In this study, we examined preceptors' ratings of administrative resident/fellow competencies in multiple domains, and we compared those to our previous results of self-rated competency by residents/fellows. In this national sample of preceptors (n=61) of administrative residency/fellowship program listed with the American College of Healthcare Executives, competency in the information management domain was ranked highest, with more than half of preceptors (55.7%) giving their residents/fellows an "A" rating. Fewer preceptors (between 30.0% and 39.2%) gave their residents/fellows an "A" rating in domains of interpersonal and emotional intelligence, analytic and conceptual reasoning, and clinical operations. Less than 20% of preceptors rated competencies as "A" level in the domains of human resources/marketing/public affairs, financial management, fund raising, and facilities management. There were significant differences in preceptor ratings compared with resident/fellow self-ratings, with preceptors often providing lower ratings than provided by resident/fellows. The findings highlight the need not only to enhance competency levels of graduates but also to address the potential mismatch in early careerists' and preceptors' views about required and attained competency levels.

Abstract The U.S. faces rising rates of overweight and obesity. Active living-urban planning and design to promote physical activity?has emerged as a strategy to combat growing obesity. The active living movement initially targeted mostly middle-class, suburban communities. In this article, I argue that planning for active living must especially address low-income, Black, and Latino communities, where obesity and related health risks are greatest and resources least available. First I review the problem of obesity and related health conditions among low-income, Black, and Latino populations in the U.S., and identify the role of insufficient physical activity in this problem. I then examine physical environment and other factors that shape opportunities for physical activity in low-income communities and communities of color. Finally, I identify strategies that may help to promote active living in urban settings to better serve these communities. Abstract The U.S. faces rising rates of overweight and obesity. Active living-urban planning and design to promote physical activity?has emerged as a strategy to combat growing obesity. The active living movement initially targeted mostly middle-class, suburban communities. In this article, I argue that planning for active living must especially address low-income, Black, and Latino communities, where obesity and related health risks are greatest and resources least available. First I review the problem of obesity and related health conditions among low-income, Black, and Latino populations in the U.S., and identify the role of insufficient physical activity in this problem. I then examine physical environment and other factors that shape opportunities for physical activity in low-income communities and communities of color. Finally, I identify strategies that may help to promote active living in urban settings to better serve these communities.

Accounting Fundamentals for Health Care Management is ideal for an introductory course in financial accounting in both undergraduate and graduate programs. This is the first book that focuses on basic accounting in health care management. This essential book contains the vocabulary of, and an introduction to, the tools and concepts employed by finance officers. It will help anyone assess financial information, ask the appropriate questions, and understand the jargon-laden answers. This book is indispensable for anyone who manages a department and a budget.

This paper analyzes proposals to remedy tax-induced distortions in health care by using new tax incentives and retaining all of the existing distortionary tax incentives. In the process of remedying some distortions, this approach magnifies others--most notably increasing the total tax preference for health care. The paper considers two examples--the Bush administration's FY 2007 budget proposal and a plan by Cogan, Hubbard and Kessler (2005)--and shows that both could result in higher health spending and reduced welfare. Finally, the paper discusses the circumstances in which tax incentives could be warranted to remedy market failures in health insurance.

The article presents information on the role of power in negotiation. Power could generate competition or conflict in negotiations, however, effective channelization of power helps in bringing the win-win situation to both the parties. Social psychologists have described power as lack of dependence on others. Individuals possessing power tend to have the approach related to the behavior that includes positive mood or searching for rewards in their environment. On the other hand, powerless individuals show a great deal of self-inhibition and fear towards potential threats. INSETS: WOMEN: INCREASE YOUR POWER AT THE TABLE;POWER ACROSS CULTURES.

This second edition of Child Psychology: A Handbook of Contemporary Issues reflects the increasingly sophisticated and varied research methods used to examine the highly complex interactions contributing to children's cognitive, emotional, and social development. Those chapters that appeared in the previous edition have been thoroughly updated and new chapters by outstanding researchers have been introduced. In addition, there is an entirely new section on Adolescence and thorough coverage of salient Ecological Influences, which make this second edition a truly comprehensive resource on the important issues in child psychology. The volume is divided into five sections - Infancy, Preschool Years, Childhood, Adolescence, and Ecological Influences - which: * Describe the nature of development and individual variations in developmental trajectories across multiple domains * Identify the processes and mechanisms underlying developmental and contextual change * Explore the varied contexts in which development unfolds, including family, school, neighborhood, and culture * Apply cutting-edge research designs, methodologies, and analytic approaches to models of development The volume provides an invaluable and practical resource for students and instructors on a wide variety of courses, and for researchers and professionals working in the field of child development.

Compelling evidence links the chemicals in household products to cancer, asthma, allergies, multiple chemical sensitivity syndrome -- also known as environmental illness -- hormonal disruption, reproductive and developmental disorders, and other conditions. Yet cleaning products are exempt from the full ingredient disclosure on product labels as required for food and personal care products and enter the marketplace with little or no testing for potential health risks.

Naturally Clean explains the dangers of traditional cleaners and provides illuminating statistics that illustrate how the chemicals found in almost every home are known or likely to cause a host of serious health problems. The book's easy-to-understand introduction discusses basic household chemistry, concepts of toxicity and types of toxic exposure, and the difference between natural, organic, and synthetic chemicals.

New York State, because of its great diversity, has more extensive social and political conflict than most states. Governing New York State: Fifth Edition provides expert assessment of how these conflicts are organized and represented, and how the political process and political institutions work to seek to resolve them. This newly updated fifth edition contains significantly revised material and covers more topics than the prior edition.

The contributors examine conflicts between New York City and the rest of the state, and between federal, state, and local governments. The role of major political parties in organizing and representing broad coalitions of different groups is reviewed, along with the role of third parties, interest groups, and the media. Political institutions that shape the political process-the governor, the legislature, the courts, and the public authorities-are discussed, along with how these institutions affect the representation of responsiveness of various groups. Finally, Governing New York State investigates the major policy areas of the state: the economy, taxes, local education, higher education, health care, welfare, transportation, and the environment.

The fourth edition of Health Politics and Policy examines the political arena in which United States health care policies are made, and provides a framework for understanding how the process works. This book conveys the excitement of health care politics and covers the issues facing the American health care system. Factors that shape health policy are discussed in detail, including values, private players, and government, as well as the resulting dynamic of these forces. A comparison of the U.S. system to others offers a foundation for understanding our system within an international context.

Medical malpractice lawsuits are common and controversial in the United States. Since early 2002, doctors' insurance premiums for malpractice coverage have soared. As Congress and state governments debate laws intended to stabilize the cost of insurance, doctors continue to blame lawyers and lawyers continue to blame doctors and insurance companies. This book, which is the capstone of three years' comprehensive research funded by The Pew Charitable Trusts, goes well beyond the conventional debate over tort reform and connects medical liability to broader trends and goals in American health policy. Contributions from leading figures in health law and policy marshal the best available information, present new empirical evidence, and offer cutting-edge analysis of potential reforms involving patient safety, liability insurance and tort litigation.

More and more, healthcare providers are committing to evidenced-based clinical practice as a rational way to deliver care. Rather than make decisions anecdotally, clinicians find that the addition of research provides statistical evidence for their decisions, and thus should result in better, more consistent care. But, what about management decisions? Shouldn't evidence also be sought by hospital executives before making strategic decisions that will affect their organizations? Do not these decisions also affect the quality and safety of patient care? And if so, what is preventing executives from using such evidence before making these decisions? This issue of Frontiers explores these questions from both the research and practitioner points of view. In the feature article, "Evidence-Based Management Reconsidered," Anthony Kovner, PhD (professor of health policy and management at New York University), and Thomas Rundall, PhD (professor of organized health systems at University of California-Berkeley), make the case for why evidence-based health services management (EBHSM) can and should be used. Kovner and Rundall suggest that EBHSM can be applied to core business transactions, as well as to operational and strategic management, and they elaborate on a five-step process for making that happen. Acknowledging that there is little use of the EBHSM approach in the field today, the authors recommend strategies to facilitate greater use of this model.

The three commentaries explore the issues raised in the above articles. All of the authors agree that evidence-based management is an idea whose time has come. From all the "evidence," it has become clear that more often than not clinical errors occur as a result of a system failure-management-type decisions made without the proper knowledge and information. So, what will it take to get EBHSM implemented throughout healthcare? Hopefully, some of the ideas and strategies presented in this issue will get us closer to that goal.

Prospective, multiyear epidemiologic studies have proven to be highly effective in discovering preventable risk factors for chronic disease. Investigations such as the Framingham Heart Study have produced blueprints for disease prevention and saved millions of lives and billions of dollars. To discover preventable environmental risk factors for disease in children, the US Congress directed the National Institute of Child Health and Human Development, through the Children's Health Act of 2000, to conduct the National Children's Study. The National Children's Study is hypothesis-driven and will seek information on environmental risks and individual susceptibility factors for asthma, birth defects, dyslexia, attention-deficit/hyperactivity disorder, autism, schizophrenia, and obesity, as well as for adverse birth outcomes. It will be conducted in a nationally representative, prospective cohort of 100,000 US-born children. Children will be followed from conception to 21 years of age. Environmental exposures (chemical, physical, biological, and psychosocial) will be assessed repeatedly during pregnancy and throughout childhood in children's homes, schools, and communities. Chemical assays will be performed by the Centers for Disease Control and Prevention, and banks of biological and environmental samples will be established for future analyses. Genetic material will be collected on each mother and child and banked to permit study of gene-environment interactions. Recruitment is scheduled to begin in 2007 at 7 Vanguard Sites and will extend to 105 sites across the United States. The National Children's Study will generate multiple satellite studies that explore methodologic issues, etiologic questions, and potential interventions. It will provide training for the next generation of researchers and practitioners in environmental pediatrics and will link to planned and ongoing prospective birth cohort studies in other nations. Data from the National Children's Study will guide development of a comprehensive blueprint for disease prevention in children.

Objective: To use publicly available secondary data to assess the impact of Brazil's Family Health Program on state level infant mortality rates (IMR) during the 1990s.

Design: Longitudinal ecological analysis using panel data from secondary sources. Analyses controlled for state level measures of access to clean water and sanitation, average income, women's literacy and fertility, physicians and nurses per 10 000 population, and hospital beds per 1000 population. Additional analyses controlled for immunisation coverage and tested interactions between Family Health Program and proportionate mortality from diarrhoea and acute respiratory infections.

Setting: 13 years (1990-2002) of data from 27 Brazilian states.

Main results: From 1990 to 2002 IMR declined from 49.7 to 28.9 per 1000 live births. During the same period average Family Health Program coverage increased from 0% to 36%. A 10% increase in Family Health Program coverage was associated with a 4.5% decrease in IMR, controlling for all other health determinants (p<0.01). Access to clean water and hospital beds per 1000 were negatively associated with IMR, while female illiteracy, fertility rates, and mean income were positively associated with IMR. Examination of interactions between Family Health Program coverage and diarrhoea deaths suggests the programme may reduce IMR at least partly through reductions in diarrhoea deaths. Interactions with deaths from acute respiratory infections were ambiguous.

Conclusions: The Family Health Program is associated with reduced IMR, suggesting it is an important, although not unique, contributor to declining infant mortality in Brazil. Existing secondary datasets provide an important tool for evaluation of the effectiveness of health services in Brazil.

Communities are traditionally built with one transportation mode and user in mindthe adult automobile driver. Recently, however, there has been an international focus on the trip to school as an opportunity to enhance childrens independent active travel. Several factors must be considered when designing programs to promote walking and bicycling. This paper examined the influence of child sex on caregivers decisions about travel mode choice to school. Caregivers of children in grades three to five from ten California Safe Routes to School communities were surveyed on their childs normal travel mode to school and factors that determined travel decisions. Results indicate that the odds of walking and bicycling to school are 40 percent lower in girls than boys; however, this relationship is significantly moderated by the caregivers own walking behavior. The findings suggest that programs that focus on increasing childrens active travel to school should consider multiple influences on health behavior, including the neighborhood physical activity of parents.

Today's healthcare IT departments are challenged with understanding the total service demand imposed by their user communities and how much of their limited resources are available to meet that demand.This challenge is being addressed through the use of new IT management and governance (IT-MG) systems.This software supports IT governance and project and portfolio management. IT-MG is a relatively new term to healthcare; it entails reviewing and managing demand for IT services from inception to completion through the application of IT resources. These systems help save time through automated reporting and quicker delivery of services; they save money by more effectively addressing resource needs
on time and on budget.The systems also reduce the number of administrative tasks through process automation; increase customer satisfaction by communicating services and deliverables more quickly and accurately; and help executives make better and more informed decisions about priorities and expectations through reporting that was previously nonexistent.This article will explore IT-MG systems and present a case study of a hospital that rapidly implemented this type of system.

This essay focuses on the design of insurance products for poor customers. Several promising innovations are described: credit life insurance, health insurance partnerships, and weather insurance. Each was created to serve populations that were previously unserved, and workable institutional solutions are emerging. The next step must be to shift from the question of what creates workable institutions to the question of how to refine designs to best serve low-income populations. In doing so, current approaches must be reassessed in order to most improve clients’ lives and to avoid doing unintended harm.

We examined racial and ethnic disparities in the total potential burden of asthma in low-income, racially/ethnically heterogeneous Chicago schools, Methods. We used the Brief Pediatric Asthma Screen Plus (BPAS+) and the Spanish BPAS+, validated, caregiver-completed respiratory questionnaires, to identify asthma and possible asthma among students in 14 racially/ethnically diverse public elementary schools. Results. Among 11 490 children, we demonstrated a high lifetime prevalence (12.2%) as well as racial and ethnic disparities in diagnosed asthma, but no disparities in prevalences of possible undiagnosed asthma. Possible asthma cases boost the total potential burden of asthma to more than 1 in 3 non-Hispanic Black and Puerto Rican children. Conclusions. There are significant racial and ethnic disparities in diagnosed asthma among inner-city schoolchildren in Chicago. However, possible undiagnosed asthma appears to have similar prevalences across racial/ethnic groups and contributes to a high total potential asthma burden in each group studied. A better understanding of underdiagnosis is needed to address gaps in asthma care and intervention for low-income communities.

Declining birthrates, increasing longevity and growing urbanization have created a new challenge for cities: how to respond to an aging population. The World Cities Project was designed to examine whether the four largest cities among the wealthiest nations of the world - New York, London, Paris and Tokyo - offer a model of what other cities will someday resemble as their populations grow older.

Perhaps the four world cities examined here will always be regarded as special cases; however, they share in common a host of important characteristics. Within them live the largest number of older people in their countries and in some neighborhoods the percent of elders 65 or older far exceeds what the census demographers project for their nations in 2030. Thus, these great cities may serve as laboratories to inquire about the implications of demographic change for health and quality of life, living arrangements and housing, and the provision of long-term care to older adults when they eventually become frail.

In France, American nostrums of unleashing market forces under the banner of "consumer-directed health care," and selective contracting by private health insurers, have gained little ground. That should not, however, lead one to conclude that the French health care system is irrelevant to the United States. The organization and financing of health care, in France, resembles, in many respects, that of the United States - more so, in fact, than do Britain's National Health Service or Canadian and German national health insurance (NHI). The French reliance on a public-private mix that includes a significant proprietary hospital sector, private fee-for-service medical practice, and enormous patient choice among a pluralistic organization of health care providers makes French NHI a model for what Senator Ted Kennedy and Congressman Pete Stark have called "Medicare for all."

Objective. Recent national survey data indicate an overall asthma prevalence of 12.2% for children who are younger than 18 years. Previous research in clinical samples of children with asthma suggests that their mothers are at greater risk for symptoms of depression. We describe the relationship between maternal symptoms of depression and having a child with asthma in a community-based sample.

Methods. After a school-based ascertainment of asthma and asthma symptoms in 15 low-income, racially/ethnically diverse public elementary schools, 1149 eligible mothers agreed to participate in a longitudinal study. Mothers either had a child with previously diagnosed asthma or a child with symptoms consistent with possible asthma or were in the randomly selected comparison group in which no child in the household had asthma. During the first interview, mothers responded to questions about their own life stressors, supports and mental health, and their children's health.

Results. In bivariate analyses of a community-based sample of children who share low-income neighborhoods, mothers of children with diagnosed or with possible undiagnosed asthma had more symptoms of depression than did mothers of children who have no asthma. Mothers of children with diagnosed or with possible undiagnosed asthma also experienced more life stressors than did mothers of children without asthma. Using nested linear regression, we estimated a model of maternal symptoms of depression. Most of the variation in Center for Epidemiologic Studies-Depression score was accounted for by life stressors and social support. There were no independent effects of either asthma status or asthma status-specific child health status on maternal symptoms of depression.

Conclusion. Children who are under care for chronic conditions such as asthma live and manage their illness outside the clinical setting. Their social context matters, and maternal mental health is related to their children's physical health. Although having a child with asthma may be "just" another stressor in the mother's social context, complex treatment plans must be followed despite the many other pressures of neighborhood and family lives.

Chronic diseases of environmental origin are a significant and increasing public health problem among the children of New York State, yet few resources exist to address this growing burden. To assess New York State pediatricians self-perceived competency in dealing with common environmental exposures and diseases of environmental origin in children, we assessed their attitudes and beliefs about the role of the environment in children's health. A four-page survey was sent to 1,500 randomly selected members of the New York State American Academy of Pediatrics in February 2004. We obtained a 20.3% response rate after one follow-up mailing; respondents and nonrespondents did not differ in years of licensure or county of residence. Respondents agreed that the role of environment in children's health is significant (mean 4.44 +/- 0.72 on 1-5 Likert scale). They voiced high self-efficacy in dealing with lead exposure (mean 4.16-4.24 +/- 0.90-1.05), but their confidence in their skills for addressing pesticides, mercury and mold was much lower (means 2.51-3.21 +/- 0.90-1.23; p < 0.001). About 93.8% would send patients to a clinic "where pediatricians could refer patients for clinical evaluation and treatment of their environmental health concerns." These findings indicate that New York pediatricians agree that children are suffering preventable illnesses of environmental origin but feel ill-equipped to educate families about common exposures. Significant demand exists for specialized centers of excellence that can evaluate environmental health concerns, and for educational opportunities.

Prospective, multi-year epidemiologic studies such as the Framingham Heart Study and the Nurses' Health Study have proven highly effective in identifying risk factors for chronic illness and in guiding disease prevention. Now, in order to identify environmental risk factors for chronic disease in children, the US Congress authorized a National Children's Study as part of the Children's Health Act of 2000. Enrollment of a nationally representative cohort of 100,000 children will begin in 2008, with follow-up to continue through age 21. Environmental assessment and examination of biomarkers collected at specified intervals during pregnancy and childhood will be a major component of the Study. Recruitment at 105 sites across the United States is planned, and will begin at 7 Vanguard Centers in 2008, including Waukesha County, Wis. The National Children's Study will provide information on preventable risk factors for such chronic diseases as asthma, certain birth defects, neurobehavioral syndromes, and obesity. In addition, the National Children's Study will provide training in pediatric environmental health for the next generation of researchers and practitioners.

Pediatricians can reduce exposures to environmental hazards but most have little training in environmental health. To assess whether Wisconsin pediatricians perceive a relative lack of self-efficacy for common environmental exposures and diseases of environmental origin, we assessed their attitudes and beliefs about the role of the environment in children's health. A 4-page survey was sent to the membership of the Wisconsin Chapter of the American Academy of Pediatrics. We obtained a 35.4% response rate after 1 follow-up mailing. Respondents agreed that the role of the environment in children's health is significant (mean 4.28 +/- .78 on 1-5 Likert scale). They expressed high confidence in dealing with lead exposure (means 4.22-4.27 +/- 1.01-1.09), but confidence in their skills for pesticide, mercury, and mold was much lower (means 2.49-3.09 +/- 1.06-1.26; P<.001). Of those surveyed, 88.6% would refer patients to a clinic "where pediatricians could refer patients for clinical evaluation and treatment of their environmental health concerns." These findings indicate that Wisconsin pediatricians agree that children are suffering preventable illnesses of environmental origin, but feel ill equipped to educate families about many common exposures. Significant demand exists for centers that can evaluate environmental health concerns, as well as for educational opportunities.

Exposure in prenatal life to methylmercury (MeHg) has become the topic of intense debate in the United States after the Environmental Protection Agency (EPA) announced a proposal in 2004 to reverse strict controls on emissions of mercury from coal-fired power plants that had been in effect for the preceding 15 years. This proposal failed to incorporate any consideration of the health impacts on children that would result from increased mercury emissions. We assessed the impact on children's health of industrial mercury emissions and found that between 316,588 and 637,233 babies are born with mercury-related losses of cognitive function ranging from 0.2 to 5.13 points. We calculated that decreased economic productivity resulting from diminished intelligence over a lifetime results in an aggregate economic cost in each annual birth cohort of $8.7 billion annually (range: $0.7-$13.9 billion, 2000 dollars). $1.3 billion (range: $51 million-$2.0 billion) of this cost is attributable to mercury emitted from American coal-fired power plants. Downward shifts in intellectual quotient (IQ) are also associated with 1566 (range: 115-2675) excess cases of mental retardation (MR defined as IQ < 70) annually. This number accounts for 3.2% (range: 0.2-5.4%) of MR cases in the United States. If the lifetime excess cost of a case of MR (excluding individual productivity losses) is $1,248,648 in 2000 dollars, then the cost of these excess cases of MR is $2.0 billion annually (range: $143 million-$3.3 billion). Preliminary data suggest that more stringent mercury policy options would prevent thousands of cases of MR and billions of dollars over the next 25 years.

Written by an international panel of distinguished global health experts, this book distills valuable lessons from a wide variety of successful health programs that have been implemented around the world. "Global Health Leadership and Management gives practical suggestions for enhancing and developing the essential skills of leadership, management, communication, and project planning for health care leaders. The book will assist health leaders to work well within their communities and effectively plan, direct, implement, and evaluate effective programs and activities. "Global Health Leadership and Management outlines and describes such core competencies as Identifying challenges and developing and managing policy Developing strategies, pathways, and solutions Creating networks and partnerships and planning for change Learning from experience to build a generation of leaders Leading and managing teams by recognizing and celebrating success

This report presents recommendations for redesigning the retirement benefits - health insurance and pension payments - for employees of the City of New York and State of New York. It includes a description of current benefits and a comparison to benefits provided by other large private and public employers.

This article describes the nature and utility of fiscal analysis in evaluating complex community interventions. Using New York University's evaluation of the Robert Wood Johnson Foundation's Urban Health Initiative as an example, the authors describe issues arising in defining and operationalizing constructs for fiscal analysis. The approach's utility is demonstrated in the use of interim findings to help redefine the program's goals for resource allocation, to modify its theory of change to include greater emphasis on state-level action, and to emphasize the importance of local public schools as resource centers and intervention targets. The fiscal analysis also provides new insights into the limitations of "preventive" versus "corrective" spending categories and helps make goals for such functional reallocation more realistic. The authors discuss limitations of fiscal analysis due to available data quality, the extent of cooperation needed from public officials to collect relevant data, and the level of expertise needed to interpret the data.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? Health Care Delivery in the United States, 8 th Edition discusses these and other core issues in the field. Under the editorship of Dr. Kovner and with the addition of Dr. James Knickman, Senior VP of Evaluation, Robert Wood Johnson Foundation, leading thinkers and practitioners in the field examine how medical knowledge creates new healthcare services. Emerging and recurrent issues from wide perspectives of health policy and public health are also discussed. With an easy to understand format and a focus on the major core challenges of the delivery of health care, this is the textbook of choice for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

Comments on the use of evidence-based approach in the area of health care financial management. Limitation of benchmarking; Barriers to the introduction of evidence-based financial management in health care; Responsibility of health care financial management educators.

This is one of the only books available that addresses financial and managerial accounting within the framework of the three major areas of the public sector. Clear and comprehensive, Finkler's unique and accessible text provides the fundamentals of financial management for those who lack a financial background so that readers can access and apply financial information more effectively. Details the many aspects of strategic and budgetary planning. Outlines the processes involved in implementing and controlling results. Features aspects of accounting unique for Health Care, not-for-profit organizations and state and local governments. Explains balance sheets, operating and cash flow statements. Provides basic foundation for financial analysis. For managers and policy-makers in public service organizations who want to make more efficient use of their organization's financial information.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? These core issues regarding our health policy are answered in this text.This is a textbook for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs

Health services research is, by nature, multidisciplinary, for it draws on the methods,concepts and theories of social sciences, which are relevant to the study of how the organization and financing of health services can improve the delivery of health care services (Gray, et al., 2003). While medicine and public health, too, are multidisciplinary enterprises drawing on such disciplines as molecular biology, physiology, anatomy, genetics, epidemiology and more, health services research departs from these disciplines in focusing not on the nature of disease and health but rather on the financing and organization of health systems.

So it is with urban health services research albeit that this field is more narrowly focused on health services in cities. The city focus has resulted in a large body of research on vulnerable groups, barriers to service access, public health clinics and community health centers. Likewise, it has led to important investigations of safetynet institutions, e.g. public hospitals and health centers, which serve a disproportionate share of uninsured and low-income patients. In addition, urban health services research has focused on a host of specific services associated with subpopulations suffering from TB, HIV/AIDS, drug addiction and other social pathologies that are typically associated with the "inner city."

Some of the highest rates of curable sexually transmitted diseases in the USA are found among adolescents. Routine, comprehensive health care that includes a sexual history may contribute to alleviating this problem. We designed and ran a three-session small-group workshop for adolescents, using local community organizations as intervention sites, with peers (typically 2-3 years older) helping facilitate the interactive sessions. Outcomes are summarized elsewhere: in this paper, we present an examination of theoretically based psychological mediating factors that we sought to influence during the intervention. Adolescents' health care-seeking beliefs, general attitudes to seeking care, and intentions to do so all changed such that they held more positive beliefs, evaluated health care more favorably, and developed stronger intentions to seek care. Furthermore, relationships among these constructs were strengthened according to theoretical precepts. Adolescents' self-efficacy and their perceptions of social norms pertaining to health care-seeking, however, were unaffected by the intervention. We explored gender differences in mediating factors, finding no interaction, although females did score higher on post-intervention attitude and intention measures.

Simply stated, health literacy is the ability to obtain, understand, and effectively use health-related information. In a recent report entitled "Health Literacy: A Prescription to End Confusion," the Institute of Medicine estimated that 90 million adults may lack the needed literacy skills to effectively use the U.S. health care system. Extrapolating from the National Adult Literacy Survey, approximately 36 percent of New York City adults would not be able to identify the name of a hospital in a short article; an additional 27 percent would not be able to fill out a standard health insurance form. Health care providers and patients typically do not identify low health literacy as a major issue, but both groups are well aware of its consequences. Health care professionals know they need improved communication with their patients so that they can better understand patient concerns and priorities, engage them as active partners in their care, improve their grasp of protocols for care management and the need for preventive care and screening, and ensure that they know when and where to seek care and how to navigate the health care system. Conversely, adults with low literacy skills often feel intimidated by the complexity of the health care system, by the forms and instructions, and by medical terminology. To avoid appearing ignorant, they may be hesitant to ask questions or express concerns, thereby compounding the problem. All of these difficulties are exacerbated when patients do not speak English well and are unfamiliar with the U.S. health care system.

Since the initial modern malpractice crisis hit Pennsylvania and the nation in the mid-1970s, two successive episodes-including one in the present, which by autumn 2005 appeared to be abating-have rocked the Commonwealth's liability insurers, medical providers, and health-care consumers. The state's political establishment was swift to respond with reform legislation in both the first crisis and the present one; a malpractice bill also passed in 1996, in the wake of the 1980s troubles. But, in 1975 and 2002 alike, passage of a comprehensive reform measure did little to alleviate pressures for continued legislative relief. Political efforts to address soaring liability premiums and other systemic malpractice woes continued for years afterwards.

Details the hospital experience of a health professional who underwent cardiac arterial bypass graft on the said urban medical center. Errors or potential errors that were cited in the way that ancillary staff, nurses and even some physicians failed in or neglected their responsibilities, both medical and humane; System failures observed, largely in the provision of nonclinical, so called hotel services; Possible cause of many of the problems identified.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care?

Health Care Delivery in the United States, 8th Edition discusses these and other core issues in the field. Under the editorship of Dr. Kovner and with the addition of Dr. James Knickman, Senior VP of Evaluation, Robert Wood Johnson Foundation, leading thinkers and practitioners in the field examine how medical knowledge creates new healthcare services. Emerging and recurrent issues from wide perspectives of health policy and public health are also discussed.

Parkinson disease (PD) and Alzheimer disease (AD), the two most common neurodegenerative disorders in American adults, are of purely genetic origin in a minority of cases and appear in most instances to arise through interactions among genetic and environmental factors. In this article we hypothesize that environmental exposures in early life may be of particular etiologic importance and review evidence for the early environmental origins of neurodegeneration. For PD the first recognized environmental cause, MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine), was identified in epidemiologic studies of drug abusers. Chemicals experimentally linked to PD include the insecticide rotenone and the herbicides paraquat and maneb; interaction has been observed between paraquat and maneb. In epidemiologic studies, manganese has been linked to parkinsonism. In dementia, lead is associated with increased risk in chronically exposed workers. Exposures of children in early life to lead, polychlorinated biphenyls, and methylmercury have been followed by persistent decrements in intelligence that may presage dementia. To discover new environmental causes of AD and PD, and to characterize relevant gene-environment interactions, we recommend that a large, prospective genetic and epidemiologic study be undertaken that will follow thousands of children from conception (or before) to old age. Additional approaches to etiologic discovery include establishing incidence registries for AD and PD, conducting targeted investigations in high-risk populations, and improving testing of the potential neurologic toxicity of chemicals.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? These core issues regarding our health policy are answered in this text.This is a textbook for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

We tested the association between the availability of primary care and income inequality on several categories of mortality in US counties. Methods. We used cross-sectional analysis of data from counties (n=3081) in 1990, including analysis of variance and multivariate ordinary least squares regression. Independent variables included primary care resources, income inequality, and sociodemographics. Results. Counties with higher availability of primary care resources experienced between 2% and 3% lower mortality than counties with less primary care. Counties with high income inequality experienced between 11% and 13% higher mortality than counties with less inequality. Conclusions. Primary care resources may partially moderate the effects of income inequality on health outcomes at the county level.

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.

Analyses at the county level show lower mortality rates where there are more primary care physicians, but this is not the case for specialist supply. These findings confirm those of previous studies at the state and other levels. Increasing the supply of specialists will not improve the United States' position in population health relative to other industrialized countries, and it is likely to lead to greater disparities in health status and outcomes. Adverse effects from inappropriate or unnecessary specialist use may be responsible for the absence of relationship between specialist supply and mortality.

Presents a letter to Edward Salsberg about the need for real evidence in physician workforce decision making. Opinion that one needs more information before making decisions about specialty composition in the health professions; Notion that primary care physicians could maintain expertise in several specialty areas by greatly limiting their practice size; Information that some health systems are trying to increase the supply of at least certain specialists.

Methyl mercury is a developmental neurotoxicant. Exposure results principally from consumption by pregnant women of seafood contaminated by mercury from anthropogenic (70%) and natural (30%) sources. Throughout the 1990s, the U.S. Environmental Protection Agency (EPA) made steady progress in reducing mercury emissions from anthropogenic sources, especially from power plants, which account for 41% of anthropogenic emissions. However, the U.S. EPA recently proposed to slow this progress, citing high costs of pollution abatement. To put into perspective the costs of controlling emissions from American power plants, we have estimated the economic costs of methyl mercury toxicity attributable to mercury from these plants. We used an environmentally attributable fraction model and limited our analysis to the neurodevelopmental impacts--specifically loss of intelligence. Using national blood mercury prevalence data from the Centers for Disease Control and Prevention, we found that between 316,588 and 637,233 children each year have cord blood mercury levels > 5.8 microg/L, a level associated with loss of IQ. The resulting loss of intelligence causes diminished economic productivity that persists over the entire lifetime of these children. This lost productivity is the major cost of methyl mercury toxicity, and it amounts to $8.7 billion annually (range, $2.2-43.8 billion; all costs are in 2000 US$). Of this total, $1.3 billion (range, $0.1-6.5 billion) each year is attributable to mercury emissions from American power plants. This significant toll threatens the economic health and security of the United States and should be considered in the debate on mercury pollution controls.

A growing body of research supports the role of outdoor air pollutants in acutely aggravating chronic diseases in children, and suggests that the pollutants may have a role in the development of these diseases. This article reviews the biologic basis of children's unique vulnerability to highly prevalent outdoor air pollutants, with a special focus on ozone, respirable particulate matter (PM 2.5 [<2.5 microm in diameter] and PM 10 [<10 microm in diameter]), lead, sulfur dioxide, carbon monoxide, and nitrogen oxides. We also summarize understanding regarding health effects and molecular mechanisms of action. Practitioners can significantly reduce morbidity in children and other vulnerable populations by advising families to minimize pollutant exposures to children with asthma, or at a broader level by educating policymakers about the need to act to reduce pollutant emissions. Management of children with asthma must expand beyond preventing exposures to agents that directly cause allergic reactions (and therefore can be diagnosed by means of skin tests) and must focus more attention on agents that cause a broad spectrum of nonspecific, generalized inflammation, such as air pollution.

To assess the cost-effectiveness of Intervention for HIV-Seropositive injection drug users-Research and Evaluation (INSPIRE), designed to reduce risky sexual and needle-sharing behaviors in research sites in four US cities (2001-2003). Methods: We collected data on program and participant costs. We used a mathematical model to estimate the number of sex partners of injection drug users expected to become infected with human immunodeficiency virus (HIV) (with and without intervention), cost of treatment for sex partners who became infected, and the effect of infection on partners' quality-adjusted life expectancy. We determined the minimum effect that INSPIRE must have on condom use among participants for the intervention to be cost-saving (intervention cost less than savings from averted HIV infections) or cost-effective (net cost per quality-adjusted life year saved less than $50,000). Results: The intervention cost was $870 per participant. It would be cost-saving if it led to 53 percent reduction in the proportion of participants who had any unprotected sex in 1 year and cost-effective with 17 percent reduction. If behavior change lasted 3 months, the cost-effectiveness threshold was 66 percent; if 3 years, the threshold was 6 percent. Conclusions: Although cost-saving thresholds may not be achievable by the intervention, we anticipate that cost-effectiveness thresholds will be attained.

Objectives. We evaluated the effectiveness of an intervention designed to increase preventive health care seeking among adolescents.

Methods. Adolescents and young adults aged 12 to 21 years, recruited from community-based organizations in 2 different communities, were randomized into either a 3-session intervention or a control condition. We estimated outcomes from 3-month follow-up data using logistic and ordinary least squares regression.

Results. Female intervention participants were significantly more likely than female control participants to have scheduled a health care appointment (odds ratio [OR]=3.04), undergone a checkup (OR=2.87), and discussed with friends or family members the importance of undergoing a checkup (OR=4.5). There were no differences between male intervention and male control participants in terms of outcomes.

Conclusions. This theory-driven, community-based group intervention significantly increased preventive health care seeking among female adolescents. Further research is needed, however, to identify interventions that will produce successful outcomes among male adolescents.

Mass transit is a critical infrastructure of urban environments worldwide. The public uses it extensively, with roughly 9 billion mass transit trips occurring annually in the United States alone according to the U.S. Department of Transportation data. Its benefits per traveler include lower emissions of air pollutants and energy usage and high speeds and safety records relative to many other common modes of transportation that contribute to human health and safety. However, mass transit is vulnerable to intrusions that compromise its use and the realization of the important benefits it brings. These intrusions pertain to physical conditions, security, external environmental conditions, and equity. The state of the physical condition of transit facilities overall has been summarized in the low ratings the American Society of Civil Engineers gives to mass transit, and the large dollar estimates to maintain existing conditions as well as to bring on new improvements, which are, however, many times lower than investments estimated for roadways. Security has become a growing issue, and numerous incidents point to the potential for threats to security in the US. External environmental conditions, such as unexpected inundations of water and electric power outages also make transit vulnerable. Equity issues pose constraints on the use of transit by those who cannot access it. Transit has shown a remarkable ability to rebound after crises, most notably after the September 11, 2001 attacks on the World Trade Center, due to a combination of design and operational features of the system. These experiences provide important lessons that must be captured to provide proactive approaches to managing and reducing the consequences of external factors that impinge negatively on transit.

The major economic effects of electric power outages are usually associated with three potential outcomes: the loss of human life and health; business losses; and declines in property value (some of which are encompassed within business losses). This report sets forth economic factors for quantifying the cost of loss of human life and injuries and business losses (including those to critical infrastructure that supports social and economic activity) as a basis for accounting for the economic outcomes of terrorist attacks. Although they have been developed for estimating effects of attacks on electric power, these factors are broadly applicable to other kinds of attacks involving deaths, injury or business loss. A variety of alternative measures and values are presented to enable users flexibility in how they are applied. This report is intended to accompany the "Electricity Case: Main Report - Risk, Consequences, and Economic Accounting" (May 31, 2005).

The usefulness of patient decision aids (PtDAs) is well documented, yet they are not in widespread use. Barriers include assuring balance and fairness (auspices matter), the cost of producing and maintaining them, and getting them into the hands of patients at the right time. The Foundation for Informed Medical Decision Making and its for-profit partner, Health Dialog, have developed a creative business model that helps overcome these barriers and has greatly expanded the reach of decision aids.

High cost patients account for a large share of Medicaid costs (20 percent of patients account for 70 to 80 percent of expenditures). This study analyzes expenditures, patterns of utilization, and diagnostic characteristics of the most costly of these patients.

This report presents data on computer access, Internet use, and factors associated with health information seeking on the Internet among a sample of youths aged 15 to 30 years in New York City. Findings from street intercept surveys indicate substantial computer access at home (62%) and frequent (everyday or a few times a week) Internet use (66%). Fifty-five percent of the sample reported seeking health information on the Internet, which was associated with positive beliefs about getting a health checkup and frequent Internet use.

Like many schools of public policy and management, New York University's Wagner School offers a capstone course in which teams of MPA students provide consultation to client organizations, This year, as the they began to assign students to teams, some members of the faculty sounded an alarm. Several of the projects might involve interviewing service recipients about sensitive issues. Other projects would give teams access to confidential information. Faculty members experience with their university human subjects review board knew that such projects, where they to be undertaken in a research context, would require lengthy and cumbersome review. Did the capstone projects need to go through the human subjects review process? If the answer was yes, the program would come to a grinding halt, given the open-endness of a capstone assignments and the bureaucratic nature of the committee application and approval process.

The objective is to determine whether caregiving grandparents are at an increased risk for depressive symptoms.

This paper examines public spending on children between 1997 and 2000 in five localities: Baltimore, Detroit, Oakland, Philadelphia, and Richmond. These cities participate in the Urban Health Initiative (UHI), a ten-year Robert Wood Johnson Foundation program aimed at improving health and safety for young people in these cities. The Center for Health and Public Service Research at New York University is evaluating the program. The evaluation seeks to determine whether collaborative efforts of interested organizations can develop and implement plans to change service delivery systems for children, and whether such changes result in better outcomes for children. A group of ten additional cities serves as a comparative benchmark.

The South Bronx is a low-income, minority community in New York City. It has one of the highest asthma rates in the country, which community residents feel is related to poor air quality. Community residents also feel that the air quality data provided by the New York State Department of Environmental Conservation (DEC) through its network of monitoring stations do not reflect the poor quality of the air they breathe. This is due to the fact that these monitoring stations are located 15 m above ground. In the year 2001 this project collected air quality data at three locations in the study area. They were collected close to ground-level at a height of 4 m by a mobile laboratory placed in a van as part of the South Bronx Environmental Health and Policy Study. This paper compares data collected by the project with data from DEC's monitoring stations in Bronx County during the same periods. The goal of the comparison is to gain a better understanding of differences in measured air quality concentrations at these different heights. Although there is good agreement in the data among DEC stations there are some important differences between ground-level measurements and DEC data. For PM_2.5 the measured concentrations by the van were similar to those recorded by DEC stations. In the case of ozone, the concentrations recorded at ground level were similar or lower than those recorded by DEC stations. For NO₂, however, the concentrations recorded at ground level were over twice as high as those recorded by DEC. In the case of SO₂, ground level measurements were substantially higher in August but very similar in the other two periods. CO concentrations measured at ground-level tend to be 60–90% higher than those recorded by DEC monitoring stations. Despite these differences, van measurements of SO₂ and CO concentrations were well below EPA standards.

In this paper we study the relationship between the unemployment rate at the time of a baby's conception and health outcomes at birth, and we explore whether this relationship is due to the effect of the unemployment rate on fertility decisions or on the health-related behavior of pregnant women. Economic models of fertility suggest that women who choose to have children in recessions may differ from women who choose to postpone fertility.

To the extent that these parental characteristics are related to children's health, differential fertility may result in differences in the health of children over the business cycle. At the same time, evidence suggests that individuals' health may improve during recessions, because the overall effect of recessions is to increase health-related activities (and to decrease risky behaviors). Therefore, changes in parental behavior over the business cycle could also affect the health of infants, even in the absence of compositional change.

We examine, for residents in two nations (U.S. and France) and the hearts of two world cities (New York, and Paris), differences in rates of mortality and hospital discharge, by area of residence, for ischemic heart disease (IHD), acute myocardial infarction (AMI), and rates of revascularization. To assess the relationship between treatment rates and the prevalence of IHD, we introduce an index based on the ratio of procedure rates to AMI hospital discharge rates and mortality. After accounting for disease prevalence, we find that procedure rates are lower in Manhattan than in Paris for both age groups, and lower in the United States than France among the 45-64 year old cohort.

Managers of a healthcare organization have numerous demands on their time, their skills, their knowledge, and their budgets. They are responsible for adapting to change, managing their office, making effective decisions, among countless other tasks.

This text�newly revised to include readings, commentary, and cases�offers a bridge from management theory to the actual world of healthcare management.

Throughout its past editions, Health Services Management has featured the best literature on health services management to help readers understand the role of the manager, organizational design and control, the blending of organization and health professionals, change (adaptation), and responsiveness (accountability). This new edition continues that effort, and features new readings.

The cases take place in a variety of organizations, including a faculty practice, a neighborhood health center, a small rural hospital, an HMO, as well as a variety of other settings.

Managers of a healthcare organization have numerous demands on their time, their skills, their knowledge, and their budgets. They are responsible for adapting to change, managing their office, making effective decisions, among countless other tasks. This text-newly revised to include readings, commentary, and cases-offers a bridge from management theory to the actual world of healthcare management that will help your students learn the role of manager in a healthcare organization.

Throughout its past editions, Health Services Management has featured the best literature on health services management to help learners understand the role of the manager, organizational design and control, the blending of organization and health professionals, change (adaptation), and responsiveness (accountability). This new edition continues that effort, and features new readings and classroom-tested cases.

The cases take place in a variety of organizations, including a faculty practice, a neighborhood health center, a small rural hospital, an HMO, as well as a variety of other settings. This book will prepare your future managers for the multitude of healthcare settings they could face in their careers.

The Balanced Budget Act of 1997 established federal grants to the states to create the State Children's Health Insurance Program (SCHIP). This presented the states with a number of implementation choices concerning administrative models for the new programs, as well as choices about eligibility standards, enrollment simplification, crowd-out, and cost sharing requirements. At the same time, the states were also implementing welfare reform. We describe the most important of these implementation choices, and using data from the Current Population Survey, we estimate the impacts of state policy on enrollment in this multiprogram environment. The results indicate that SCHIP programs that are administered as Medicaid expansions are more successful than either separate SCHIP plans or combination programs in enrolling children. States that remove asset tests and implement presumptive eligibility and self-declaration of income have higher enrollment levels. Continuous eligibility and adoption of mail-in applications have no effect on overall enrollment. Waiting periods and premiums reduce enrollment. Stringent welfare reform reduces children's enrollment, despite federal policy that was intended to protect children from the consequences of welfare reform. The negative impacts of a number of these policy reforms substantially reduce enrollment, potentially offsetting the more favorable impacts of other policy choices. We estimate that if all states adopted the policy options that facilitate program use, enrollment for children with family incomes less than 200 percent of the poverty line could be raised from the current rate of 42 percent to 58 percent.

The states have implemented the State Children's Health Insurance Program (SCHIP) in a variety of ways. We describe these choices and estimate the resulting enrollment impacts. Many widely adopted policies, including mail-in applications and twelve- month continuous eligibility, have had limited impacts. Other policies that increase enrollment, including presumptive eligibility and self-declaration of income, have not been widely adopted. SCHIP programs administered as Medicaid expansions have been more successful in enrolling children than either separate SCHIP plans or combination programs. Waiting periods, premiums, and welfare reform have had important negative impacts on children's program enrollment.

Bush continues a trend toward smaller agendas begun in the wake of the 1981 tax cuts, which sharply constrained the amount of federal funding for large scale, new programs. He also continues a trend among Republican presidents toward a �less-is-more� philosophy of domestic policy. His agenda is half as large as Richard Nixon's first-term agenda in 1969-72, a third smaller than Ronald Reagan's first-term agenda in 1981-84, and a quarter smaller than his father's first-term agenda in 1989-92. Although less ambitious than his predecessors, Bush's limited number of large-scale, new proposals have been undeniably bold. His tax cuts, education reform, social security revisions, prescription drug coverage, and homeland security reorganization are easily classified as large-scale, new proposals, and match up with the large-scale, new proposals of the past such as civil rights, voting rights, and Medicare under presidents John F. Kennedy and Lyndon Johnson, environmental protection, revenue sharing, and national health insurance under Richard M. Nixon, energy and social security reform under Jimmy Carter, tax cuts under Ronald Reagan, budget reform under George H. W. Bush, and national health care, Americorps, and welfare reform under Bill Clinton. However, what sets George W. Bush apart is the relatively shallow depth of his agenda. Whereas Kennedy and Johnson pursued 54 large-scale, new proposals in their two first terms, and Nixon another 18, Bush has pursued just five in his. Simply put, George W. Bush has placed all of his domestic policy proposals in a very small basket. Half of his agenda consists of small-scale, conventional proposals, including expanded drug treatment, pension reform, and an energy package that pales in comparison to the energy bills of previous administrations.

O objetivo da pesquisa foi adaptar e aplicar um instrumento para medir dimensões organizacionais do sistema de atenção básica no município de Petrópolis (RJ), comparando as dimensões organizacionais selecionadas em dois tipos de unidades: as do Programa Saúde da Família (PSF) e as Unidades Básicas de Saúde (UBS) tradicionais. A pesquisa utilizou a metodologia de informantes-chave. A ferramenta testada foi aplicada de forma rápida o que sugere que ela pode ser empregada nas avaliações regulares do desempenho das unidades. Conclui-se que apesar de Petrópolis ter realizado avanços importantes na atenção básica, enfrenta vários desafios, incluindo: melhorar acesso, reforçar o papel da atenção básica como porta de entrada no sistema, alcançar maior integralidade na atenção à saúde, melhorar a coordenação e aumentar a orientação para a comunidade.

Background: Retesting 3 to 4 months after treatment for those infected with chlamydia and/or gonorrhea has been recommended.

Goal: We compared various methods of encouraging return for retesting 3 months after treatment for chlamydia or gonorrhea.

Study: In study 1, participants were randomly assigned to: 1) brief recommendation to return, 2) intervention 1 plus $20 incentive paid at return visit, or 3) intervention 1 plus motivational counseling at the first visit and a phone reminder at 3 months. In study 2, participants at 1 clinic were randomly assigned to 4) intervention 1, 5) intervention 1 plus phone reminder, or 6) intervention 1 plus motivational counseling but no telephone reminder.

Results: Using multiple logistic regression, the odds ratios for interventions 2 and 3, respectively, compared with intervention 1 were 1.2 (95% confidence interval [CI], 0.6-2.5) and 2.6 (95% CI, 1.3-5.0). The odds ratios for interventions 5 and 6 compared with intervention 4 were 18.1 (95% CI, 1.7-193.5) and 4.6 (95% CI, 0.4-58.0).

Conclusions: A monetary incentive did not increase return rates compared with a brief recommendation. A reminder phone call seemed to be the most effective method to increase return.

The purpose was to examine attitudinal and contextual factors associated with the occurrence of sexual health assessments during adolescent primary care visits. A total of 313 primarily African-American youth aged 11-21 years from 16 community-based organizations in suburban Maryland and in New York City completed questionnaires focusing on sexually transmitted diseases (STD) and health care. The analysis examined the relationship of sexual activity, attitudes, and presence of the parent at the health care visit with discussion of three sexual health topics and testing for STD at the most recent health care visit. Data were analyzed using Chi-square tests and logistic regression. Overall, 74% of respondents reported that they had talked about at least one sexual health topic at their last health care visit but only 32% had discussed all three topics of sexual behavior, birth control, and STD. Females were more likely than males to discuss birth control although there were no gender differences in the overall likelihood of talking about a sexual health topic. Few adolescents initiated discussion of sexual issues. Positive attitudes toward discussing sexual issues with a provider and absence of a parent at the visit were independently associated with higher odds of discussing at least one sexuality topic and STD testing. Although relatively large numbers of adolescents in the sample received sexual health assessments, the proportion was below recommended guidelines. The opportunity to speak privately with a clinician and having positive attitudes about discussing sex with a doctor appear to be important influences on the receipt of sexual health assessments. Improving the quality of adolescent preventive care will require creating a health care environment that facilitates discussion of sexual health issues

The South Bronx is a low-income, minority community in New York City. It has one of the highest asthma rates in
the country, which community residents feel is related to poor air quality. Community residents also feel that the air quality data provided by the New York State Department of Environmental Conservation (DEC) through its network
of monitoring stations do not reflect the poor quality of the air they breathe. This is due to the fact that these
monitoring stations are located 15m above ground. In the year 2001 this project collected air quality data at three
locations in the study area. They were collected close to ground-level at a height of 4m by a mobile laboratory placed in a van as part of the South Bronx Environmental Health and Policy Study. This paper compares data collected by the project with data from DEC's monitoring stations in Bronx County during the same periods. The goal of the comparison is to gain a better understanding of differences in measured air quality concentrations at these different heights. Although there is good agreement in the data among DEC stations there are some important differences between ground-level measurements and DEC data. For PM2.5 the measured concentrations by the van were similar to those recorded by DEC stations. In the case of ozone, the concentrations recorded at ground level were similar or lower than those recorded by DEC stations. For NO2, however, the concentrations recorded at ground level were over twice as high as those recorded by DEC. In the case of SO2, ground level measurements were substantially higher in August but very similar in the other two periods. CO concentrations measured at ground-level tend to be 60-90% higher than those recorded by DEC monitoring stations. Despite these differences, van measurements of SO2 and CO concentrations were well below EPA standards.

Background: Gender disparities in the treatment of coronary artery disease (CAD) have been extensively documented in studies from the United States. However, they have been less well studied in other countries and, to our knowledge, have not been investigated at the more disaggregated spatial level of cities.

Objective: This study tests the hypothesis that there is a common international pattern of gender disparity in the treatment of CAD in persons aged ≥65 years by analyzing data from the United States, France, and England and from their largest cities-New York City and its outer boroughs, Paris and its First Ring, and Greater London.

Methods: This was an ecological study based on a retrospective analysis of comparable administrative
data from government health databases for the 9 spatial units of analysis: the 3 countries, their 3 largest
cities, and the urban cores of these 3 cities. A simple index was used to assess the relationship between
treatment rates and a measure of CAD prevalence by gender among age-adjusted cohorts of patients.
Differences in rates were examined by univariate analysis using the Student t test for statistical differences
in mean values.

Results: Despite differences in health system characteristics, including health insurance coverage, availability
of medical resources, and medical culture, we found consistent gender differences in rates of percutaneous
transluminal coronary angioplasty and coronary artery bypass grafting across the 9 spatial units.
The rate of interventional treatment in women with CAD was less than half that in men. This difference
persisted after adjustment for the prevalence of heart disease.

Conclusions: A consistent pattern of gender disparity in the interventional treatment of CAD was seen
across 3 national health systems with known differences in patterns of medical practice. This finding is
consistent with the results of clinical studies suggesting that gender disparities in the treatment of CAD
are due at least in part to the underdiagnosis of CAD in women.

Investing in Children, Youth, Families, and Communities takes a theoretically exciting and socially critical view of human development and the power of context to shape positive outcomes. Co-editors Kenneth I. Maton, Cynthia J. Schellenbach, Bonnie J. Leadbeater, and Andrea L. Solarz bring together leading social scientists and policy experts to discuss what helps or hinders healthy development.

A transformative theme, from deficits to strengths, emerges in this book, as it surveys the mounting evidence that programs that shore up resilience can and do work. Empirically rich chapters show how children, youth, families, and communities can be vital resources in countering the challenges posed by violence, abuse, neglect, and other obstacles to development. It provides concrete examples of programs that recognize, strengthen, and marshal the abilities of individuals and groups traditionally assumed to be deficient or in need of "fixing."

Uniquely, this book also extends the scientific findings to real-world program and policy implications. Each chapter is co-authored by scholars and policy experts with complementary strengths, bringing together expertise in the psychosocial aspects of an issue and expertise in social policy.

Study objective: The study tests the extent to which primary care physician supply (office based primary care physicians per 10 000 population) moderates the association between social inequalities and infant mortality and low birth weight throughout the 50 states of the USA.

Design: Pooled cross sectional, time series analysis of secondary data. Analyses controlled for state level education, unemployment, racial/ethnic composition, income inequality, and urban/rural differences. Contemporaneous and time lagged covariates were modelled.

Setting: Eleven years (1985-95) of data from 50 US states (final n = 549 because of one missing data point).

Main results: Primary care was negatively associated with infant mortality and low birth weight in all multivariate models (p<0.0001). The association was consistent in contemporaneous and time lagged models. Although income inequality was positively associated with low birth weight and infant mortality (p<0.0001), the association with infant mortality disappeared with the addition of sociodemographic covariates.

Conclusions: In US states, an increased supply of primary care practitioners-especially in areas with high levels of social disparities-is negatively associated with infant mortality and low birth weight.

 At any given moment, about 3 million American women, men, and children are homeless. And another 5 million Americans spend over 50% of their incomes on housing, meaning that one missed paycheck, one health crisis, or one unpaid utility bill can push them out the door into homelessness. Homelessness is one of the major social problems and personal and family tragedies of the contemporary world. No community, city, or nation is immune and the lack of affordable housing and a decline in secure, well-paying jobs means that the problem will only get worse. The Encyclopedia of Homelessness is the first systematic effort to organize and summarize what we know about this complex topic that impacts not only the homeless but all of society. The Encyclopedia focuses on the current situation in the United States with a comparative sampling of homelessness around the world.

At any given moment, about 3 million American women, men, and children are homeless. And another 5 million Americans spend over 50% of their incomes on housing, meaning that one missed paycheck, one health crisis, or one unpaid utility bill can push them out the door into homelessness. Homelessness is one of the major social problems and personal and family tragedies of the contemporary world. No community, city, or nation is immune and the lack of affordable housing and a decline in secure, well-paying jobs means that the problem will only get worse. The Encyclopedia of Homelessness is the first systematic effort to organize and summarize what we know about this complex topic that impacts not only the homeless but all of society. The Encyclopedia focuses on the current situation in the United States with a comparative sampling of homelessness around the world.

As the HIV/AIDS epidemic enters its third decade, rates of infection continue to rise in ethnic minority populations. Though the prevalence of HIV among Asian and Pacific Islander (A&PI) gay men remains to be clearly documented, research has shown that these men engage in relatively high rates of HIV risk behavior. The social discrimination that minority gay men experience may impact their HIV risk behavior and mental health (Diaz & Ayala, 2001). This article examines the experiences of and response to social discrimination among A&PI gay men, and their links to HIV risk behaviors. The study analyzes 166 narrative episodes of discrimination, as well as data on HIV risk obtained from in-depth interviews with 23 A&PI gay men. Results showed that A&PI gay men experience types of discrimination across a variety of contexts. Homophobia and anti-immigrant discrimination were linked to confrontation and social network-based responses whereas discrimination based in stereotypes of passivity / submission were linked with self-attribution. A&PI gay men who used confrontational, social network-based or avoidance response types showed less HIV risk than those who did not. Conversely, A&PI gay men who responded to discrimination with self-attribution showed greater HIV risk behaviors. These findings indicate that experiences of social discrimination and responses to discrimination may impact A&PI gay men's well-being and health.

As we enter the third decade of the AIDS epidemic, HIV/AIDS is the leading cause of death for Black U.S. citizens between the ages of 25-44. Black MSM have the highest incidence of AIDS in the U.S. Research is needed on the individual and contextual factors that place these men at risk. This study asks: 1) What are the profiles of social network and social/political group involvement for Black MSM? 2) Do levels of peer norms, AIDS knowledge, self-efficacy, and AIDS ethnocentrism differ for Black MSM according to their social networks and social activity? 3) Does HIV-risk differ for Black MSM according to their social involvement? METHODS: The sample consisted of 318 Black MSM. The average age was 31 years old, and 88% of the participants were single. 33% of the sample reported engaging in sexual behavior with both men and women. Measures included age, education level, make-up of social networks (race, sexual orientation), participation in social/political groups of Black gay, White gay and heterosexual types, levels of condom efficacy, peer norms, AIDS knowledge and AIDS ethnocentrism and number of instances of unprotected anal intercourse (UAI) in the past 6 months. Data were analyzed using cluster analysis, regression analysis and ANOVA. RESULTS: Men who were active in social/political groups were less likely to engage in UAI than men who were not active. This effect was mediated by higher condom efficacy and lower AIDS ethnocentrism. The study also showed that men with largely Black and gay networks reported higher UAI than men with White gay social networks. CONCLUSION: Results show that different social patterns among Black MSM can lead to different outcomes regarding HIV-risk. These findings will inform AIDS prevention efforts for Black MSM, and promote use of a framework that incorporates both individual and contextual factors in understanding HIV-risk.

Awareness of youth violence has increased in recent years, resulting in more interest in programs that can prevent violent and aggressive behavior. Although overall rates of violence among young people have declined since the mid-1990s, rates of some forms of youth aggression, violence, and crime remain high. National data reveal that, each year, about 15 percent of high school students are involved in a physical fight at school and 8 percent are threatened or injured with a weapon. 1 Urban youth are at particular risk for exposure to violence and victimization.

This report describes one of the largest and longest running school-based violence prevention programs in the country-the Resolving Conflict Creatively Program (RCCP)-and discusses the results of a rigorous evaluation conducted by the National Center for Children in Poverty (NCCP) at Columbia University's Mailman School of Public Health. The evaluation provides concrete evidence that early, school-based prevention initiatives such as the RCCP can work and should be included in communities' efforts to prevent violence among children and youth.

One of the challenges in monitoring the Nation's health care safety net is that safety net services are provided in a myriad of different configurations, largely at the local level. Book 1. Data for Metropolitan Areas presents data from 90 metropolitan areas in 30 States and the District of Columbia, including 354 counties and 171 cities. The data describe the health care safety net where 80 percent of Americans with family incomes below the Federal poverty line live.

Seven percent of newborns in the United States weigh in at less than five and one half pounds. These "low birth weight" babies face challenges that others will never know--challenges that begin with a greater risk of infant mortality and extend well into adulthood in the form of health and developmental problems. Because low birth weight is often accompanied by social risk factors such as minority racial status, low education, young maternal age, and low income, the question of causes and consequences--of precisely how biological and social factors figure into this equation--becomes especially tricky to sort out. This is the question that The Starting Gate takes up, bringing a novel perspective to the nature-nurture debate by using the starting point of birth as a lens to examine biological and social inheritance. Seven percent of newborns in the United States weigh in at less than five and one half pounds. These "low birth weight" babies face challenges that others will never know--challenges that begin with a greater risk of infant mortality and extend well into adulthood in the form of health and developmental problems. Because low birth weight is often accompanied by social risk factors such as minority racial status, low education, young maternal age, and low income, the question of causes and consequences--of precisely how biological and social factors figure into this equation--becomes especially tricky to sort out. This is the question that The Starting Gate takes up, bringing a novel perspective to the nature-nurture debate by using the starting point of birth as a lens to examine biological and social inheritance.

There is a growing movement toward evidence-based management in healthcare. This movement extends to healthcare financial management. However, there are barriers to the use of evidence by healthcare financial managers. These barriers are largely the result of culture (management culture is substantially different from clinical culture) and education. If healthcare financial managers are to become better at generating and using evidence, educators must do a better job of preparing them to do so. If we provide more education regarding the goals of research and about the different types of research methods, then healthcare financial managers can become educated consumers of evidence. If we provide more examples of evidence that has been generated by research in our classes, and if we give the students experience in gathering evidence, we have a chance of increasing the use of evidence-based management in healthcare.

Highlights the "Agenda Setting for Health Care Management Research," conference held in New York City on January 23-24, 2003. Generating research funding; Barriers to using management research; Overcoming barriers to funding.

This article critically reviews published literature on the relationship between income inequality and health outcomes. Studies are systematically assessed in terms of design, data quality, measures, health outcomes, and covariates analyzed. At least 33 studies indicate a significant association between income inequality and health outcomes, while at least 12 studies do not find such an association. Inconsistencies include the following: (1) the model of health determinants is different in nearly every study, (2) income inequality measures and data are inconsistent, (3) studies are performed on different combinations of countries and/or states, (4) the time period in which studies are conducted is not consistent, and (5) health outcome measures differ. The relationship between income inequality and health is unclear. Future studies will require a more comprehensive model of health production that includes health system covariates, sufficient sample size, and adjustment for inconsistencies in income inequality data.

Objective
To assess the contribution of primary care systems to a variety of health outcomes in 18 wealthy Organization for Economic Cooperation and Development (OECD) countries over three decades.

Data Sources/Study Setting
Data were primarily derived from OECD Health Data 2001 and from published literature. The unit of analysis is each of 18 wealthy OECD countries from 1970 to 1998 (total n=504).

Study Design
Pooled, cross-sectional, time-series analysis of secondary data using fixed effects regression.

Data Collection/Extraction Methods
Secondary analysis of public-use datasets. Primary care system characteristics were assessed using a common set of indicators derived from secondary datasets, published literature, technical documents, and consultation with in-country experts.

Principal Findings
The strength of a country's primary care system was negatively associated with (a) all-cause mortality, (b) all-cause premature mortality, and (c) cause-specific premature mortality from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease, and heart disease (p<0.05 in fixed effects, multivariate regression analyses). This relationship was significant, albeit reduced in magnitude, even while controlling for macro-level (GDP per capita, total physicians per one thousand population, percent of elderly) and micro-level (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption) determinants of population health.

Conclusions
(1) Strong primary care system and practice characteristics such as geographic regulation, longitudinality, coordination, and community orientation were associated with improved population health. (2) Despite health reform efforts, few OECD countries have improved essential features of their primary care systems as assessed by the scale used here. (3) The proposed scale can also be used to monitor health reform efforts intended to improve primary care.

Tools for Monitoring the Health Care Safety Net offers strategies and concrete tools for assessing local health care safety nets. With topics ranging from estimating the size of local uninsured populations to using administrative data to presenting information to policymakers, it can assist state and local health officials, planners, and analysts in assessing the capacity and viability of their existing safety net providers as well as understand the characteristics and health outcomes for the populations served.

Les villes de New York, Londres, Paris et Tokyo concentrent une part majeure de l'activité et de la richesse de leurs nations. Elles connaissent une forte densité de population, et notamment de personnes âgées. Elles disposent en outre d'un potentiel en équipement, réseaux et infrastructures de soins médicaux très important par rapport aux autres agglomérations.

Examiner le vieillissement de leur population et comparer les systèmes de santé et de soins dans ces quatre mégapoles est l'objet d'un programme de recherche international, qui vise à s'interroger sur les adaptations des systèmes sanitaires et sociaux à la longévité croissante de la population.

C'est parmi les quatre villes Tokyo qui présente la densité la plus élevée de personnes âgées de 65 ans et plus, mais Paris celle de personnes très âgées (85 ans et plus).

À Tokyo, les personnes âgées vivent également moins souvent seules que dans les autres mégapoles, les centres urbains de Manhattan, Paris et Londres concentrant en particulier une forte proportion de femmes très âgées et vivant seules.

Si ces quatre villes ont un équipement médical et hospitalier plus important en centre urbain qu'en périphérie, la densité en lits médicalisés et de long séjour apparaît inférieure à Londres et à Tokyo.

Les services d'aide à domicile, plus denses dans les centres urbains, sont plus difficiles à comparer mais semblent légèrement mieux assurés dans le centre de Londres.

BACKGROUND AND PURPOSE: The goal of this study was to test whether primary care reduces the impact of income inequality on stroke mortality. METHODS: This study used pooled time-series cross-sectional analysis of 11 years of state-level data (n=549). Analyses controlled for education levels, unemployment, racial/ethnic composition, and percent urban. Contemporaneous and time-lagged covariates were modeled. RESULTS: Primary care was negatively associated with stroke mortality in models including all covariates (P<0.0001). The impact of income inequality on stroke mortality was reduced in the presence of primary care (P<0.0001) but disappeared with the addition of covariates (P>0.05). CONCLUSIONS: In the absence of social policy that addresses sociodemographic determinants of health, primary care promotion may serve as a palliative strategy for combating stroke mortality and reducing the adverse impact of income inequality on health.

Kenya has a rich history of local governance, both from ethnic-group traditions and the system set up during the British colonial era, when local governments were fairly independence (1963), when Kenya's economy and population growth accelerated, demands were so heavy that some local governments could not deliver key services adequately. This situation, combined with the central government's desire for political consolidation to minimize ethnic power conflicts that increased in the postcolonial era, prompted the government to weaken local authorities. Key services (health, education, major roads) were recentralized, and the local graduated personal tax (GPT) was taken over by the center. Grants were established to compensate local governments for their revenue losses, but they were gradually phased out. Control over local governments expanded, with few spending, revenue, or employment decisions permitted without scrutiny by the Ministry of Local Government (MLG).

Studies over the last decade have demonstrated the effectiveness of public health interventions based on social and behavioral science theory for many health problems. Little is known about the extent to which health departments are currently utilizing these theories. This study assesses the application of social and behavioral science to programs in the New York City Department of Health (NYCDOH). Structured open-ended interviews were conducted with executive and program management staff of the health department. Respondents were asked about the application of social and behavioral sciences within their programs, and about the benefits and barriers to increasing the use of such approaches. Themes related to the aims of the study were identified, a detailed coding manual developed, narrative data were coded independently by two investigators (kappa.85), and data analyzed. Interviews were conducted with 61 eligible individuals (response rate 88%). The most common applications of social and behavioral science were individual-level behavior change to prevent HIV transmission and community-level interventions utilizing community organizing models and/or media interventions for health promotion and disease prevention. There are generally positive attitudes about the benefits of utilizing these sciences; however, there are also reservations about expanded use because of resource constraints. While NYCDOH has successfully applied social and behavioral sciences in some areas of practice, many areas use them minimally or not at all. Increasing use will require additional resources. Partnerships with academic institutions can bring additional social and behavioral science resources to health departments and benefit researchers understanding of the health department environment.

Beth Weitzman and Diana Silver from New York University's Center for Health and Public Service Research offer their experience integrating a comparison group design into a theory of change approach.

Objectives. This investigation examined the effectiveness of intensive efforts to include frequently absent students in order to reduce bias in classroom-based studies.

Methods. Grade 10 students in 13 New York City high schools (n = 2049) completed self administered confidential surveys in 4 different phases: a 1-day classroom capture, a 1-day follow-up, and 2 separate 1-week follow-ups. Financial incentives were offered, along with opportunities for out-of-classroom participation.

Results. Findings showed that frequently absent students engaged in more risk behaviors than those who were rarely absent. Intensive efforts to locate and survey chronically absent students did not, however, significantly alter estimates of risk behavior. Weighting the data for individual absences marginally improved the estimates.

Conclusions. This study showed that intensive efforts to capture absent students in classroom-based investigations are not warranted by the small improvements produced in regard to risk behavior estimates.

A population-based Pneumocystis carinii pneumonia (PCP) Index was developed in New York City to identify geographic areas and subpopulations at increased risk for PCP. Methods. A zip code-level PCP Index was created from AIDS surveillance and hospital discharge records and defined as (number of PCP-related hospitalizations)/(number of persons living with AIDS). Results. In 1997, there were 2262 hospitalizations for PCP among 39 740 persons living with AIDS in New York City (PCP Index = .05691). PCP Index values varied widely across neighborhoods with high AIDS prevalence (West Village = .02532 vs Central Harlem = .08696). Some neighborhoods with moderate AIDS prevalence had strikingly high rates (Staten Island = .14035; northern Manhattan = .08756). Conclusions. The PCP Index highlights communities in particular need of public health interventions to improve HIV-related service delivery.

This book takes the conversation between bioethics and health policy to a new level. Moving beyond principles and normative frameworks, bioethicists writing in the volume consider the actual policy problems faced by health care systems, while policy-makers reflect on the moral values inherent in both the process and content of health policy. The result is a vigorous dialogue with some of the nation's leading experts at the interface of ethics and health policy. the book provides a history of the values implicit in U.S. health policy, a discussion of the federal and state roles in policymaking, an ethical examination of the social goals expressed through various policies, an analysis of the role of public opinion in the creation of health policy, and an exploration of the value of the private sector in health policy. In addition, the authors examine some of the major ethical controversies in health policy, such as the challenge of balancing ethical concerns with economic realities, the need to allocate scarce health resources, the call for heightened accountability, and the impact of various policies on vulnerable populations. The book concludes with an examination of the ethical issues in health services research, including the threats to privacy that arise in such research. To a greater extent than any previous volume, it establishes a strong connection between the disciplines of medical ethics and health policy.

A major issue on the national agenda in the United Kingdom is how to improve public services. There is no single, simple solution. A serious commitment to that goal will require additional resources and innovative leadership that can use the funding wisely. Such an effort also will require new organizational forms for the delivery of services. Alternatives to both traditional public bureaucracies and for-profit businesses are likely to be an essential component of designs for more cost effective public services. The Public Management Foundation (PMF) in London is a ‘think tank' that has begun to address the emerging need for new organizational structures. Their suggestion is to develop an entity that they call a ‘public interest company' (PIC). Such a body is proposed as one of many ways to help improve services: ‘Our collective point is that the way in which the British system allows organisations to deliver public services has been too restrictive and a far wider variety of organisational forms for public service delivery needs to be encouraged. The public interest company will be just one of these.'

To the Editor: Hack et al. (Jan. 17 issue)1 report that 20-year-olds who had very low birth weight have a lower rate of risk-taking behavior than their normal-birth-weight peers, and the authors describe this finding as "reassuring." McCormick and Richardson, in their editorial,2 suggest that the avoidance of risk-taking behavior indicates a special "resilience" in very-low-birth-weight children and their families. I disagree.

The purposes of this paper are to (1) review the 24-hour intake of a nationally representative sample of adolescents, (2) describe data from a 24-hour food intake record from a sample of adolescents with diabetes, and (3) discuss the implications of this nutritional information for diabetes health providers.

The American Cancer Society puts it bluntly: "We're fat and it's killing us." Obesity is rising at epidemic rates and, according to a first-ever Surgeon General's report on obesity (issued in 2001), it may soon surpass tobacco as the chief cause of preventable death in the United States. Obesity has been directly linked to heart disease, diabetes, stroke, infertility, and cancer. Each year, obesity costs the nation an estimated $120 billion in medical care and takes some 280,000 lives. Body weight is rising fastest among young Americans-the most dramatic stories feature heart attacks among obese six year-olds.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care and access to care? These core questions regarding our health policy are answered in this text.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care and access to care? These core questions regarding our health policy are answered in this text.

It is no longer clear that the federal government work force can pass the following five tests of a healthy public service, which are that it should be:
-Motivated by the public good, not security or a stable paycheck.
-Recruited from the top of the labor market, not the bottom.
-Given the tools to do its job well.
-Rewarded for a job well done, not just showing up day after day.
-Trusted by the people and leaders it serves.

Consumers dissatisfied with their health plan can either "exit" (switch service providers) or "voice" (complain to the current provider). Policymakers' efforts to help consumers voice their dissatisfaction to health plans or external mediators have been disappointing, in part because little is known about the determinants of voice. This article represents the first comprehensive assessment of voicing in response to problematic experiences with health plans. A national consumer survey from 1999 is used to test hypotheses about characteristics of problems, patients, and settings that might inhibit voice and assess state regulations intended to enhance voice. Although problems associated with plans led to more voice than exit, voice is circumscribed by several factors: certain groups, such as racial minorities, do not express their grievances as often; episodes with severe health consequences for patients are not reported as regularly. The findings suggest that even though regulatory initiatives have not increased the frequency of voice, they have made grievances more effective, at least in jurisdictions where citizens know about the laws.

This study assessed the effectiveness of a sexually transmitted disease (STD)/HIV behavior change intervention in increasing women's use of the female condom. Methods. A total of 604 women at high risk for STDs and HIV in New York City, Baltimore, Md, and Seattle, Wash, enrolled in a randomized controlled trial of a small-group, skills-training intervention that included information and skills training in the use of the female condom. Results. In a logistic regression, the strongest predictors of use were exposure to the intervention (odds ratio [OR] = 5.5; 95% confidence interval [CI] = 2.8,10.7), intention to use the female condom in the future (OR = 4.5; 95% CI = 2.4, 8.5), having asked a partner to use a condom in the past 30 days (OR = 2.3; 95% CI = 1.3, 3.9), and confidence in asking a partner to use a condom (OR = 1.9; 95% CI = 1.1, 3.5). Conclusions. Clinicians counseling women in the use of the female condom need to provide information, demonstrate its correct use with their clients, and provide an opportunity for their clients to practice skills themselves.

Community interventions are rare in the field of sexually transmitted disease (STD) control and prevention. The goals of the Gonorrhea Community Action Project are to design and implement interventions for the reduction of gonorrhea in high-prevalence areas and to increase the appropriateness and effectiveness of STD care in the participating communities. Key to conducting the formative research and developing the interventions was the creation of a community-academic-health department collaborative partnership. Using a staged model, this article presents a case study of collaboration development in the community of Harlem, New York.

The quality of the environment in communities with large minority populations has been a growing concern particularly with respect to public health given the potential for greater
exposure among minorities and the lower availability of health services to address such exposures. A public health and environmental policy analysis is being conducted by the Institute for Civil Infrastructure Systems (ICIS) at New York University's Wagner Graduate School of Public Service (NYU-Wagner) to address some of these issues in the South Bronx. The Wagner School study is part of a larger project funded by the U.S. EPA about environmental issues in the
South Bronx, NY that aims to provide relationships among air quality, transportation, waste transfer activity, and demographic characteristics in the South Bronx.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? Health Care Delivery in the United States, 8 th Edition discusses these and other core issues in the field. Under the editorship of Dr. Kovner and with the addition of Dr. James Knickman, Senior VP of Evaluation, Robert Wood Johnson Foundation, leading thinkers and practitioners in the field examine how medical knowledge creates new healthcare services. Emerging and recurrent issues from wide perspectives of health policy and public health are also discussed. With an easy to understand format and a focus on the major core challenges of the delivery of health care, this is the textbook of choice for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

This report recommends a comprehensive reassessment of federal health policies, programs, and processes, including federal-state roles and relationships, and some immediate actions to promote and protect the nation's health and to provide leadership in world health. The report concentrates on the challenges facing the secretary of the U.S. Department of Health and Human Services (DHHS) as the head of the lead health agency in the federal government. The federal government is responsible for five main functions related to health policy: financing; public health protection; collecting and disseminating information about U.S. health and health care delivery systems; capacity building for population health; and direct management of services.

Unlike the current categorical, or highly specialized, approach leading to policies and programs addressing the needs of a specific population, illness, or organizational constituency, a new, comprehensive approach to policy for the 21st century should promote coordinated efforts across programs in order to achieve three goals:

* create conditions that lead to longer, healthier lives for all Americans;
* eliminate health disparities;
* protect communities from avoidable health hazards and help them to address their own health problems.

This report analyzes the administrative complexities and problems that limit the impact of the subsidized health insurance programs available to New Yorkers. It recommends reform strategies and calls on the Governor to assign responsibility to the State Health Commissioner for redesigning the system.

This article uses data from the Health and Retirement Study to examine the employment patterns of workers aged 50 and above who have experienced an involuntary job loss. Hazard models for returning to work and for exiting post-displacement employment are estimated and used to examine work patterns for 10 years following a job loss. Our findings show that a job loss results in large and lasting effects on future employment probabilities. Four years after job losses at age 55, the employment rate of displaced workers remains 20 percentage points below the employment rate of similar nondisplaced workers.

Managers of a healthcare organization have numerous demands on their time, their skills, their knowledge, and their budgets. They are responsible for adapting to change, managing their office, making effective decisions, among countless other tasks.

This book, newly revised to include readings, commentary, and cases, offers a bridge from management theory to the actual world of healthcare management. Throughout its past editions, Health Services Management has featured the best literature on health services management to help readers understand the role of the manager, organizational design and control, the blending of organization and health professionals, change (adaptation), and responsiveness (accountability). This edition continues that effort, and features new readings.

This book helps nurses develop and refine good budgeting skills - a necessity in today's economy-driven health care system. Clearly written and thoroughly understandable, this new edition shows first-line nurse managers and their immediate supervisors how to work effectively with financial staff and management, and how to develop, monitor, and maintain departmental and institutional budgets. It is written at a level that assumes no previous financial management experience or expertise on the part of the reader.

One of the few books that addresses financial and managerial accounting within the three major areas of the public sector � government, health, and not-for-profit�the Second Edition provides the fundamentals of financial management for those pursuing careers within these fields. With a unique presentation that explains the rules specific to the public sector, this book outlines the framework for readers to access and apply financial information more effectively. Employing an engaging and user-friendly approach, this book clearly defines essential vocabulary, concepts, methods, and basic tools of financial management and financial analysis that are imperative to achieving success in the field. This book is intended for financial managers and general managers who are required to obtain, understand, and use accounting information to improve the financial results of their organizations, specifically within the areas of government or public policy and management, not-for-profit management, and health policy and management.

The superior performance of HMOs in providing preventive care--both in the population at-large (Miller and Luft, 1994), and within the elderly Medicare population (Ballard et al., 1997; Potosky et al., 1998; Retchin and Brown, 1990)--may be due to the favorable organizational, infrastructural, or cultural characteristics of managed care systems. For example, HMOs have historical roots in a health maintenance and wellness orientation (Lawrence, Mattingly, and Ludden, et al., 1997). HMOs also encourage patients to have a primary care provider, and they have been leaders in the use of technologies like computerized reminder systems, which are effective in promoting the regular use of preventive care services (Mandelson and Thompson, 1998). However, other factors may also contribute to HMO successes in the preventive care arena. Managed care enrollees typically face few financial barriers to care. To the extent that HMOs offer no-cost or low-cost preventive care services, and to the extent that cost is a barrier to receiving preventive care in the FFS sector, HMOs are likely to perform better. It is also possible that those who enroll in HMOs are attitudinally and behaviorally more receptive to preventive care. For example, some studies have found HMO enrollees to be better educated, healthier, and more optimistic about the benefits of preventive care than their FFS counterparts (Bernstein, Thompson, and Harlan, 1991; Porrell and Turner, 1990; Lichtenstein et al., 1992).

Focuses on the importance of adequate management information for the performance of hospital boards in the United States. Responsibilities of board members in healthcare organizations; Adaptation of organization mission and strategy; Key recommendations to board members and managers.

Managers of a healthcare organization have numerous demands on their time, their skills, their knowledge, and their budgets. They are responsible for adapting to change, managing their office, making effective decisions, among countless other tasks. This text-newly revised to include readings, commentary, and cases-offers a bridge from management theory to the actual world of healthcare management that will help your students learn the role of manager in a healthcare organization.

This book of updated cases emphasizes a manager's need for skills in strategy, operations, and relations. To aid both professors and students, the cases are divided into the same categories as are used in Health Services Management: Readings and Commentary, Seventh Edition: role of the manager, control, organizational design, professional integration, adaptation, and accountability. All of the cases have been tested in the classroom.

Social capital has become a popular subject in the literature on determinants of health. The concept of social capital has been used in the sociological, political science, and economic development literatures, as well as in the health inequalities literature. Analysis of its use in the health inequalities literature suggests that each theoretical tradition has conceptualized social capital differently. Health researchers have employed a wide range of social capital measures, borrowing from several theoretical traditions. Given the wide variation in these measures and an apparent lack of consistent theoretical or empirical justification for their use, conclusions about the likely role of "social capital" on population health may be overstated or even misleading. Elements of a research agenda are proposed to further elucidate the potential role of factors currently subsumed under the rubric of "social capital."

Performance measures are central to managing infrastructure assets, since they provide quantitative benchmarks and express values and preferences that are important for decision making. For example, one performance measure for decisions on upgrading an electrical power line is the improvement in service reliability, measured in terms of annual customer interruption hours. This paper first presents an overall framework for developing performance measures for infrastructure decision-making. The framework is then illustrated with an example that involves a decision of whether or not to place overhead power lines underground in order to improve performance measured as service reliability, health and safety, operation and maintenance cost, and impacts on property values.

The international scientific community has begun to focus upon the reality of global climate change and sophisticated research techniques provide increasingly accurate models of the potential impacts of associated weather extremes, disease outbreaks, and global and local environmental destruction. Yet decision-making institutions have not, for the most part, incorporated global climate change in their policies and planning efforts. This report presents the implications of climate change, thus far considered largely in a global context, in very local terms. As research and discussion of climate change begin to focus on anticipated regional impacts, decision-makers in the Metropolitan East Coast (MEC) Region and elsewhere should begin to consider and implement practical adaptation policies affecting land use, infrastructure, natural resource management, public health, and emergency and disaster response.

The basic facts are increasingly well-known. Young children (under 6 years of age) have the highest poverty rates of any age group in the United States (Shirk, Bennett, & Aber, 1999) and in most other major Western industrialized democracies (Rainwater & Smeeding, 1995). In addition, poverty experienced in early childhood, especially extreme poverty, is more detrimental to children's future development than poverty experienced later in life (Duncan, Brooks-Gunn, & Klebanov, 1994). And, although it is difficult to tease out the effects of family-level poverty compared to that of neighborhood-level poverty, when researchers do so, it appears that family-level poverty has the stronger influence on children's development, including their mental health (Aber, 1994; Brooks-Gunn, Duncan & Aber, 1997).

Objective. We sought to understand why certain Medicaid managed care organizations (MMCOs) implemented child development services or programs and how they had done so. We also sought to identify barriers and facilitators to successful initiation and implementation of child development programs.

Methods. We conducted 9 key informant interviews and 4 site visits, and performed qualitative analyses to identify major themes across responses.

Results. We identified a small number of MMCOs with child development services. High-level support was crucial for program initiation; physician buy-in, staff support, and strong working relationships with outside health professionals or agencies were principal factors in successful program implementation.

Conclusions. MMCOs that were committed to implementing child development services were successful in doing so, without external funding or regulatory mandate. The results provide valuable strategies for MMCOs interested in developing programs and for researchers and advocates interested in promoting child development services for low-income children. Key words: Medicaid managed care, child development services.

In the absence of universal coverage and an effective primary care delivery system for vulnerable populations, hospital emergency departments (EDs) are the ultimate safety net for many patients. This is especially true in New York City, where nearly 75 percent of ED visits in 1998 were for nonemergent care, or for emergent care that could have been treated in a doctor's office.1 Another 7 percent of visits required care in the ED, but were for potentially preventable conditions such as acute flare-ups of asthma or diabetes. New Yorkers who rely on EDs lack continuity in their health care and end up using costlier services. Why do so many patients depend on hospital emergency departments for primary care? Do they seek emergency care immediately, or do they have time and opportunity to obtain care at a doctor's office or neighborhood clinic? Do these patients have a usual source of care other than the ED? Do they have any contact with the health care system prior to their ED visit? Does insurance status, race, ethnicity, national origin, or gender have an influence on ED use?

To answer these questions, the Center for Health and Public Service Research at New York University conducted face-to-face interviews with 669 emergency department patients ages 18 to 55 at four hospitals in the Bronx.

The inability of the nation's health care delivery system to assure access to basic primary care services for large segments of the population has meant that hospital emergency departments (EDs) are the providers of first and last resort for millions of Americans. Individuals who cannot afford the cost of an office visit, or who are unwilling to wait for care in overcrowded and understaffed community clinics or hospital outpatient departments, rely on EDs for primary care. But reliance on the ED means patients lack continuity in their health care and use costlier services. Moreover, economic constraints cause many of the uninsured to delay seeking treatment until their medical condition has seriously worsened. Had they received treatment earlier in an ambulatory care setting, the trip to the ED might have been avoided.

For the uninsured and many low-income people, hospital emergency departments (EDs) are a crucial entryway to the health care system. New York City's uninsured-27 percent of the nonelderly population in 1998, up from 20 percent in 1990-rely heavily on the ED for their medical care. Residents who regularly get their health care at an ED do not have regular doctors or continuity in their care, use costlier services, and often receive treatment that could have been avoided. Low-income New Yorkers may be depending on emergency department care even more as Medicaid enrollment declines and physician reimbursement rates are cut. This Issue Brief describes patterns of ED use throughout
New York City and discusses some of the ways to improve the availability of primary care services and reduce ED dependency.

Two key questions are addressed regarding the intersection of socioeconomic status, biology, and low birth weight over the life course. First, do the income and other socioeconomic conditions of a mother during her pregnancy affect her chances of having a low-birth-weight infant net of her own birth weight, that of the father, and other family-related, unobserved factors? Second, does an individual's birth weight status affect his or her adult life chances net of socioeconomic status? These questions have implications for the way we conceive of the relationship between socio- economic status and health over the life course, specifically in sorting out causal directionality. We use intergenerational data from the Panel Study of Income Dynamics, for the years 1968 through 1992. Results of sibling comparisons (family- fixed-effects models) demonstrate that maternal income does not appear to have a significant impact on birth weight. However, low birth weight results in lower educational attainment net of other factors. These findings suggest that, when considered across generations, causality may not be as straightforward as implied by cross-sectional or unigenerational longitudinal studies.

This paper explores the relationship between racial segregation and racial disparities in the prevalence of low birth weight. The paper has two parallel motivations. First, the disparities between black and white mothers in birth outcomes are large and persistent. In 1996, 13 percent of infants born in the United States to black mothers weighed less than 2,500 grams (5.5 pounds, or low birth weight), compared with just 6.3 percent of all infants born to white mothers. And the consequences may be grave. Low birth weight is a major cause of infant mortality and is associated with greater childhood illness and such developmental disorders as cerebral palsy, deafness, blindness, epilepsy, chronic lung disease, learning disabilities, and attention deficit disorder. 1 Given the strong connection between race and residence in this country, it seems plausible that residential location may shape these differentials.

Second, while there is a growing literature on the costs of racial segregation, it has largely focused on economic outcomes such as education and employment. This paper aims to develop a fuller understanding of the costs of racial segregation by considering birth outcomes as well as such behaviors as tobacco and alcohol use among pregnant mothers. As Glaeser emphasizes (in his paper in this volume), information, ideas, and values are often transmitted through face-to-face interaction, and thus their transmission may be blocked by segregation. This includes information related to job openings and may include information and norms related to behavior and care during pregnancy.

Adopting in large part the methodology of David Cutler and Edward L. Glaeser, the paper thus examines how levels of racial segregation affect the birth outcomes of black mothers. 2 It examines influences on both black and nonblack mothers in an attempt to identify the differential effect of segregation on black mothers.

In recent years, it has become common for physicians to become managers of new programs and ventures. In some cases, the physician is acting as a manager of a large organization, such as a hospital, nursing home, or integrated delivery system. In other cases, the physician my be acting as an owner of a sole or group practice. In all cases, the physician decision maker needs tools to ascertain the likely profitability of the new programs and ventures. Break-even analysis can be a helpful tool in such situations.

Covering the financial topics all nurse managers need to know and use, this book explains how financial management fits into the healthcare organization. You'll study accounting principles, cost analysis, planning and control management of the organization's financial resources, and the use of management tools.

A letter to the editor and a response to the letter by Nancy L. Van Devanter about the shortage of public health professionals and the need to support efforts to enhance public health training are presented.

This study evaluates the effectiveness of two strategies�communication and condom skills training�for increasing condom-protected sex in a sample of 510 high-risk women ages 17 to 61. Baseline and 3- and 6-month postintervention interview data were gathered in three cities participating in a randomized trial of a six-session, group skill-building intervention. This analysis was conducted for the entire sample and for six subgroups categorized by age, single or multiple partners, and history of childhood sexual abuse. The dependent variable was the odds ratio of protected sex acts at each follow-up. Structural equation modeling was used to estimate effects for two intervention pathways. The pathway through condom skills increased the odds of protected sex for the intervention group (2 difference = 35, df = 2, p < .05) as well as for all subgroups. The pathways through communication were significant for the intervention group (2 difference = 23, df =3, p < .05) but fully effective only for participants under 30 and participants who reported childhood sexual abuse. The effectiveness of both pathways diminished at 6 months. WINGS demonstrates that condom skills training can increase protected sex for a heterogeneous group of women. Further research needs to examine how such skill training translates into use of condoms by male partners. To increase the duration of intervention effects, booster sessions may need to be incorporated.

This issue brief based on findings from The Commonwealth Fund 1999 National Survey of Workers' Health Insurance reports that most Americans believe employers are the best source of health coverage and that they should continue to serve as the primary source in the future. Almost all of those surveyed also favored the government providing assistance to low-income workers and their families to help them pay for insurance.

Learn the professional and personal skills necessary to succeed as a healthcare executive. This book covers everything from finding your niche to working with clinicians. Topics covered include: * Where health services managers work * How to build an ideal career * What skills make a good manager * How to manage physicians, boards, and others * How to advance within an organization and within the industry

Explores the concept of evidence-based management, demonstrates how it can enhance health management practice, and introduces an organizational structure for promoting the evidence-based approach. Challenge of making better-informed strategic decisions; Management research in healthcare; Approaches related to evidence-based management; Evidence-based management decision making; Case vignettes.

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? These core issues regarding our health policy are answered in this text.This is a textbook for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

Improvements in health care and declining birth rates have combined to create rapidly aging populations throughout the industrialized world. By 2020, for example, nearly seventeen percent of the US population is expected to be over the age of sixty-five. In Japan that mark has already been passed, with more than one-quarter of the population expected to be over sixty-five by 2020. At the same time, the world's population is increasingly concentrated in urban areas: the United Nations estimates that by 2025, sixty-one percent of the world's population will live in cities. As both urbanization and population aging increase, we will need models of how to accommodate this population shift and examples to emulate in dealing with these phenomena.

Thoroughly presents today's health care system, its administration and its dissemination.

Approximately 3.1 million State residents (one of every six New Yorkers) have no health insurance. This report describes the uninsured population in New York State and the public programs that currently finance medical care for the uninsured. It also identifies the inadequacies of these programs and makes recommendations for reform.

Essentials of Cost Accounting for Health Care Organizations, Second Edition is a comprehensive text that applies the tool and techniques of cost accounting to the health services field. It is an essential tools for all professionals who need to deal with the challenges of managing health facilities in a difficult economic environment.

How to secure an adequate measure of unity among citizens in a liberal democratic state? Versions of this question formed the brunt of communitarian critiques of liberalism over the past two decades. Most liberal respondents took aim in return at communitarians' own vision of a healthy political society, while others emphasized the shared values or purposes indigenous to the liberal tradition. Yet as the liberal/communitarian debate dissolves into a common center, it appears that this immense body of theoretical exchanges has left the problem of national union no closer to solution. Liberal theorists now affirm this issue's centrality; as Will Kymlicka writes, "[i]dentifying the bases of social unity in multinational states is... one of the most pressing tasks facing liberals today." Meanwhile, communitarians like Michael Sandel have come to acknowledge the importance of a national, not only neighborhood, sense of mutual trust and solidarity. But no coherent principled or practical unionist design has emerged from the two sides' convergence.

Water pollution from agricultural pesticides continues to be a public concern. Given that the use of such pesticides on the farm is largely governed by voluntary behavior, it is important to understand what drives farmer behavior. Health belief models in public health and social psychology argue that persons who have adverse health experiences are likely to undertake preventive behavior. An analogous hypothesis set was tested here: farmers who believe they have had adverse health experiences from pesticides are likely to have heightened concerns about pesticides and are more likely to take greater precautions in dealing with pesticides. This work is based on an original survey of a population of 2700 corn and soybean growers in Maryland, New York, and Pennsylvania using the U.S. Department of Agriculture data base. It was designed as a mail survey with telephone follow-up, and resulted in a 60 percent response rate. Farm operators report experiencing adverse health problems they believe are associated with pesticides that is equivalent to an incidence rate that is higher than the reported incidence of occupational pesticide poisonings, but similar to the reported incidence of all pesticide poisonings. Farmers who report experiencing such problems have more heightened concerns about water pollution from fertilizers and pesticides, and illness and injury from mixing, loading, and applying pesticides than farmers who have not experienced such problems. Farmers who report experiencing such problems also are more likely to report using alternative pest management practices than farmers who do not report having such problems. This implies that farmers who have had such experiences do care about the effects of application and do engage in alternative means of pest management, which at least involve the reduction in pesticide use.

The effectiveness of current groundwater protection policies depends largely on farmers' voluntary compliance with leaching reduction measures, an important component of which is their willingness to adopt costlier production practices in order to prevent leaching of chemicals. Data from an original survey of 1611 corn and soybean growers in the mid-Atlantic region were used to estimate farmers' willingness to pay to prevent leaching of pesticides into groundwater. The results indicate that farmers are willing to pay more for leaching prevention than nonfarm groundwater consumers, both absolutely and relative to total income. The primary motivation appears to be concern for overall environmental quality rather than protection of drinking water or the health and safety of themselves and their families. Hobby farmers are willing to pay more than farmers with commercial activity. Certified pesticide applicators are willing to pay less than farmers without certification.

Objective
To assess the extent of physical disability in juvenile rheumatoid arthritis (JRA), classified according to subtype, and whether synovitis or flexion contractures are present on examination.

Methods
This retrospective study included 88 JRA patients and 50 controls without musculoskeletal disease. The outcome measure was the disability index (DI) derived from the Childhood Health Assessment Questionnaire (CHAQ).

Results
DI scores for JRA patients with synovitis (mean 0.49, range 0-1.88) and without synovitis (mean 0.37, range 0-1.75) were significantly higher (P < 0.001 for both groups) than for controls (mean 0.06, range 0-0.75, P < 0.001), but not significantly different from one another. Similarly, DI scores for JRA patients with and without any flexion contractures were higher than for controls, but not significantly different from one another. DI scores for JRA patients with both synovitis and flexion contractures were significantly higher than DI scores for JRA patients with neither, but were not distinguishable from JRA patients with synovitis only or flexion contractures only. Likewise, DI scores for JRA patients lacking synovitis and flexion contractures were not significantly different than those for JRA patients with one or the other. DI scores for systemic and polyarticular patients were higher than for pauciarticular patients, and DI scores for all 3 subtypes were higher than for controls.

Conclusion
Our findings suggest that many JRA patients, including those with pauciarticular JRA, have problems with physical function, even when synovitis and flexion contractures are not present. Further attention and research is needed to elucidate the causes or origins of disability in JRA patients with seemingly well-controlled disease. We recommend that health status instruments like the CHAQ be more widely used for JRA patients to complement other assessments, especially in planning occupational and physical therapy.

This article reflects on a need for social and behavioral science expertise in public health departments in the U.S. for the prevention of sexually transmitted diseases (STD). In the developed world, the U.S. has the highest rates of STD, higher than for some developing countries. As a result of sexual behaviors, which are shaped by social and environmental factors in communities, individuals are at risk for STD. A landmark report by the Institute of Medicine in 1997 concluded that the outbreak of STD is influenced by the lack of awareness among the general public, lack of skills and training among health professionals and the absence of an effective national system for the prevention of STD.

Study objectives: The purpose of this study was to confirm the validity of a brief screen for pediatric asthma in schools.

Background: Asthma is the most common chronic disease of childhood, yet the frequency with which this condition is recognized among school-aged children varies widely. Several methods are used to increase the accuracy of detection of asthma, but many are cumbersome and difficult to apply on a large scale.

Design: We elected to validate a five-question instrument, the Brief Pediatric Asthma Screen (BPAS), to screen for the presence of asthma among children attending school in Region 5 of the Chicago school district, where the schools report a 2.7% frequency of asthma. The questionnaire was distributed to the parents of grade-school children at the time of report-card pick-up.

Setting: A clinical assessment was performed on a selected group of children whose parents completed the questionnaire in a school and in a hospital outpatient clinic.

Participants: Of 4,147 questionnaires that we distributed, 1,796 (43%) were returned. We excluded 341 children (19% of the total sample) whose parents reported that they had been diagnosed with asthma. The remaining pool indicated that the children of 183 responders (10%) had symptoms suggestive of asthma, while 1,272 parents (71%) indicated that their children did not have symptoms of asthma.

Measurements and results: We selected 90 of the respondents who did not indicate that their children had a diagnosis of asthma. Of this group, 81 completed the validation, in which their responses suggested symptoms of asthma (n = 34) or no asthma symptoms (n = 47). The children of these respondents were given a blinded clinical evaluation consisting of history, physical examination, and spirometry. The survey demonstrated a sensitivity of 75% and a specificity of 81.2% for the presence of asthma among those who were unaware of the diagnosis.

Conclusions: The BPAS is brief, can be filled out by parents, and appears accurate in detecting asthma.

To determine the effects of aspects of residency training on AIDS-related treatment practices. METHOD: The authors conducted a nationwide longitudinal panel study of 394 physicians who graduated in 1989 from six medical schools in New York State. Data were collected during the participants' fourth year of medical school, their third year of residency training, and six years after they had graduated from medical school. Questionnaires sought information about AIDS-related practice behaviors, including avoiding invasive procedures, minimizing contact, emphasizing AIDS prevention and education, and volume of people with AIDS treated. RESULTS: Aspects of residency training had a sustained impact on how the physicians cared for patients with AIDS but not on the numbers of patients they treated. Determinants of treatment practices included aspects of the residency environment (e.g., emphasis on problem solving, student orientation; p < .01), characteristics of the faculty (e.g., commitment to teaching, tolerance of varied viewpoints), cynicism about patient care (p < .001), social biases (homophobia and aversion to intravenous drug users; p < .001), and AIDS-related attitudes (p < .01). CONCLUSIONS: Fundamental changes to residency training, all of which are associated with learner-centered education, can improve physicians' treatment of their patients with HIV and AIDS.

This book is a collection of 18 essays by health services researchers that analyze Medicaid managed care, its historical context, its implementation in several states, its applicability to disabled and other special needs populations, and its potential for monitoring quality and provider performance.

Text discussing disability research from a life course perspective and emphasizing the reality that people of all ages are at risk of being disabled. For policy makers and researchers.

When capital and labor markets are imperfect, choice sets narrow, and parents must choose how to ration available funds and time between their children. One consequence is that children become rivals for household resources. In economies with pro-male bias, such rivalries can yield gains to having relatively more sisters than brothers. Using a rich household survey from Ghana, we find that on average if children had all sisters (and no brothers) they would do roughly 25-40% better on measured health indicators than if they had all brothers (and no sisters). The effects are as large as typical quantity-quality trade-offs, and they do not differ significantly by gender.

Explains several accounting approaches for healthcare organizations planning to acquire physician and ambulatory care practices. Acquisition arrangements; Historical cost; Constant dollar value; Replacement/economic cost; Opportunity-cost approach; Income approach; Enhancement opportunities.

To develop and validate a measure of contemporary life stressors. STUDY SETTING: Three interview studies: Study 1 (pilot), 32 caregivers receiving case management services for a child with chronic illness; Study 2 (validation), 311 caregivers of children receiving general pediatric care at a university clinic; Study 3 (reliability), 17 caregivers of children with a complex medical diagnosis. STUDY DESIGN: Study 1: item development via discussions with case managers; piloted with caregivers. Study 2 examined psychometric properties of the measure and correlated it with the CES-D, a measure of depressive symptomatology and the PRQ85-Part 2, a measure of perceived social support, to establish its convergent construct validity. Study 3 established the test-retest reliability of the measure over two weeks by correlating two administrations of the index. DATA COLLECTION: Face-to-face interviews in homes (Study 1) or in clinic waiting rooms (Studies 2 and 3) and by telephone (Study 3 retest). PRINCIPAL FINDINGS: The CRISYS is a flexible, multidimensional tool that demonstrates strong face, content, and construct validity, and excellent test-retest reliability. The format is easy to use and well accepted by respondents and is suitable for low-income populations. CONCLUSIONS: Researchers will find the CRISYS useful when evaluating the success of a clinical model or a healthcare system, and the effectiveness of an insurance plan or a government program. Clinicians may also find that the CRISYS is an effective screen for family needs.

This study examined predictors of entry onto shelter and subsequent housing stability for a cohort of families receiving public assistance in New York City. Methods. Interviews were conducted with 266 families as they requested shelter and with a comparison sample of 298 families selected at random from the welfare caseload. Respondents were reinterviewed 5 years later. Families with prior history of shelter use were excluded from the follow-up study. Results. Demographic characteristics and housing conditions were the most important risk factors for shelter entry; enduring poverty and disruptive social experiences also contributed. Five years later, four fifths of sheltered families had their own apartment. Receipt of subsidized housing was the primary predictor of housing stability among formerly homeless families (odd ratio [OR] = 20.6, 95% confidence interval [CI]= 9.9, 42.9). Conclusions. Housing subsidies are critical to ending homelessness among families.

Poverty has been shown to negatively influence child health and development along a number of dimensions. For example, poverty-net of a variety of potentially confounding factors-is associated with increased neonatal and post-neonatal mortality rates, greater risk of injuries resulting from accidents or physical abuse/neglect, higher risk for asthma, and lower developmental scores in a range of tests at multiple ages.

Despite the extensive literature available that addresses the relationship between poverty and child health and development, as yet there is no consensus on how poverty should be operationalized to reflect its dynamic nature. Perhaps more important is the lack of agreement on the set of controls that should be included in the modeling of this relationship in order to determine the "true" or net effect of poverty, independent of its cofactors. In this paper, we suggest a general model that should be adhered to when investigating the effects of poverty on children. We propose a standard set of controls and various measures of poverty that should be incorporated in any study, when possible.

Explores approaches in improving the effectiveness of nonprofit hospitals' boards of trustees as shown by the Alpha Health Care System and Beta Hospital. Kellogg project on effective governance; Factors influencing changes; Board assessment; Initiation of board development; Importance of time management; Chief executive officer's support to strengthen board effectiveness.

Part of the Controversial Issues series, this text presents a series of clear and lively debates on current issues in gerontology, authored by leading academic authorities in the field. The text presents a broad overview of issues and questions facing the field, including areas of policy/programs, health, social services, professional and family life, and more. The debates are current and very readable; the text is "user-friendly," and was designed to stimulate student discussion, debate, as well as critical thinking. The text is a "must" for students considering careers in the field of gerontology. The non-technical, brief and lively format of the debates makes them accessible to all students. Issues covered include whether or not to legalize suicide; whether to reduce Social Security benefits; whether to institute means-testing for Medicare; whether affirmative action programs should be instituted for older persons; and the potential dismantling of the aging services network.

Many interesting economic hypotheses entail differences in behaviors of groups within a population, but analyses of pooled samples shed only partial light on underlying segmentations. Finite mixture models are considered as an alternative to methods based on pooling. Robustness checks using t-regressions and a Bayesian analogue to the likelihood ratio test for model evaluation are developed. The methodology is used to investigate pro-son bias in child health outcomes in Bangladesh. While regression analysis on the entire sample appears to wash out evidence of bias, the mixture models reveal systematic girl-boy differences in health outcomes.

In a randomised clinical trial, quality of health care as reflected in patient outcomes and cost of health care was compared between two groups of high-risk childbearing women: women diagnosed with diabetes or hypertension in pregnancy. The control group was discharged routinely from the hospital. The intervention group was discharged early using a model of clinical nurse specialist transitional follow-up care. During pregnancy, the intervention group had significantly fewer rehospitalisations than the control group. For infants of diabetic women enrolled in the study during their pregnancy, low birth weight was three times more prevalent in the control group than in the intervention group. The postpartum hospital charges for the intervention group were also significantly less than for the control group. The mean total hospital charges for the intervention group were 44 percent less than for the control group. The mean cost of the clinical specialist follow-up care was two percent of the total hospital charges for the control group. A net savings of $13,327 was realised for each mother-infant dyad discharged early from the hospital.

Reports on the rates of preventable hospital admissions among low-income populations in the United States even with the efforts of improving primary health care. Comparison of low-income populations health outcomes between U.S. and Canada; Implications of results for U.S. policy makers.

The purpose of this study was to assess the relationship between syphilis and human immunodeficiency virus (HIV) infection in injection drug users. Methods. A 6-year prospective study of 790 injection drug users receiving methadone maintenance treatment in the Bronx, NY, was conducted. Results. Sixteen percent (4/25) of HIV-seroconverting patients, 4.8% (16/335) of prevalent HIV-seropositive patients, and 3.5% (15/430) of persistently HIV-seronegative patients were diagnosed with syphilis. Incidence rates for early syphilis (cases per 1000 person-years) were 15.9 for HIV-seroconverting patients, 8.9 for prevalent HIV-seropositive patients, and 2.9 for persistently HIV-seronegative patients. Early syphilis incidence was higher among women than men (8.4 vs 3.2 cases per 1000 person-years). Independent risks for early syphilis included multiple sex partners, HIV seroconversion, paid sex, and young age. All HIV seroconverters with syphilis were female. Conclusions. Diagnosis of syphilis in drug-using women reflects high-risk sexual activity and is associated with acquiring HIV infection. Interventions to reduce the risk of sexually acquired infections are urgently needed among female drug users.

Examines a demonstration program to develop skills and experience for middle managers ar a mid-sized urban hospital in the United States. Background information on the management development program at the New York Downtown Hospital; Participation by middle and senior management; Program curriculum; Program weaknesses, opportunities, threats; Recommendations for replication.

This case examines the expanding role of managed care programs in improving health care for the poor while controlling runaway health care costs. The case asks what the commissioner of health in a large eastern state should do to effectively monitor Medicaid managed care programs in her state. The commissioner faces intense pressures for cost containment and strong, but not universal, support for the managed care solution to health care cost problems. The commissioner is herself concerned that the cost savings attributed to managed care may not be real and that the unintended effects on health care may be adverse. Her immediate challenge is to determine what kinds of data she should require service providers to submit to her agency so that she may effectively monitor managed care programs for health care quality, provide positive feedback to health care providers, and establish politically credible program oversight.

Few instruments exist for the assessment of adolescent mental health. In order to examine the appropriateness of the Mental Health Inventory (MHI) for use with adolescents, secondary analyses were conducted of the large subsample (n = 953) of adolescents who participated in the community-based Rand Health Insurance Study. The reliability and readability of the MHI were confirmed. Subscales reflecting Psychological Well-Being and Psychological Distress were derived. The MHI, with its adolescent norms, is recommended for the assessment of adolescent mental health, particularly in studies in which comparison to a nonpsychiatric, normative adolescent population is indicated.

The impact of training on physicians' commitment to professional values is examined, using a cohort design to assess the evolution of attitudes toward AIDS during residency training. Cohorts of surgeons training in the same six residency programs were followed at key junctures, and their outlooks on three AIDS-related attitudes were examined: willingness to treat people with AIDS (PWAs), concern about exposure to HIV, and perceived benefits of treating AIDS. The findings revealed a consistent, negative impact of training on all three attitudes. Cohort and period (historical) effects were limited: younger cohorts more often viewed treating PWAs as a clinically valuable experience, and greater concern about exposure was evidenced as training progressed. The findings yield new evidence of the importance of residency training to professional socialization. More knowledge of alterable aspects of residency training that play a role is key to assuring that physicians emerge with a dedication to fulfilling their social responsibilities.

Understanding the impact of training on the development of physicians' attitudes toward AIDS is important to furthering our knowledge of the mechanisms through which socialization affects professional outlook, as well as promoting an adequate supply of providers to treat people with AIDS (PWAs). This prospective panel study collected data on 383 physicians at two critical stages: as fourth year medical students and as third-year residents. Aspects of residency training (e.g., residents' morale and positive faculty role models) were the most powerful predictors of increase in willingness was primarily a product of negative social attitudes - homophobia and IVDU-phobia (aversion to intravenous drug users). Cynicism toward patient care acted as a trigger activating the negative effects of IVDU-phobia; having an acquaintance who is HIV positive mediated the negative impact of homophobia. Notably, cynicism was associated with basic aspects of training (specific characteristics of the faculty and of the educational milieu). The findings support a view of socialization as pervasive process implicating intrinsic aspects of training and having an impact on a broad spectrum of outlooks. Accordingly, interventions must address structural characteristics that transcend AIDS-specific concerns.

The objective is to examine whether the higher hospital admission rates for chronic medical conditions such as asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes in low-income communities resulted from community differences in access to care, prevalence of the diseases, propensity to seek care, or physician admitting style.

This report examines the high cost of City health insurance. The approach includes both an historical review of the City's program and comparative analysis of the practices of other large public and private employers. The report recommends structural reforms that would yield nearly $600 million in recurring savings and still provide employees and retirees with benefits better than most of their counterparts in government and business.

Talks about the significance of capitated arrangements in hospitals. Detail about the financial incentives under capitation.

Thoroughly presents today's health care system, its administration and its dissemination.

Reports that environmental epidemiology increasingly is being used as a foundation for environmental health policy. Approaches to interpretation; Rules of evidence; Meta-analysis; Relationship between disease and risk factors; Studies compared; Chemicals at forefront of health policy debates; Dioxins; Benzene; Formaldehyde; Expanding number of health effects; Exposure specificity.

The use of meta-analysis in environmental epidemiology can enhance the value of epidemiologic data in debates about environmental health risks. Meta-analysis may be particularly useful to formally examine sources of heterogeneity, to clarify the relationship between environmental exposures and health effects, and to generate information beyond that provided by individual studies or a narrative review. However, meta-analysis may not be useful when the relationship between exposure and disease is obvious, when there are only a few studies of the key health outcomes, or when there is substantial confounding or other biases which cannot be adjusted for in the analysis. Recent increases in the use of meta-analysis in environmental epidemiology have highlighted the need for guidelines for the application of the technique. Guidelines, in the form of desirable and undesirable attributes, are presented in this paper for various components of a metaanalysis including study identification and selection; data extraction and analysis; and interpretation, presentation, and communication of results, Also discussed are the appropriateness of the use of meta-analysis in environmental health studies and when metaanalysis should or should not be used.

Understanding more about the psychological state of persons notified of human immunodeficiency virus (HIV) infection is critical for designing notification and counseling programs that will have the most positive effect. Methods. The subjects were blood donors who had been notified of HIV infection by the New York Blood Center. A nurse elicited a medical history, performed a limited medical examination, and asked the subjects to complete a questionnaire that included questions about drug use, sexual behavior, and psychological characteristics. The subjects completed another questionnaire approximately 2 weeks later. Results. The average depressive symptom scores for both men and women were substantially higher than scores typically found in representative population samples. More than a quarter of the men and more than a third of the women reported seeking psychological or psychiatric services in the first few weeks following notification. Conclusions. Anticipating and meeting individuals' psychological needs may be necessary if HIV screening programs are to address effectively the needs of persons infected with HIV.

To learn more about how people who did not volunteer for testing react to information about HIV infection, we assessed short-term behavior changes in HIV-positive blood donors. Methods. Blood donors who were notified at the New York Blood Center that they were HTV positive were asked to participate in a study. A nurse elicited a medical history, performed a limited medical examination, and asked participants to complete a questionnaire that included questions about drug use, sexual behavior, and psychological characteristics. Participants were asked to return in 2 weeks to complete another questionnaire. Results. Many fewer men and women reported engaging in unsafe sexual behaviors in the 2 weeks preceding the follow-up visit than had reported such behaviors prior to notification. These changes were greater than those other investigators have reported, but about 40% of the participants still reported unsafe sexual activity at the follow-up interview. Conclusions. To make nonvolunteer screening programs for HIV infection more effective in reducing the spread of HTV infection, we need to learn more about how to help people change their high-risk behaviors.

This paper describes the sociodemographic and behavioral characteristics of 173 blood donors who were confirmed by Western blot tests to have antibodies to human immunodeficiency virus (HIV), the etiologic agent for acquired immunodeficiency syndrome (AIDS). Seropositive donors were predominately young, unmarried, and male, and major risk factors could be identified for almost all donors. However, more than 20 per ¢ of the study participants were women, and many participants were not aware that they were at risk of infection. The heterogeneity of the study population, the lack of awareness among many subjects of risk factors and self-exclusion procedures, and the high level of distress among many subjects after notification, emphasize the need for intensive, well-designed education and support programs.

One hundred and seventy-eight denial laboratory technicians and 69 non-exposed controls participated in an epidemiological respiratory study. Eight technicians who had a mean of 28 years' grinding nonprecious metal alloys were diagnosed as having a simple pneumoconiosis by chest radiograph. Mean value for per cent predicted FVC and FEV[sub 1] were reduced among male nonsmoker technicians compared to male nonsmoker controls: after controlling for age. there was also a reduction in spirometry with increasing work years. An industrial hygiene survey was conducted in 13 laboratories randomly selected from 42 laboratories stratified by size and type of operation in the Sah Lake City, Utah metropolitan area. Personal exposures to beryllium and cobalt exceeded the Threshold Limit Values (TLVs) in one laboratory. Occupational exposures ia dental laboratories need to be controlled to prevent beryllium-related lung disorders as well as simple pneumoconiosis.