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A list of books related to medical care including "Health in the Later Years," 3rd edition, by Armeda Ferrini, is presented.

A list of books related to medical care including the "Understanding Childhood Obesity," by J. Clinton Smith, is presented.

The article reports on the announcement of Vision Care Section of the American Public Health Association in the U.S. of its awards program for 1987. The association solicits nominations in the three categories of awards including distinguished achievement, outstanding student and outstanding paper or project. The distinguished achievement award is the highest honor bestowed by the Vision Care Section, designed to recognize the leaders in vision care and public health. The outstanding student award provides recognition to a student who has demonstrated the ability in the promotion of vision care in the public health field. The paper or project award is designed to recognize an individual, institution, or group that have significantly contributed to the advancement of vision care.

Records of hospital inpatients were abstracted for 5,000 newly diagnosed cancer patients admitted in 1982-83 to 17 Comprehensive Cancer Centers and 17 Community Hospital Oncology Programs. Generally available data items (silent record rate less than 5 per cent for the typical institution) included: age, race, sex, dates of hospitalization, zip code of residence, pathological stage, dates of biopsy and surgery, numbers of nodes examined and positive, certain diagnostic procedures, and some radiotherapy descriptors. For other data items, there was enormous variability in completeness and high institution-to-institution variation. Record completeness did not differ consistently between comprehensive and community cancer centers. We conclude that the hospital patient record is useful for tracking the frequency of surgical and related events. However, studies of diagnostic and therapeutic procedures should not rely solely on the hospital medical record due to the high rates of silent records. INSET: Medical Literature at Risk of Deterioration from Acid in Paper. [ABSTRACT FROM AUTHOR]

This paper describes a pilot case-finding survey which allowed statistical resolution of a number of methodological issues facing researchers who conduct such surveys. The pilot study for a national survey assessing the incidence, prevalence, and economic impact of head and spinal cord injuries, was conducted in eight geographically representative country sites and involved a study of field procedures in several different types of medical facilities. The scope of this paper is limited to the study of procedures used in hospitals. It concluded that: (1) inexperienced field staff were as productive as experienced field staff for activities such as listing discharges and abstracting patient records; (2) field staff familiarity with facility record systems was associated with success in securing hospital cooperation; (3) endorsements by national chapters of relevant professional arid health-related associations were sufficient for securing hospital cooperation; and (4) neither hospital characteristics (e.g., size) nor the degree of participation by cooperating hospitals was associated with any significant differences in field staff productivity. [ABSTRACT FROM AUTHOR]

The purpose of this paper was to trace the development of the Neighborhood Health Center Program supported under section 314(e) of the Public Health Service Act, as amended, and to extract from this project grant experience some implications for the best future use of federal health services project grant funds. These implications were drawn in the context of emerging federal and private sector initiatives in the areas of financing, organization, and delivery of health services, such as health maintenance organizations and national health insurance. Although the paper was presented 2 years ago, the authors feel the conclusions in the paper remain germane today. [ABSTRACT FROM AUTHOR]

Health planning in this paper is considered as a developmental process in which different types of planning appear at different times. These types are discussed and the place in the complex health care system developing in the United States is assessed. [ABSTRACT FROM AUTHOR]

Predictions that measles would be eradicated through vaccination have not been fulfilled. The reasons for this failure are analyzed in this paper, and the possibilities for successful action against measles are outlined. [ABSTRACT FROM AUTHOR]

We conducted a bibliometric and content analysis of research on health inequalities produced in Latin American and Caribbean countries. In our bibliometric analysis (n = 576), we used indexed material published between 1971 and 2000. The content analysis (n = 269) covered the period 1971 to 1995 and included unpublished material. We found recent rapid growth in overall output. Brazil, Chile. and Mexico contributed mostly empirical research, while Ecuador and Argentina produced more conceptual studies. We found, in the literature reviewed, a relative neglect of gender, race, and ethnicity issues. We also found remarkable diversity in research designs, however, along with strong consideration of ecological and ethnographic methods absent in other research traditions. (Am J Public Health. 2003;93:2037-2043) [ABSTRACT FROM AUTHOR]

Highlights the contributions of Louis Tompkins Wright in health care racial integration in the United States. Family background; Educational attainment; Details on his career in the military. [ABSTRACT FROM AUTHOR]

The following six papers examine a broad range of disease processes and relevant social conditions, such as urban living, social disorganization, poverty, socioeconomic status, and emotional conflict and instability, and show that much illness and death is caused, directly and indirectly, by social and personality factors. [ABSTRACT FROM AUTHOR]

Objective. The assessment of the adequacy of prenatal care utilization is heavily shaped by the way in which utilization is measured. Although it is widely used, the current major index of utilization, the Kessner/Institute of Medicine Index, has not been subjected to systematic examination. This paper provides such an examination. Methods. Data from the 1980 National Natality Survey are used to disaggregate the components of the Kessner Index for detailed analysis. An alternative two-part index, the Adequacy of Prenatal Care Utilization Index, is proposed that combines independent assessments of the timing of prenatal care initiation and the frequency of visits received after initiation. Results. The Kessner Index is seriously flawed. It is heavily weighted toward timing of prenatal care initiation, does not distinguish timing of initiation from poor subsequent utilization, inaccurately measures utilization for full-or post-term pregnancies, and lacks sufficient documentation for consistent computer programming. Conclusions. The Adequacy of Prenatal Care Utilization Index offers a more accurate and comprehensive set of measures of prenatal care utilization than the Kessner Index. [ABSTRACT FROM AUTHOR]

Ecological studies have been evaluated in epidemiological contexts in terms of the "ecological fallacy." Although the empirical evidence for a lack of comparability between correlations derived from ecological- and individual-level analyses is compelling, the conceptual meaning of the ecological fallacy remains problematic. This paper argues that issues in cross-level inference can be usefully conceptualized as validity problems, problems not peculiar to ecological-level analyses. Such an approach increases the recognition of both potential inference problems in individual-level studies and the unique contributions of ecological variables. This, in turn, expands the terrain for the location of causes for disease and interventions to improve the public's health. [ABSTRACT FROM AUTHOR]

There is the expectation that outcomes research and the promulgation of medical practice guidelines will be able to identify and hopefully reduce the amount of unnecessary or inappropriate medical care through a variety of methods, including utilization review. However, past efforts by public and private insurers to deny claims on the basis of formal technology assessments or practice guidelines have frequently been overturned by the courts for multifarious reasons. This paper examines the court's reluctance to accept a variety of technology assessment methods in coverage policy decisions. The paper reviews the options that have been proposed to restrict judicial involvement in the formulation of coverage policy and then proposes a new option that employs a more precise taxonomy of medical practice assessment. [ABSTRACT FROM AUTHOR]

A review of the five centuries since Columbus discovered America helps us understand the mutual contributions of the Old and the New Worlds to the history of diseases and their treatment. It also shows the consequences of this "mutual discovery" as they are currently emerging in the fields of health, culture, and the environment. To evaluate the multiple aspects of the interchange between the Old and New Worlds, this paper discusses the following the causes of the rapid decline of the original American populations; the diffusion of communicable diseases between the two civilizations; the health consequences of nutritional changes on both sides of the Atlantic; drug addictions, as they developed through the centuries and as they exist today; the ways diseases were and are evaluated, prevented, diagnosed, and treated; and the mutual impact of different models of health services. Arguing that a major global change following the discovery of America was the transition from isolation of the two worlds to communication, and more recently, to global interdependence the paper also discusses some problems of bioethical relevance and the possible impact of new epidemics. Finally, it suggests that a critical analysis of the past may help stimulate future cooperation and solidarity. [ABSTRACT FROM AUTHOR]

Abstract: This paper presents the prevalence rates of schizophrenia and major affective disorders by age and race among a random sample of male jail detainees. Subjects were administered the National Institute of Mental Health Diagnostic Interview Schedule (NIMH-DIS). The jail prevalence rates were then compared with general population data from the five-city Epidemiologic Catchment Area program using difference of proportion tests and loglinear analysis. After controlling for demographic differences between the jail and five-city samples, the jail prevalence rates were still two to three times higher than those in the general population. These findings suggest several public policy modifications concerning the psychiatric management of our burgeoning jail population. (Am J Public Health 1990; 80:663-669.) [ABSTRACT FROM AUTHOR]

Abstract: This paper estimates the economic costs of Alzheimer's Disease to individuals and to society, based on review of published Alzheimer's Disease-related research. The analysis is derived from epidemiological projections and cost information for the United States population in 1983. Estimated costs include both direct medical care and social support costs, as well as indirect costs, such as support services provided by family or volunteers, and the value of lost economic productivity in Alzheimer's Disease patients, Mid-range estimates of net annual expected costs for an Alzheimer's Disease patient, excluding the value of lost productivity, are $18,517 in the first year and $17,643 in subsequent years, with direct medical and social services comprising about half of these costs. Under base case assumptions, the total cost of disease per patient in 1983, was $48,544 to $493,277, depending upon patient's age at disease onset. The estimated present value of total net costs to society for all persons first diagnosed with Alzheimer's Disease in 1983 was $27.9-31.2 billion. Development of a public or private insurance market for the economic burdens of Alzheimer's Disease would fill some of the gaps in the current US system of financing long-term chronic disease care. [ABSTRACT FROM AUTHOR]

Abstract: This paper reports the home-facility and level of care changes, discharges, and deaths over a five-year period for 1,653 clients newly admitted in 1978 to a long-term care program in British Columbia, Canada. Five years after admission, of clients initially admitted to care at home (N = 1241), 34,3 per ¢ were still in the program (14.5 per ¢ unchanged; 6.7 per ¢ at home but at a higher level of care, and 11.7 per ¢ in facilities). Of the remainder, 38.9 per ¢ had died and 26.8 per ¢ had been discharged. Findings for those initially admitted to care in facilities (N = 412) are remarkably similar. After five years, 28.4 per ¢ of these clients were still in the program; 39.3 per ¢ had died. Moves from facility to home care were few (2.4 per ¢). Despite their advanced age at admission (X = 74.7, S.D. 14.6), one-third were still in the program five years later, some with status virtually unchanged. INSET: Health Implications of Smokeless Tobacco Use. [ABSTRACT FROM AUTHOR]

The earthquakes that hit Mexico City in September 1985 caused considerable damage both to the population and to important medical facilities. The disaster took place while the country was undertaking a profound reform of its health care system. This reform had introduced a new principle for allocating and distributing the benefits of health care, namely, the principle of citizenship. Operationally, the reform includes an effort to decentralize the decision-making authority, to modernize the administration, to achieve greater coordination within the health sector and among sectors, and to extend coverage to the entire population through an ambitious primary care program. This paper examines the health context in which the reform was taking place when the September earthquakes hit. After presenting the damages caused by the quakes, the paper analyzes the characteristics of the immediate response by the health system. Since many facilities within the system were severely damaged, a series of options for reconstruction are posited. The main lesson to be learned from the Mexican case is that cuts in health care programs are not the inevitable response to economic or natural crises. On the contrary, it is precisely when the majority of the population is undergoing difficulties that a universal and equitable health system becomes most necessary. [ABSTRACT FROM AUTHOR]

Abstract: This paper presents estimates of t11,2 number of diagnostic x-ray examinations performed in the United States. the population dose delivered, the percentage of that dose contributed by credentialed and noncredentialed operators, and one measure of performance: collimation of the x-ray beam. An estimated 82 per ¢ of medical x-ray examination:, are performed by voluntarily certified (ARRT or ARCRT) operators. These procedures contribute 90 per ¢ of the radiation dose to the population. Data from the Nationwide Evaluation of X-Ray Trends (NEXT) program indicate that certified operators collimate the x-ray beam somewhat better than noncertified for chest examinations. They also indicate in it difference,; in collimation practices may be attributed to the type of facility as well as to the credentials of the operators. One third of the medical x-ray machines are in states presently requiring licensure of operators. It appears from these estimates that instituting operator licensure in the remaining states may reduce population dose by a maximum of one or two per ¢. (Am J Public Health 1985:75:270-274.) [ABSTRACT FROM AUTHOR]

Abstract: This paper presents home serendipitous findings from an ethnohistorical study of public health nursing in rural New England. In the course of that study, a model of population-based nursing revealed itself thai some would condemn as antiquated: it may, however, hold great possibilities for addressing the nation's current and future health problems, particularly health maintenance of the elderly and care of the chronically ill. In keeping with the criteria used to evaluate primary health care the model is examined for the extent to which it is accessible, available, accountable. acceptable, comprehensive, coordinated, and cost-effective. The policy implications of this model for the organization and financing of community health care are explored. [ABSTRACT FROM AUTHOR]

Aggregate-level (macro) data are sometimes used when examining health care issues. Although they may be more accessible than individual (micro) observations, their interpretation is subject to ecological bias which in most cases is not measurable. This paper examines the implications of using aggregate-level data by conducting two separate analyses (micro and macro). Using as a database hospital episodes of care for the North Carolina Medicare aged population, regression models are developed from an examination of geographic grouping effects to explore the impact of extended care services, skilled nursing facility, and home health agency care on acute care hospital days. Specific problems encountered are: variable definition, collinearity, variance reduction, dilution of effect, spurious correlation, and observation influence. Stronger collinear (correlation among independent variables) relations occur at the macro-level than at the micro-level and spurious macro-correlations result from model specification and definition of interaction effects. [ABSTRACT FROM AUTHOR]

This paper describes the place and level of care of an urban and a semi-rural health unit for which 1,653 clients began their experience in British Columbia's Long-Term Care (LTC) program and where they were one and three years later. Three years after admission, 54 per cent of 759 clients initially admitted at home to the lowest level of care were still active clients: 25.8 per cent unchanged. 11.3 per cent at home but at a higher level of care, 16.9 per cent had moved to facilities. 25.4 per cent had died: the remainder of this group had been discharged from LTC. A similar proportion of the 184 clients admitted to the lowest level of care in facilities were still in the program at the end of three years. In contrast, 25 per cent of those admitted to the highest level of care at home (N=60) and 14.1 per cent of those admitted to the highest level in facilities (N-64) remained in the program after three years. The potential of the study data for planning purposes is suggested. [ABSTRACT FROM AUTHOR]

Abstract: The 1980 Census data provide a valuable resource for health services research on Hispanics. Hispanics are the fastest growing minority group in the United States and yet there is a paucity of large-scale empirical research on their health care and access needs. This paper describes how the census can assist in: 1) estimating the overall health care needs of this group. 2) identifying target groups within the Hispanic population who may have special health care problems (e.g., children, elderly, pregnant women. etc.); and 3) using other data sources to improve the quality of studies carried out on Hispanics. It also discusses problems in using the census for Hispanic health services research and some strategies for dealing with these problems. [ABSTRACT FROM AUTHOR]

Abstract: Emergency Medical Service (EMS) evaluation is usually conducted on an aggregated, system-wide basis, despite the fact that there is substantial geographical variation in EMS performance. This paper suggests a method for the identification and analysis of geographically disaggregated EMS performance, using Seattle's Medic I program as an example. (Am J Public Health 1981; 71:841-844.) [ABSTRACT FROM AUTHOR]

Abstract: Data presented in This paper were obtained from interviews of 1,129 Chicanas in Los Angeles in 1973. The women were 15-44 years of age, and married to Chicanos. While the level of contraceptive use prior to the last pregnancy was somewhat lower for Chicanas than for all women in the United States. they were equally successful in their fertility planning. For Chicano contraceptors, the success rate ranged from 65 per ¢ before the first pregnancy to 42 per ¢ before the fourth, a little higher than for all women in the United Stales. For non-contraceptors, there were similar differences in success between the two groups. These findings suggest that the higher fertility of Chicanas is a consequence of their desire for larger families rather than unsuccessful family planning. The findings on the determinants of fertility planning success suggest that ethnicity and type of health facility care for the last pregnancy are more important variables than age, age at marriage, socioeconomic status and religiosity. [ABSTRACT FROM AUTHOR]

This paper examines the uses of some health status indices in measuring equity of access to medical care. Empirical examples are provided using data from national surveys of the U.S. population conducted from 1964 through 1976. A simple indicator, mean number of physician visits, suggests that between 1963 and 1976 the poor improved their position relative to the rest of the population and, indeed, currently enjoy the highest level of access. However, a second measure, the use-disability ratio indicates that the poor may still receive less care relative to their need. A third measure, the symptoms-response ratio suggests how norms of appropriate behavior might be incorporated into an access measure. [ABSTRACT FROM AUTHOR]

This paper examines the relative importance of various independent variables for predicting five separate measures of physician utilization in a rural community. The independent variables include socioeconomic, demographic, attitudinal, and health status factors. The results are comparable to those of national studies which find that health status is the primary determinant of utilization. Income, price measures, and travel time are notable for their relative unimportance in this rural area. This suggests that resources are more likely to be allocated on the basis of medical need within a given health care market than across a number of market areas. [ABSTRACT FROM AUTHOR]

This paper presents trends in the growth in the US uninsured population, using cross-sectional national estimates from 1977, 1987, 1989, and 1992 and focusing specifically on coverage problems experienced by Hispanic Americans. An examination of the composition of uninsured persons added between 1977 and 1992 shows that almost 40% of the difference is accounted for by persons of Hispanic origin, with those of Mexican origin alone constituting 27%. In addition, the annual average rate of growth in the uninsured Hispanic population between 1977 and 1992 was 9.7%, compared with only 2.3% for the uninsured non-Hispanic population. [ABSTRACT FROM AUTHOR]

How do planners and politicians relate to each other? This is the question to which this paper addresses itself. The analysis deals with various aspects including choice of problem, its analysis, values related to the problem, allocation of resources, program design and a number of other facets. [ABSTRACT FROM AUTHOR]

Attitudes toward the liberalized abortion law in New York State were assessed among obstetrician-gynecologists in the state. This paper presents findings on various issues and relates them to a number of variables. In general, the New York State practitioners were found to favor the new law and to take a rather liberal view of some critical social issues involved in abortion. [ABSTRACT FROM AUTHOR]

This paper provides information on contraceptive practices of women in certain low-income areas useful for family planning agencies, and examines the utilization patterns of the medically indigent poor as compared with others in low income areas. [ABSTRACT FROM AUTHOR]

This paper presents a group process for conducting an exploration of the qualitative and quantitative elements, patterns and total structure of a health care problem under preliminary investigation. Reasons for employing the nominal group process as a pilot research instrument are given. The authors emphasize that it is appropriate for some problems but not for others. [ABSTRACT FROM AUTHOR]

Do organized employee protests for the improvement of health services have a positive aspect? This paper endeavors to show some of the potentially positive contributions of such movements and the need for understanding the social context of organized protest. [ABSTRACT FROM AUTHOR]

Abstract: This paper illustrates the usefulness of cartographic and centrographic methods in examining the locational characteristics of health care resources, such as specialist physicians' offices. Cartographic analysis involving map comparisons not only describes the nature of particular spatial patterns, but it also suggests relevant hypotheses on the basis of observed locational relationships among the mapped phenomena. Centrographic analysis generally substantiates the findings of simple map analysis by providing certain objective quantitative measures regarding the basic characteristics of a point distribution; additionally, it generates a graphic summary, the Standard Deviational Ellipse (SDE), which offers a convenient means for direct comparison of multiple spatial patterns. The essentially complementary nature of the two methods is highlighted, and it is concluded that they are most useful when used in conjunction With one another. [ABSTRACT FROM AUTHOR]

Abstract: Three conditions render the use of standard methodologies inappropriate in solving location-allocation problems. This paper presents one alternative method for assigning an emergency aircraft to one of three hospitals in northern Chile when standard approaches are not suitable. Graph analyses and the demographic potential measures are used in the case presented. The main advantages of this alternative approach are its computational ease and the use of more than one method. [ABSTRACT FROM AUTHOR]

The article comments on the paper published in this periodical titled "Theory and Action for Health Promotion: Illustrations from the North Karelia Project," by Alfred McAlister. The said project materialized as a reaction to a community demand that the high rates of cardiovascular disease in Eastern Finland be remedied. The North Karelia Project was not an experiment in testing the effectivity of a discrete intervention strategy but a representation of an operational program demonstration and analysis. The project must be regarded as a potential case study instead of a critical analysis of the effects of health promotion.

The article focuses on the cases of infant mortality and morbidity in England in 1909 until the present. In 1909, there are bout 120 of the 1,000 infants born alive died before reaching their first birthday not only in England but also to countries which were now considered developed or industrialized. However, infant mortality today in most rich countries had been cut down to about 10 percent than what it was 70 years ago which is primarily because of better social welfare and public health services. One reason for the adequate decline in infant mortality during the twentieth century is the improvement in nutrition which plays a very important role in infant mortality. In the decline in the U.S. infant mortality is the spread of various family planning methods.

This paper documents oral health and public health expenditures for fiscal years 1984, 1986, 1988, and 1989, as reported by state health agencies. During this period, reported national expenditures for public and oral health increased 68% and 46%, respectively; between successive fiscal years, fewer states (73%, 67%, 57%) reported increased oral health expenditures, while increasingly more states reported no categorical oral health expenditures. Block grant expenditures for oral health increased overall but decreased as a percentage of total oral health expenditures; 16 stages reported no block grant expenditures for oral health in fiscal year 1989, perhaps reflecting either substantial state support, or marginal to nonexistent oral health programs in these states. [ABSTRACT FROM AUTHOR]

This paper offers an historical review, an assessment of the present status, and some indication of the immediate future of federal programs in the field of occupational health. [ABSTRACT FROM AUTHOR]

The threshold of the new millennium offers an opportunity to celebrate remarkable past achievements and to reflect on promising new directions for the field of public health. Despite historic achievements, much will always remain to be done (this is the intrinsic nature of public health). While every epoch has its own distinct health challenges, those confronting us today are unlike those plaguing public health a century ago. The perspectives and methods developed during the infectious and chronic disease eras have limited utility in the face of newly emerging challenges to public health. In this paper, we take stock of the state of public health in the United States by (1) describing limitations of conventional US public health, (2) identifying different social philosophies and conceptions of health that produce divergent approaches to public health, (3) discussing institutional resistance to change and the subordination of public health to the authority of medicine, (4) urging a move from risk factorology to multilevel explanations that offer different types of intervention, (5) noting the rise of the new "right state" with its laissez-faire attitude and antipathy toward public interventions, (6) arguing for a more ecumenical approach to research methods, and (7) challenging the myth of a value-free public health. (Am J Public Health. 201)0;90:25-33) [ABSTRACT FROM AUTHOR]

Objectives. This paper analyzes the impact of seven chronic conditions (three nonfatal: arthritis, visual impairment, hearing impairment; four fatal: ischemic heart disease, chronic obstructive pulmonary disease, diabetes mellitus, malignant neoplasms) on US adults aged 18 and older. Impact refers to how readily a condition prompts activity limitations, physician visits, and hospital stays. Methods. Data come from three national health surveys and vital statistics. For comparability, a single disease classification scheme was applied, and new rates were estimated. Frequency, impact, and prominence of the target conditions are studied via rates, ratios of rates, and ranks, respectively. Results. In young adulthood, the nonfatal conditions prompt limitations less readily than do the fatal ones, but by older ages, arthritis and visual impairment have a limiting impact equivalent to that of fatal conditions. Despite high prevalence and limitations, nonfatal conditions stand well below fatal conditions for health services use. Conclusions. Although statistics on frequency, impact, and prominence all indicate conditions' "importance," they give only weak clues about specific service needs of affected persons. The persistent finding that nonfatal conditions do not receive health services care commensurate with their prevalence and impact reflects long-standing imbalanced attention on fatal conditions in research and medical care. [ABSTRACT FROM AUTHOR]

The U.S. medical care reflects the priorities and influence of academic health centers. This paper describes the leadership role assumed by one academic health center, the State University at Buffalo's School of Medicine and Biomedical Sciences and its eight affiliated hospitals, to serve its region by promoting shared governance in educating graduate physicians and in influencing the cost and quality of patient care. Cooperation among hospitals health insurance payers, the business community, state government, and physicians helped establish priorities to meet community needs and reduce duplication of resources and services; to train more primary care physicians; to introduce shared governance into rural health care delivery; to develop a regional management information system; and to implement health policy. This approach, spearheaded by an academic health center without walls, may serve as a model for other academic health centers as they adapt to health care reform. [ABSTRACT FROM AUTHOR]

Objective. This paper examines how medical care obtained by children enrolled in a Medicaid health maintenance organization (HMO) differs from that obtained by similar children who receive care from fee-for-service Medicaid providers. Methods. In a randomized trial, some Medicaid households were assigned to remain in a traditional fee-for-service arrangement and others were randomly selected to join a Medicaid prepaid plan (an HMO). Participating household recorded data on children's health status and use of medical care. Results. The prepaid plan members and the fee-for-service recipients received equivalent numbers of checkup visits, but the children in the prepaid plan made significantly fewer acute care visits. This plan appeared to target its services to children with the greatest health care needs. However, the content of health visits in the two systems did not differ, nor did prepaid and fee-for-service enrollees use the emergency room differently. Conclusions. It is possible to design a Medicaid HMO that achieves financial savings without reducing services to the most vulnerable patients, However these findings alone do not provide a basis for widespread policy change in the direction of Medicaid HMOs. Further research is needed to establish whether the children treated in the HMO differed in health outcomes from those treated by fee-for-service care. [ABSTRACT FROM AUTHOR]

Objectives. developed countries have seen declining mortality rates for heart disease, together with an alleged decline in incidence and seemingly paradoxical increase in health care demands. This paper presents a model for forecasting the plausible evolution of heart disease morbidity. Methods. The simulation model combines data from different sources. It generates acute coronary event and mortality rates from published data on incidences, recurrences, and lethalities of different heart disease conditions and interventions. Forecasts are based on plausible scenarios for declining incidence and increasing survival. Results. Mortality is postponed more than incidence. Prevalence rates of morbidity will decrease among the young and middle-aged but increase among the elderly. As the milder disease states act as risk factors for the more severe states, effects will culminate in the most severe disease states with a disproportionate increase in older people. Conclusions. Increasing health care needs in the face of declining mortality rates are no contradiction, but reflect a tradeoff of mortality for morbidity. The aging of the population will accentuate this morbidity increase. [ABSTRACT FROM AUTHOR]

Adults, defined here as people between 15 and 59 years of age, in developing countries have a high risk of premature death and suffer from frequent morbidity and high rates of chronic impairment. Their ill health imposes a major burden on health services and large negative consequences on families, communities, and societies. This paper describes the level and impact of adult mortality and morbidity, and highlights some of its characteristics and causes, which in some cases contradict commonly held beliefs. It concludes that "adult health" is a legitimate public health concern for developing countries that is not being addressed. An agenda for remedial research and action is proposed. [ABSTRACT FROM AUTHOR]

Objectives. Proposition 99 added 25 cents to the California state cigarette tax and mandated that 20% of the new revenues be spent on tobacco education and prevention programs. This paper examines the implementation of these programs and the tobacco industry's response to Proposition 99. Methods. Political expenditure data for twelve tobacco firms and associations were gathered from California's Fair Political Practices Commission and secretary of state's Political Reform Division. Tobacco education expenditure data were collected from Governor's Budgets and the Department of Finance. Results. Since Proposition 99 passed, tobacco industry political expenditures in California have risen 10-fold, from $790 050 in the 1985-1986 election of $7 615 091 in the 1991-1992 election. The tobacco industry is contributing more heavily to the California legislature than to Congress. A statistical analysis of data on campaign contributions indicates that California legislators' policy-making is influenced by campaign contribution from the tobacco industry. Since fiscal year 1989-1990, the state has ignored the voters' mandate and spent only 14.7% of the new revenues to tobacco education. Medical care programs received more money than permitted by the voters. Conclusions. The tobacco industry has become politically active in California following the passage of Proposition 99. One result may be that the state has underfunded tobacco education by $174.7 million through the 1993-1994 fiscal year. The estimated redirection of funds to medical care would essentially eliminate the tobacco education campaign by the year 2000. [ABSTRACT FROM AUTHOR]

In this paper, it is argued that oral contraceptives should be available without prescription. Prescription status entails heavy costs, including the dollar, time and psychological costs of visiting a physician to obtain a prescription, the financial and human costs of unintended pregnancies that result from the obstacle to access caused by medicalization of oral contraceptives, and administrative costs to the health care system. After a review and evaluation of the reasons for strict medical control or oral contraceptives in the United States, safety concerns anticipated in response to the proposal discussed here are addressed. Also, concerns the prescription status is necessary for efficacious use are evaluated. It is concluded that neither safety nor efficacy considerations justify prescription status for oral contraceptives. Revised package design and patient labeling could allow women to screen themselves for contraindication, to educate themselves about danger signs, and to use oral contraceptives safety and successfully. Several alternatives to providing oral contraceptives by prescription with current package design and labeling and selling them over the counter are suggested; the proposals discussed would make these safe and effective contraceptives easier to obtain and to use. [ABSTRACT FROM AUTHOR]

Objectives. Under the Omnibus Budget Reconciliation Act of 1987, Medicare reduced physician fees for 12 procedures identified as over prices. This paper describes trends in the use of these procedures and other physician services by medicare patients during the 4-year period surrounding the implementation of the 1987 budget act. Methods. Medicare physician claims files were used to develop trends in physician-services use from 1986 to 1989. Services were grouped into four categories: overpriced procedure, other surgery, medical care, and ancillary tests. Results. Growth in the volume of overpriced procedures slowed substantially after the 1987 budget act was implemented. Moreover, the reduction in the rate of volume growth for these procedures differed little among specialties or areas. In comparison, the rate of volume growth fell modestly for other surgery, was unchanged for medical care, and increased for ancillary tests. Conclusions. Increases do not necessarily occur in the volume of surgical procedures whose Medicare fees are reduced. Although the conclusions that may be drawn from a descriptive analysis are limited, these findings suggest that concerns that the resource-based Medicare fee schedule will lead to higher surgery rates may be unwarranted. [ABSTRACT FROM AUTHOR]

Objectives. Little is known about the effect of a noncompletion on telephone surveys of health issues. This paper identifies a little-studied source of noncompletion, passive refusal, and evaluates its contribution to noncompletion bias along with tow other sources: noncooperation and noncontact. Passive refusals include respondents who repeatedly request callbacks and households where interviewers repeatedly encounter an answering machine. Methods. Measures of noncompletion (noncooperation, passive refusal, and noncontact), demographic and socioeconomic characteristics, health risk factors, and indicators of health care access and health status were collected through the Orange County Health Surveys on 4893 respondents. The surveys sampled by random-digit dialing and interviewed by computer-assisted telephone. Results. Passive refusals have a substantial impact on completion rates and bias due to noncompletion. Commonly used definitions for completion rates were definitions for completion rates may underestimate the bias due to noncompletion because they omit passive refusals. After we controlled for demographic and socioeconomic factors, few noncompletion biases appeared on selected health indicators. Conclusions. These results suggest improved reporting of completion rates and support a multivariate framework for studying noncompletion in telephone health surveys. [ABSTRACT FROM AUTHOR]