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The state of Oregon decided to cover all potentially eligible Medicaid citizens to 100% of poverty. Previously, Oregon had covered persons up to 67% of poverty. In order to keep overall program costs in check. Oregon decided to limit the number of services that its Medicaid program would cover. Oregon's normative choice was to contain program costs by covering all eligible persons up to 100% of poverty, while at the same time uniformly limiting access to certain services for everyone in the overall group of eligible persons. The state developed a prioritization list of medical services and priced the components on the list. The amount of money ultimately available for the Medicaid program was a political decision informed by data about the cost of different services and influenced by the priorities set through an independent process of priority-setting. Physicians were asked to determine what works medically, how well it works, and what benefits accrue to patients. Recognizing that physician perspectives on efficacy might vary from patients' perspectives on valuation of benefits, Oregon's planners developed a method for valuing medical outcomes that stemmed from particular medical interventions. This blend of medical fact and value to patients allowed for comparing valuations by introducing cost considerations. Condition-treatment (CT) pairs linked a medical condition with one or more courses of treatment. The goal was to determine the likely incremental medical benefit from a given treatment. In addition, Oregon developed a Quality-of-Well-Being scale to determine the net patient benefit from medical intervention and used a telephone survey to value that net benefit. A cost-benefit ratio was derived, and a prioritization of CT pairs was developed. The article analyzes and evaluates Oregon's use of cost-benefit calculations in the allocation of Medicaid funds, noting that Oregon itself backed away from many of the implications of its cost-benefit analysis and that the Americans with Disabilities Act has constrained use of quality-of-life judgments in Medicaid resource allocation decision-making.
OBJECTIVE: Late in 2001, the State of Oregon filed suit against Attorney General John Ashcroft, seeking to halt his recent directive that physicians who comply with the Oregon Death with Dignity Act by writing a lethal prescription for a controlled substance should be prosecuted for violating the federal Controlled Substances Act (CSA). This special article reviews the history of the series of challenges to the Oregon Act since its initial adoption in 1994, with particular consideration of the arguments on both sides of Oregon v. Ashcroft and the disposition of the case by the district court. DESIGN: The article utilizes an historical review of the Oregon Act, including legal and political challenges to it, as well as discussion of the 3 years of data on the experience with legalized physician-assisted suicide in Oregon, and analysis of the legal issues in the current litigation. CONCLUSIONS: The federal district court concluded that the Attorney General's interpretation of certain provisions of the CSA so as to preclude the writing of a lethal prescription where otherwise permitted by state law as a legitimate medical practice was inconsistent with the CSA and, therefore, beyond the scope of his authority. The Oregon Act will continue in force while the Attorney General's appeal of the district court ruling is considered by the Ninth Circuit Court of Appeals.
BACKGROUND AND METHODS: In 1997, Oregon legalized physician-assisted suicide. We have previously reported data on terminally ill Oregon residents who received prescriptions for lethal medications under the Oregon Death with Dignity Act and who died in 1998. We now report similar data for 1999, obtained from physicians' reports, death certificates, and interviews with physicians. We also report data from interviews with family members. RESULTS: Information on 33 persons who received prescriptions for lethal medications in 1999 was reported to the Oregon Health Division; 26 died after taking the lethal medications, 5 died from their underlying illnesses, and 2 were alive as of January 1, 2000. One additional patient, who received a prescription in 1998, died after taking the medication in 1999. Thus, 27 patients died after ingesting lethal medications in 1999 (9 per 10,000 deaths in Oregon), as compared with 16 patients in 1998 (6 per 10,000). The median age of the 27 patients who died in 1999 after taking lethal medications was 71 years. The most frequent underlying illnesses were cancer (in 17 patients), amyotrophic lateral sclerosis (in 4), and chronic obstructive pulmonary disease (in 4). All 27 patients had health insurance, 21 were receiving hospice care, and 13 were college graduates. According to both physicians and family members, patients requested assistance with suicide for several reasons, including loss of autonomy, loss of control of bodily functions, an inability to participate in activities that make life enjoyable, and a determination to control the manner of death. CONCLUSIONS: In the second as compared with the first year of legalized physician-assisted suicide in Oregon, the number of patients who died after ingesting lethal medications increased, but it remained small in relation to the total number of persons in Oregon who died. Patients who request assistance with suicide appear to be motivated by several factors, including loss of autonomy and a determination to control the way in which they die.
The Oregon Basic Health Services Act of 1989 seeks to establish universal access to basic medical care for all currently uninsured Oregon residents. To control the increasing cost of medical care, the Oregon plan will restrict funding according to a priority list of medical interventions. The basic level of medical care provided to residents with incomes below the federal poverty line will vary according to the funds made available by the Oregon legislature. A rationing plan such as Oregon's which potentially excludes medically necessary procedures from the basic level of health care may be just, for the right to publically-sponsored medical care is restricted by opposing rights of private property. However, the moral acceptability of the Oregon plan cannot be determined in the absence of knowing the level of resources to be provided. Finally, Oregon to date has failed to include the individuals being rationed in discussions as to how the scarce resources are to be distributed.
OBJECTIVE: In 1991 the Oregon Board of Medical Examiners initiated a separate category for the complaint of sexual misconduct. Investigated complaints of sexual misconduct brought to the Oregon Board of Medical Examiners were analyzed for the years 1991 to 1995 to serve as a baseline. Comparison was made to the Federation of State Medical Boards sexual misconduct data for 1991 and 1992. STUDY DESIGN: One hundred complaints brought against 80 licensees were evaluated by practitioner's degree, age group, sex, specialty, and disposition of complaints for the years 1991 to 1995. The allegations were classified into behavior categories of sexual impropriety, sexual transgression, and sexual violations. RESULTS: Sexual misconduct was the allegation in 5.9% of the complaints investigated for the study period. Oregon had more sexual misconduct complaints than the average reported to the Federation of State Medical Boards for the years 1991 and 1992. Most (72%) complaints came from the patients or their families. Two female physicians (2.4%) had sexual boundary complaints. Sexual misconduct complaints increased by a risk ratio of 1.44 with advancing age by decades. Allegations classified into behavior categories according to severity revealed 39% sexual impropriety, 31% sexual transgression, and 30% sexual violation. Reportable disciplinary actions occurred only with multiple allegations of sexual impropriety (6.5%) and for sexual transgression (27%) whereas sexual violation allegations often had one complainant but there were 54% reportable disciplinary actions. Family practice, obstetrics and gynecology, and psychiatry had the highest incidence of sexual misconduct complaints whereas psychiatry and obstetrics and gynecology had the highest incidence of reportable disciplinary actions. Twenty-five percent of the closed cases resulted in reportable disciplinary actions. This analysis is discussed in relationship to legal and ethical issues and the goal of zero tolerance. CONCLUSIONS: Oregon has a higher percentage of sexual misconduct complaints than the average for 42 states reporting to the Federation of State Medical Boards for the years 1991 and 1992. Analysis of the Oregon Board's experience for the study years will provide a baseline for future evaluation and as an educational resource for the Oregon Board of Medical Examiners and professional and specialty societies. Ethical standards, the reporting and investigative processes, and the legal framework are in place and lessen the incidence of sexual misconduct and work toward zero tolerance.
Oregon's land-use planning program is often cited as an exemplary approach to forest and farmland conservation, but analyses of its effectiveness are limited. This article examines Oregon's land-use planning program using detailed spatial data describing building densities in western Oregon. An empirical model describes changes in building densities on forest and agricultural lands from 1974 to 1994, as a function of a gravity index of land's commuting distance to cities of various sizes, topographic characteristics, and zoning adopted under Oregon's land-use planning program. The effectiveness of Oregon's land-use planning program is evaluated based on the statistical significance of zoning variables and by computing estimated areas of forest and agricultural lands falling into undeveloped, low-density developed, and developed building density categories, with and without land-use zoning in effect. Results suggest that Oregon's land-use planning program has provided a measurable degree of protection to forest and agricultural lands since its implementation.
Water samples from 26 Oregon beaches were analyzed for Escherichia coli (E. coli) and enterococci concentrations by the Oregon Department of Human Services (ODHS) Public Health Laboratory. Nine Oregon beaches exceeded US Environmental Protection Agency's (USEPA) single sample maximum density of 104 enterococci colony forming units (cfu) per 100 mL with levels ranging from 121 to 4325 most probable number (MPN)/100 milliliters (mL). Otter Rock at South Cove had the highest enterococci concentration at 4352 MPN/100 mL. The results from two Oregon beaches exceeded Oregon Department of Environmental Quality's (ODEQ) estuarine E. coli standard of 406 organisms/100 mL. Otter Rock at South Cove had the highest E. coli concentration at 1850 MPN/100 mL while Road's End had an E. coli density of 771 MPN/100 mL. Results of this study suggest that adopting USEPA's marine enterococci standard in lieu of the ODEQ's estuarine standard will lead to increased Oregon beach water standard failures.
BACKGROUND: Since the Oregon Death with Dignity Act was passed in November 1994, physicians in Oregon have faced the prospect of legalized physician-assisted suicide. We studied the attitudes and current practices of Oregon physicians in relation to assisted suicide. METHODS: From March to June 1995, we conducted a cross-sectional mailed survey of all physicians who might be eligible to prescribe a lethal dose of medication if the Oregon law is upheld. Physicians were asked to complete and return a confidential 56-item questionnaire. RESULTS: Of the 3944 eligible physicians who received the questionnaire, 2761 (70 percent) responded. Sixty percent of the respondents thought physician-assisted suicide should be legal in some cases, and nearly half (46 percent) might be willing to prescribe a lethal dose of medication if it were legal to do so; 31 percent of the respondents would be unwilling to do so on moral grounds. Twenty-one percent of the respondents have previously received requests for assisted suicide, and 7 percent have complied. Half the respondents were not sure what to prescribe for this purpose, and 83 percent cited financial pressure as a possible reason for such requests. The respondents also expressed concern about complications of suicide attempts and doubts about their ability to predict survival at six months accurately. CONCLUSIONS: Oregon physicians have a more favorable attitude toward legalized physician-assisted suicide, are more willing to participate, and are currently participating in greater numbers than other surveyed groups of physicians in the United States. A sizable minority of physicians in Oregon objects to legalization and participation on moral grounds. Regardless of their attitudes, physicians had a number of reservations about the practical applications of the act.
OBJECTIVE: In November 1998, Oregon voters passed Ballot Measure 58, which allowed Oregon adoptees > or = 21 years of age access to their original birth records, which are sealed at adoption. The objective of this study was to evaluate the impact of the measure on the Oregon Health Division (since renamed Oregon Health Services) by assessing procedures used and resources needed after implementation of Measure 58. METHODS: Vital records employees were interviewed about processing, storage, and archive retrieval procedures for pre-adoption birth records before, during, and after the implementation of Measure 58 and the effect on their usual workload. Personnel time, space, and fiscal resources used to process requests for pre-adoption records were also calculated. RESULTS: The Oregon Health Division began to receive requests from adoptees immediately following the passage of Measure 58 in November 1998, but due to legal challenges, they could not be processed until May 31, 2000. From June 2, 2000, through October 20, 2000, 12 staff members and two supervisors issued more than 4,700 pre-adoption birth records while also processing their normal workload, which averages more than 135,400 vital record orders annually. Due to the need for retrieval from archives, requests for pre-adoption birth records were estimated to take 75 hours to process vs. 2-3 minutes for standard requests. Each batch of approximately 75 pre-adoption birth records required approximately 12.5 person-hours from vital records staff and 3-4 person-hours from archive personnel; in addition, supervisors spent time responding to incomplete orders, informing the public and the media, and responding to concerns of adoptees, birth parents, and adoptive parents. Fewer than 1% of requests went unfilled. CONCLUSIONS: Implementation of Measure 58 utilized substantial resources of the Oregon Health Division. States contemplating similar legislation should consider increasing personnel and resources, preparing for intense public and media interest, and reorganizing the storage of adoptees' original birth records so they are easily retrieved.
This paper presents for the first time the annual suicide incidence rates of residents from four Oregon state institutions for a 5-year (1983-1987) period of time. The suicide rate for inmate-patients of the Forensic Psychiatric Program (for the care and treatment of individuals who have been found guilty of serious crime and to be mentally ill) is 820/100,000. This represents a suicide rate 51 times higher than the rate for Marion County or the state of Oregon. This is also one of the highest annual suicide rates ever reported. The suicide rate for patients of the Oregon State Hospital is 289/100,000, which is similar to other reported suicide rates in hospitalized mentally ill populations. This rate is approximately 18 times higher than the rate for Marion County or the state of Oregon. The suicide rate for inmates of Oregon's four correctional institutions is approximately 29/100,000, which is similar to other reported rates for prisoners. This rate is approximately 1.8 times higher than the rate for Marion County or the state of Oregon. The suicide rate for residents of the Fairview Training Center (for care of the mentally retarded and developmentally disabled) is zero.
The authors examine whether Oregon's 1990, 1991, 1992, and 1993 prioritized lists were ranked in a manner consistent with cost-effectiveness. Two sets of cost-effectiveness data are used: data from economic analyses and Oregon's own cost-effectiveness data. Comparing the ranks of Oregon's lists with the ranks of cost-effectiveness estimates from the literature reveals Spearman correlations of -0.08 for the 1990 list, +0.39 for the 1991 list, +0.25 for the 1992 list, and +0.24 for the 1993 list. Comparing Oregon's lists with Oregon's own cost-effectiveness data reveals rank correlations of +0.99 for the 1990 list, +0.06 for the 1991 list, -0.05 for the 1992 list, and -0.03 for the 1993 list. Thus, there appear to be essentially no relationship between the 1990 list and cost-effectiveness estimates from the economic literature and modest positive relationships between the 1991-93 lists and the literature. In addition, there is virtually no relationship between the 1991-93 lists and Oregon's own cost-effectiveness data. Further, the correlations are very different from +1.0, suggesting that other factors are at play. For example, the 1993 list that is currently being implemented was ranked primarily by improvement in five-year survival and human judgment, not cost-effectiveness.
Asthma is one of the most common chronic diseases. The prevalence of asthma appears to be increasing. National data have suggested that Oregon's asthma mortality rate has been twice as high as the national average. The prevalence and impact of asthma are not systematically assessed or tracked within Oregon. We estimated the current asthma prevalence and mortality using data from statewide hospital discharge data, the 1995 Behavioral Risk Factor Surveillance Survey, and school registration data from the Portland area. A conservative estimate of Oregon's current asthma prevalence is 6-7% and lifetime asthma prevalence is estimated at 6-11% for both adults and children. It appears that current asthma prevalence increases during adolescence. The Willamette Valley, an area known for high pollen counts, does not have a higher rate of hospital discharges per capita than other areas within the state. Oregon's apparent higher asthma mortality may be the result of the Oregon State Health Division's aggressive policies toward accurate reporting on death certificates. Oregon's age distribution may also contribute to the apparent higher asthma mortality rate.
In November 1996, residents of Oregon approved a ballot measure increasing the cigarette tax by 30 cents (to 68 cents per pack). The measure stipulated that 10% of the additional tax revenue be allocated to the Oregon Health Division (OHD) to develop and implement a tobacco-use prevention program. In 1997, OHD created Oregon's Tobacco Prevention and Education Program (TPEP), a comprehensive, community-based program modeled on the successful tobacco-use prevention programs in California and Massachusetts. To assess the effects of the tax increase and TPEP in Oregon, OHD evaluated data on the number of packs of cigarettes taxed before (1993-1996) and after (1997-1998) the ballot initiative and implementation of the program. Oregon's results also were compared with national data. This report summarizes the results of the analysis, which indicate that consumption of cigarettes in Oregon declined substantially after implementation of the excise tax and TPEP and exceeded the national rate of decline.
BACKGROUND: Environmental tobacco smoke is a leading environmental asthma trigger and has been linked to the development of asthma in children and adults. Smoking cessation and reduced exposure to secondhand tobacco smoke are key components of asthma management. We describe a partnership involving two state agencies and 14 health plans; the goal of the partnership was to decrease smoking and exposure to environmental tobacco smoke among Medicaid-insured Oregonians with asthma. CONTEXT: Oregon's asthma rate is higher than that of the national population, and approximately one third of Oregonians with asthma smoke. The Health Promotion and Chronic Disease Prevention Program (HPCDP) in the Oregon Department of Human Services has collaborated with the Office of Medical Assistance Programs (OMAP) to promote preventive care at the population level. METHODS: Two HPCDP programs--the Oregon Asthma Program and the Oregon Tobacco Prevention and Education Program--worked with OMAP to launch the statewide Asthma-Tobacco Integration Project in 2003. A primary focus of the project is the development of partnerships among health plans, health care providers, and large health care organizations to integrate asthma management and smoking control through systems innovations and provider education. OMAP and its participating health plans also decided to focus cessation efforts on its members with chronic diseases. In addition, HPCDP has collaborated with OMAP to distribute educational tools and information about tobacco's impact on asthma morbidity to Oregon's health care providers who serve low-income Oregonians. CONSEQUENCES: The partnership between OMAP and HPCDP program staff members has allowed them to discuss problems, leverage resources, and obtain support for many public health initiatives. In addition, OMAP-HPCDP collaboration on educational workshops and outreach to health care providers has helped convince quality improvement specialists and administrators about the importance of addressing smoking among patients with asthma. The Asthma-Tobacco Integration Project has also led to formative research aimed at increasing community involvement in promoting tobacco-free environments. INTERPRETATION: Collaboration between HPCDP and OMAP has been an important factor in Oregon's successful smoking cessation efforts in general and in recent efforts to address tobacco use among Oregonians with asthma.
Suicide is the third leading cause of death among adolescents aged 15-19 years in the United States and second among adolescents in Oregon. During 1959-1961 and during 1990-1992, the rate of suicide in Oregon increased sixfold among 15-19-year-olds. During 1988-1991, the suicide rate for adolescents in Oregon (15.5 deaths per 100,000) was 39.6% higher than the U.S. rate (11.1). Because of the magnitude of this problem, in 1987 the state legislature in Oregon mandated that hospitals treating a child aged < or = 17 years for injuries resulting from a suicide attempt report the attempt to the State Health Division, Oregon Department of Human Resources, and that the patient be referred for counseling; the Oregon Adolescent Suicide Attempt Data System (ASADS) was established in 1988. This report presents an analysis of data for adolescents aged < or = 17 years from ASADS during 1988-1993.
Cytopathogenicity of Bovine viral diarrhea virus (BVDV) is correlated with expression of the nonstructural protein NS3, which can be generated by processing of a fusion protein termed NS2-3. For the cytopathogenic (cp) BVDV strain Oregon, NS2-3 processing is based on a set of point mutations within NS2. To analyze the correlation between NS2-3 cleavage and cytopathogenicity, a full-length cDNA clone composed of cDNA from BVDV Oregon and the utmost 5'- and 3'-terminal sequences of a published infectious BVDV clone was established. After transfection of RNA transcribed from this cDNA clone, infectious virus with similar growth characteristics to wild-type BVDV Oregon could be recovered that also exhibited a cytopathic effect. Based on this cDNA construct and published cp and noncp infectious clones, chimeric full-length cDNA clones were constructed. Analysis of the recovered viruses demonstrated that the presence of the NS2 gene of BVDV Oregon in a chimeric construct is sufficient for NS2-3 processing and a cp phenotype. Since previous studies had revealed that the amino acid serine at position 1555 of BVDV Oregon plays an important role in efficient NS2-3 cleavage, mutants of BVDV Oregon with different amino acids at this position were constructed. Some of these mutants showed NS2-3 cleavage efficiencies in the range of the wild-type sequence and allowed the recovery of viruses that behaved similarly to wild-type virus with regard to growth characteristics and cytopathogenicity. In contrast, other mutants with considerably reduced NS2-3 cleavage efficiencies propagated much more slowly and reverted to viruses expressing polyproteins with sequences allowing efficient NS2-3 cleavage. These viruses apparently induced cytopathic effects only after reversion.
BACKGROUND AND METHODS: On October 27, 1997, Oregon legalized physician-assisted suicide. We collected data on all terminally ill Oregon residents who received prescriptions for lethal medications under the Oregon Death with Dignity Act and who died in 1998. The data were obtained from physicians' reports, death certificates, and interviews with physicians. We compared persons who took lethal medications prescribed under the act with those who died from similar illnesses but did not receive prescriptions for lethal medications. RESULTS: Information on 23 persons who received prescriptions for lethal medications was reported to the Oregon Health Division; 15 died after taking the lethal medications, 6 died from underlying illnesses, and 2 were alive as of January 1, 1999. The median age of the 15 patients who died after taking lethal medications was 69 years; 8 were male, and all 15 were white. Thirteen of the 15 patients had cancer. The case patients and controls were similar with regard to sex, race, urban or rural residence, level of education, health insurance coverage, and hospice enrollment. No case patients or controls expressed concern about the financial impact of their illness. One case patient and 15 controls expressed concern about inadequate control of pain (P=0.10). The case patients were more likely than the controls to have never married (P=0.04) and were more likely to be concerned about loss of autonomy due to illness (P=0.01) and loss of control of bodily functions (P=0.02). At death, 21 percent of the case patients and 84 percent of the controls were completely disabled (P<0.001). CONCLUSIONS: During the first year of legalized physician-assisted suicide in Oregon, the decision to request and use a prescription for lethal medication was associated with concern about loss of autonomy or control of bodily functions, not with fear of intractable pain or concern about financial loss. In addition, we found that the choice of physician-assisted suicide was not associated with level of education or health insurance coverage.