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PubMed1998

Physician equity in health care delivery systems: three alternative models.

The 1990s have seen many health care organizations attempting to merge, acquire, or affiliate with physician groups. Many have failed to provide physicians a stake in the success of the newly formed enterprise, frequently resulting in declining physician productivity, poor morale, and large operating losses. These problems warrant a reexamination of the traditional acquisition model of growth in favor of structures that retain a physician ownership component. This article examines three models of health care organization in which physicians share in the success of the enterprise and compares them in terms of ownership structure, governance, and funds flow.

Delivery of Health Care, Integrated↗
PubMedDate not supplied

Distribution of residence duration in owner occupied housing.

Residence duration was determined in owner occupied household by employing tax records that identify changes in ownership. Residence duration was estimated by selecting a random sample of households from Multnomah County, Oregon and using the interval between the two most recent changes in ownership. Residence duration was observed to be consistent with an exponential distribution with a mean of 13.6 years. While mean residence duration in this study was consistent with the results of other studies, the distribution of residence duration in this study was not consistent with the results of another study. The distribution of residence duration is important in establishing the distribution of exposure in a population using probabilistic risk assessment methods.

Environmental Exposure↗
PubMed1998

Hospitals' vertical integration into skilled nursing: a rational approach to controlling transaction costs.

Using 1985 and 1988 American Hospital Association data, this study examines 1,523 hospitals nationwide and concludes that hospitals' ownership of skilled nursing facilities helps minimize the transaction costs associated with post-acute patient transfers while productively using empty hospital beds. Unfortunately, such ownership creates complex cost, quality, and accessibility trade-offs in terms of the skilled nursing care provided.

American Hospital Association↗
PubMed1998

Nonprofit conversion: theory, evidence, and state policy options.

OBJECTIVE: To describe the contributions of nonprofit hospitals and health plans to healthcare markets and to analyze state policy options with regard to the conversion of nonprofits to for-profit status. DATA SOURCES/STUDY SETTING: Secondary national and state data from a variety of sources, 1980-present. STUDY DESIGN: Policy analysis. DATA COLLECTION/EXTRACTION METHODS: Development of a conceptual economic framework; analysis of empirical, legal, and theoretical literature; and review of statutes, rules, and court decisions. PRINCIPAL FINDINGS: Three main rationales support special status for nonprofits, especially hospitals: charity care, other community benefits, and consumer protection. The main social rationale for for-profits is their incentives for better efficiency. There are reasons to expect that nonprofit and for-profit goals differ; however, measured differences in community hospital cost, prices, and quality between nonprofit and for-profit hospitals are undetectable or inconclusive. Nonprofit hospitals do provide more uncompensated care than for-profit hospitals. Similarities between nonprofit and for-profit hospitals may exist because nonprofits may set norms that for-profits follow to some degree. States have substantial power and discretion in overseeing nonprofit conversions. Some have regularized oversight through new legislation that constrains, but does not eliminate, state officials' discretion. These statutes may be deferential to converting entities and their buyers or may be very restrictive of them. CONCLUSIONS: Overseeing the appropriate disposition of nonprofit assets in individual conversions is extremely important. States should also monitor local market conditions through community benefits assessments and other data collection, however, to accurately assess (and possibly redress) what is lost or gained from conversion. Local market conditions are likely more important in determining hospital behavior than ownership form. Potentially, a mix of for-profit and nonprofit hospitals in a given market may improve market performance due to constraints the two ownership types may exercise over one another. If nonprofits disappear, the states may need to maintain quality and access norms through regulation.

Community-Institutional Relations↗
PubMed1998

The smoking gun: do clinicians follow guidelines on firearm safety counseling?

OBJECTIVES: To describe clinicians' behavior regarding firearm safety counseling practices, develop a model to predict current counseling behavior, and identify resources that might positively influence willingness to counsel according to medical guidelines. DESIGN: Four hundred sixty-five primary care Los Angeles County, California, pediatricians, family physicians, and pediatric nurse practitioners who serve families with children aged 5 years and younger received mailed questionnaires; 325 (70%) responded. MAIN OUTCOME MEASURE: Clinician self-reported behavior. RESULTS: Of the respondents, 80% stated that they should counsel on firearm safety; only 38% do so. Of those clinicians who currently counsel, only 20% counsel more than 10% of their patient families. Firearm safety counseling behavior is positively associated with a clinician being 49 years or younger (odds ratio [OR]=2.19, P=.02); a perception that counseling is beneficial (OR=2.62, P=.02); and household handgun ownership (OR=2.47, P=.02). Clinician households that report gun ownership counsel differently than those clinicians who report not possessing a household gun. There are no significant differences in the rates of counseling across specialties and crime area types. Forty-one percent of clinicians report that patient education handouts would increase their likelihood of counseling. CONCLUSIONS: In Los Angeles County gaps exist between clinicians' views of the benefits of counseling families with young children regarding firearm safety and their actual behavior. Guidelines and handouts are available from major medical organizations. Research should focus on how to get practitioners to use available materials, enabling them to better adhere to guidelines.

Adult↗
PubMed1999

Firearm storage practices and children in the home, United States, 1994.

OBJECTIVES: To estimate the national prevalence of firearm ownership and storage practices in the home, to compare storage practices in homes with and without children, and to analyze demographic characteristics related to firearm storage practices in homes with children. DESIGN: A 1994 random-digit dialing telephone survey. We weighted the data to provide national estimates. PARTICIPANTS: English- and Spanish-speaking adults in households in 50 states and Washington, DC. MAIN OUTCOME MEASURES: Ownership of working powder firearm(s) in home and/or vehicle and firearm storage practices in the home. RESULTS: Of 5238 households surveyed, one third kept at least 1 firearm in the home and/or vehicle. Of 1598 households with firearm(s) in the home and known firearm storage practices, 21.5% kept at least 1 gun loaded and unlocked in the home, 30.0% stored all firearms unloaded and locked, and 48.5% stored firearms in a manners classified between these 2 practices. Households with children were more likely than households without children to store all firearms unloaded and locked (41.5% vs 20.9%); households without children were more likely than households with children to store at least 1 firearm loaded and unlocked (29.8% vs 11.1%). Among households with children and firearms, there were regional differences with respect to storage practices. CONCLUSIONS: These prevalence data show that children are potentially exposed to firearms in many households. This health threat illustrates the need for education about the issue of pediatric firearm injuries and for interventions to minimize associated risks. Health care providers should take advantage of opportunities to counsel patients regarding firearm safety in the home.

Adolescent↗
PubMed2002

Parent-reported environmental exposures and environmental control measures for children with asthma.

BACKGROUND: Mounting evidence suggests that indoor allergens and irritants contribute to childhood asthma. National asthma guidelines highlight the importance of their reduction as part of comprehensive asthma treatment. OBJECTIVES: To assess the prevalence of potential environmental triggers, to identify risk factors for such exposures, and to determine whether prior parental education about trigger avoidance is associated with fewer such exposures. SETTING AND PATIENTS: Children with asthma in practices affiliated with 3 managed care organizations. INTERVENTIONS: Parents of 638 children, aged 3 to 15 years, were interviewed on enrollment in a randomized trial of asthma care improvement strategies. Parents reported recent asthma symptoms and exposures to potential environmental triggers. Multivariate models were used to identify specific demographic risk factors for environmental exposures and to determine if prior education was associated with fewer such exposures. RESULTS: Exposures to environmental triggers were frequent: 30% of households had a smoker, 18% had household pests, and 59% had furry pets. Other exposures included bedroom carpeting (78%) and forced-air heat (58%). Most children did not have mattress (65%) or pillow (84%) covers. Of the parents, 45% reported ever receiving written instructions regarding trigger avoidance and 11% reported them given in the past year. However, 42% reported discussing triggers in the home environment with a clinician in the past 6 months. In multivariate models, predictors of smoking at home included low annual family income and lower parental educational attainment. Dog ownership was associated with low educational attainment, and dog and cat ownership were less likely with black race. Reports of pests were increased for black children compared with white children. Black race was associated with lower rates of other exposures, including bedroom carpeting. After controlling for potential confounders, there was no association of reduced exposures with prior receipt of environmental control instructions. CONCLUSIONS: Exposure to potential environmental triggers is common, and recommended trigger avoidance measures are infrequently adopted. While specific exposures may vary with demographic and socioeconomic variables, all children are at risk. New methods for educating parents to reduce such exposures should be tested.

Adolescent↗
PubMed1996

Gun storage patterns in US homes with children. A pediatric practice-based survey. Pediatric Practice Research Group.

OBJECTIVE: To describe gun storage patterns in gun-owning families with children. DESIGN: Survey of parents attending participating offices. SETTING: Twenty-nine urban, suburban, and rural pediatric practices in Chicago, Ill; New Jersey; Houston, Tex; Utah; Georgia; Iowa; and South Carolina. SUBJECTS: Parents of children attending offices for well- or sick-child care. SELECTION PROCEDURE: Consecutive sample of families seen during the 1-week study period. MEASUREMENTS AND ANALYSES: Logistic regression models were constructed to identify sociodemographic factors associated with keeping guns loaded. RESULTS: Of 5233 surveys, 1682 (32%) indicated ownership of at least one powder firearm. Of the gun-owning families, 61% reported at least one gun unlocked, and 15% reported at least one gun loaded. Rifles were more often stored unlocked (62% rifles vs 52% handguns, P<.001, z=4.60; two-proportion z-test), but handguns were more likely to be kept loaded (3% rifles vs 27% handguns, P<.001). Seven percent of gun-owning families reported at least one gun unlocked and loaded (handguns 12 times more likely than rifles). Only 30% of households reported all guns stored unloaded and locked up. The best-fit logistic regression model for keeping a gun loaded identified four predictor variables: owning a gun for self-protection, work-related gun ownership, owning a handgun, and no men in the home. CONCLUSIONS: Because most gun-owning families store guns loaded, unlocked, or both, anticipatory guidance should address gun storage in all such families. Interventions designed to alter the way work guns are dealt with after work, and to provide safe and effective means of self-protection might affect these storage patterns.

Child↗
PubMed2005

University-based science and biotechnology products: defining the boundaries of intellectual property.

The pharmaceutical and biotechnology industries have long relied on patenting as the primary means of allocating ownership and control over new discoveries. Yet, patent protection is a double-edged sword that has major implications for the future of innovation in biomedical science in the United States. Excessive "upstream" patenting of genes and molecular targets could hinder further research by creating a need for expensive and inefficient cross-licensing. However, limiting such basic science patenting could allow private entities to use the results of years of costly publicly funded research to produce and market lucrative products without compensating university- or public sector-based innovators. Academic and other nonprofit research centers would, therefore, be deprived of revenue for pursuing novel therapeutics or other seminal research work that may not be patentable. Recent court cases illustrate the inherent conflicts in allocating ownership and control of basic biomedical discoveries. Several options exist to avoid the complex problems of overlapping basic science patents while still rewarding pivotal discoveries and encouraging further innovation. These include establishing basic science patent pools and mandating arbitration arrangements that would assign credit and royalties for biotechnology innovations that depend on prior research that was performed, financed, or both in the public sector.

Academic Medical Centers↗
PubMed2005

Non-legislative interventions for the promotion of cycle helmet wearing by children.

BACKGROUND: Helmets reduce bicycle-related head and facial injuries for bicyclists of all ages in all types of crash. We aimed to identify non-legislative interventions that are effective in promoting helmet use among children, so future campaigns can be designed on a firm evidence base. OBJECTIVES: to assess the effectiveness of non-legislative interventions (compared to a lack of interventions) in increasing helmet use among children; to identify possible reasons for differences in the effectiveness of interventions; to evaluate effectiveness with respect to social group; to identify any adverse consequences of interventions. SEARCH STRATEGY: We searched 11 electronic databases and manually searched other sources of potentially relevant data. SELECTION CRITERIA: We included randomised controlled trials, cluster randomised controlled trials and controlled before and after studies. Studies included participants aged 0 to 18 years and described interventions to promote helmet use not requiring enactment of legislation. Studies had to report at least one of the following outcomes: observed helmet wearing; self-reported helmet ownership; self-reported helmet wearing. DATA COLLECTION AND ANALYSIS: Data were extracted by two reviewers working independently. Study results were adjusted to account for clustering. A random-effects model was used to pool data in meta-analyses. Heterogeneity was explored with sub-group analyses. MAIN RESULTS: Twenty-two studies were included. The odds of observed helmet wearing were significantly greater amongst those receiving non-legislative interventions (OR 2.30, 95% CI 1.37 to 3.85). Sub-group analysis indicated the effect may be greater for community-based studies (OR 4.30, 95% CI 2.24 to 8.25) and those providing free helmets (OR 4.35, 95% CI 2.13 to 8.89) than for those providing subsidised helmets (OR 2.02, 95% CI 0.98 to 4.17) and for those set in schools (OR 1.82, 95% CI 0.94 to 3.52). We found no significant effect of non-legislative interventions in increasing self-reported helmet ownership, but they were associated with a significant increase in self-reported helmet wearing (OR 3.90, 95% CI 1.42 to 10.69), particularly amongst interventions set in schools (OR 4.73, 95% CI 1.09 to 20.49) but there was significant unexplained heterogeneity between effect sizes for these two outcomes. AUTHORS' CONCLUSIONS: Community-based studies that include the provision of free helmets alongside an educational component increase observed helmet wearing in the areas in which they are set. There is some evidence that interventions in schools and those providing subsidised helmets may increase observed helmet wearing, but possibly to a lesser extent than those set in communities and those providing free helmets.

Adolescent↗
PubMed2006

Loud calling, spacing, and cohesiveness in a nocturnal primate, the Milne Edwards' sportive lemur (Lepilemur edwardsi).

Dispersed pair-living primates provide a unique model for illuminating the evolution of mechanisms regulating spacing and cohesiveness in permanently cohesive groups. We present for the first time data on the spatiotemporal distribution and loud-calling behavior of the Milne Edwards' sportive lemur, known to forage solitarily during the night, but to form stable male-female sleeping groups during the day. Data include radio-tracking observations of sleeping associations, and focal follows of pair partners during dispersal in the evenings and reunions in the mornings. Male-female pairs forming stable sleeping associations during the day were pair-bonded. They used sleeping sites and home ranges exclusively, and exchanged loud calls at potentially restricted resources during dispersal in the evenings and during reunion in the mornings. Direct agonistic conflicts between pairs and others were rare. The acoustic analysis of loud calls revealed nine major call types. They carry signatures for sex and pair identity, and provide the substrate for signaling and the potential for recognizing pair ownership. Thus, pairs use loud call exchanges as a vocal display for signaling territory ownership, thus limiting direct aggressive encounters between neighbors and strangers. Altogether, our findings provide the first empirical evidence for the hypothesis that loud calling has evolved as a key mechanism for regulating space use and cohesiveness in dispersed pair-living primates.

Animals↗
PubMed2004

Scent wars: the chemobiology of competitive signalling in mice.

Many mammals use scent marks to advertise territory ownership, but only recently have we started to understand the complexity of these scent signals and the types of information that they convey. Whilst attention has generally focused on volatile odorants as the main information molecules in scents, studies of the house mouse have now defined a role for a family of proteins termed major urinary proteins (MUPs) which are, of course, involatile. MUPs bind male signalling volatiles and control their release from scent marks. These proteins are also highly polymorphic and the pattern of polymorphic variants provides a stable ownership signal that communicates genome-derived information on the individual identity of the scent owner. Here we review the interaction between the chemical basis of mouse scents and the dynamics of their competitive scent marking behaviour, demonstrating how it is possible to provide reliable signals of the competitive ability and identity of individual males.

Animal Communication↗
PubMed2001

Reconsideration of discharge data to measure competition in the hospital industry.

Economists have long used state-collected discharge data to construct Hirschman-Herfindahl (HH) indices measuring hospital competition. Since data are collected to determine the facility providing the service rather than ownership, the difference between the number of reporting facilities and the number of competitors has grown over time due to mergers and networking activities. Consequently, the validity of the discharge HH methodology, as currently employed, is in doubt. Comparing the annual census of New York state acute-care hospitals by the State and the American Hospital Association (AHA), we find that it is increasingly important to account for changes in ownership when constructing such indices.

Abstracting and Indexing↗
PubMed2000

The importance of being gravid: egg load and contest outcome in a parasitoid wasp.

Owners have often been found to have an advantage in animal contests. One explanation of this is that the resource under dispute is of greater value to the owner than to the intruder (nonowner). Such 'resource value asymmetries' may be caused by intrinsic factors, such as the physiological state of the contestants. Females of the bethylid wasp Goniozus nephantidis fight for possession of paralysed hosts. A recent study found that larger females tend to win but owner status also confers an advantage. We tested the hypothesis that ownership advantage is linked to differences in egg load (the number of unlaid ripe eggs) between contestant females. Egg loads were highly variable and positively influenced by age, nutrition, body size and host ownership. Owners almost always won owner-intruder contests. The outcomes of owner-owner contests (in which size and status asymmetries were absent) were strongly influenced by differences in egg load. Copyright 2000 The Association for the Study of Animal Behaviour.

Journal Article↗
PubMed2001

Multiple asymmetry and concord resolutions of a conflict.

A model for a population-game with multiple asymmetry is studied, in which the participants are assumed to be different from one another both in size and in status as owners or non-owners of a territory. Only owners can reproduce, hence natural selection is assumed to operate in favor of the increase of ownership-time. Conditions for the evolutionary stability of the Bourgeois Principle of owner-priority, despite difference in body size, are characterized. It is shown that ownership-priority tends to be at least partially replaced by strength-priority as the availability of habitats, the expected longevity of potential intruders and the harm inflicted on the loser of an aggressive confrontation decrease, and as the expected longevity of the owner increases. It is further established that the combined effect of all these parameters can be characterized by a single parameter, referred to as the concord coefficient of the population. Finally, when this parameter reaches a certain critical level, only strength-priority can prevail. If the concord coefficient decreases below this critical level, no priority-rule can remain stable in the population, in which case aggressive confrontations cannot be avoided, at least in certain situations. In this case, it is shown that aggression emerges first among low-rank individuals.

Aggression↗
PubMedDate not supplied

Are adolescents receptive to current sales promotion practices of the tobacco industry?

BACKGROUND: The tobacco industry increased the portion of its marketing budget for sales promotion to $2.5 billion in 1993. Although it claims not to target those under age 18 years, it is important to determine the extent to which adolescents are affected as participation may lead to smoking initiation. METHODS: California population surveys, conducted in 1993 among youth ages 12-17 years (N = 5,531) and in 1994 among both youth (N = 1,735) and adults (N = 4,170), asked questions regarding possession and willingness to use promotional items. RESULTS: In 1994, young adults (18-24 years) were the most likely to possess a promotional item (27.5 +/- 4.1, +/- 95% confidence limit). However, willingness to use an item was highest among those ages 15-17 years (35.4 +/- 3.4%) and was also high among those ages 12-14 years (24.4 +/- 2.7%). Among youth, ownership or willingness to use promotional items was more likely for boys, whites, those reporting below average school performance, and those smoking or susceptible to smoking. Youth ownership of promotional items increased from 1993 to 1994, as did the frequency of their obtaining items from coupons. CONCLUSIONS: Promotional marketing undertaken by the tobacco industry was effective in capturing the interest of adolescents, although actual acquisition was highest among young adults. The rapidly increasing interest in tobacco promotional items from 1993 to 1994 may soon translate into increased adolescent smoking rates.

Adolescent↗
PubMed1994

Young adult suicide and exposure to television: a comment.

In an earlier study, Centerwall explored the relationship between ownership of television and rising youth suicide rates. The present study examined changes in youth suicide rates from 1960 to 1970 in the states of America as a function of television ownership in 1960. It seemed that youth suicide rates rose more in the wealthier states, and the social variable of wealth may be more important than any particular manifestation of this wealth, such as purchasing major appliances.

Adolescent↗
PubMed1993

Technology evaluation in a US hospital: the role of clinical engineering.

Appropriate deployment of technological innovation contributes to improvement in the quality of healthcare delivered, containment of cost, and an increased access to the healthcare system. Hospitals have been allocating a significant portion of their resources to procuring and managing capital assets; they are continuously faced with demands for new medical equipment and are asked to manage existing inventory for which they are not well prepared. To objectively manage their investment, hospitals are developing medical technology management programmes that need pertinent information and methods for new equipment planning as well as for reduction in the ownership costs of existing equipment. Clinical engineers can identify new medical equipment, review their institution's technological position, develop equipment-selection criteria, supervise installations and monitor postprocurement performance to meet their hospital's programme's objectives. This programme, together with cost accounting analysis, will objectively guide the capital assets decisionmaking process. The result of systematic planning and execution, the programme will assure the lowest life-cycle costs at the best performance. The clinical engineer's skills and expertise are needed to facilitate the adoption of an objective methodology for implementing the programme, thus improving the match between the hospital's needs and budget projections, equipment performance and cost of ownership.

Biomedical Engineering↗