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PubMed2002

Periarterial papaverine application improves intraoperative kidney function during laparoscopic donor nephrectomy.

BACKGROUND: Laparoscopic donor nephrectomy decreases disincentives to donation frequently associated with the disadvantages of open surgery. However, concerns have been raised regarding graft quality, since the incidence of delayed graft function is higher when compared with open procedures. This may be caused by amelioration of kidney perfusion due to the elevated intraabdominal pressure and to a mechanically induced renal angiospasm during donation. This study was addressed to reveal whether the renal periarterial application of papaverine is able to enhance renal blood flow during laparoscopic nephrectomy. MATERIALS AND METHODS: Twelve male piglets underwent left laparoscopic donor nephrectomy after endoscopic occlusion of the right renal vessels and ureter. Urine output and creatinine clearance were determined as indicators of renal blood flow. In the treatment group (n = 6) papaverine hydrochloride was administered to the tissue surrounding the renal artery prior to preparation of the vessels and results were compared with those of controls (n = 6). Free sodium excretion was measured to preclude prerenal failure. RESULTS: In the control group the mean urine output was 0.015 ml/min/kg and the mean creatinine clearance was 0.95 ml/min/kg. In pigs treated with papaverine the mean urine output was 0.052 ml/min/kg and the mean creatinine clearance was 2.22 ml/min/kg. The differences were significant (urine output, P = 0.02; creatinine clearance, P = 0.038). CONCLUSIONS: Papaverine improves renal function during laparoscopic kidney harvest when applied in the vicinity of the renal artery prior to vascular preparation.

Animals↗
PubMed1998

Financial incentives and primary care provision in Britain: do general practitioners maximise their income?

The system of remunerating general practitioners (GPs) in Britain underwent significant changes in April 1990 with the implementation of a new contract between individual GPs and health authorities. The changes were a precursor to a wide-ranging programme of reforms of the British National Health Service. This paper investigates the relationship between financial incentives and the provision of primary health care services in Britain. A comprehensive anonymized data set was used, comprising information on 208 general practices in Scotland which serve just under one million people. An econometric model was tested to identify the determinants of cross-practice variation in the magnitude of the changes in GPs' remuneration levels between the two contracts. A linear programming model was used to examine the GPs' response to the financial incentives built into the new contract. The results of the econometric model indicated that the main beneficiaries of the 1990 contract were the practices which had expanded over the 1989-92 period, re-structured the GPs' partnership and made use of managerial skills by employing a practice manager; those practices also had larger lists in 1992 and relatively more patients attracting deprivation payments. The linear programming model showed that only a small minority of the practices (4.8%) maximised the remuneration from the new contract. Optimal solutions concerning income maximization strategies identified financial disincentives in the fee structure of the remuneration system associated with the provision of selected services and the care of particular groups of patients. The successful adoption of these strategies would involve cream skimming and selective service provision. However, there is no conclusive evidence of British GPs engaging in such activities.

Age Factors↗
PubMed1996

Women's transitions in the labour market: a competing risks analysis on German panel data.

"This paper analyses the transitions between the three states of non-employment, part-time and full-time work of a sample of married women living in West Germany....A non-parametric duration analysis shows that women have a similar attachment to full-time and part-time work in terms of survival, and that survival in non-employment is shorter than in the other two states. Estimates of a parametric discrete-time competing risks duration model show that wives of retired husbands go into full-time work, children under 3 years have a disincentive effect on part-time work and that part-time work is a state that German women prefer to stay in and not a first step to full-time employment, whereas foreign women living in West Germany prefer full-time jobs."

Demography↗
PubMed1986

Issues in the treatment of mentally retarded patients in the community mental health system.

Developmental disability, particularly mental retardation, both affects a person's cognitive functioning and places that person on an alternative track of development which, when combined with social, political and economic pressures, places the developmentally disabled person at increased risk for mental illness. The presenting symptoms of mental illness will be modified by the mentally retarded person's cognitive impairment, personality development, and massively different life experience, as will the nature of his interactions with helping agencies. Evaluation, diagnosis and treatment must evolve from an alliance with the mentally retarded persons, not with caretaking agencies, and must be modified to take into account the retarded person's powerlessness. The therapist must be prepared to act as both advocate and bridge-builder for the patient, with the patient's increasing participation. The therapist must be prepared to steer between the Scylla of ignorance about the diagnosis and treatment of mental illness in the mentally retarded and the Charybdis of financial disincentives for human service agencies to collaborate in their care. The advantages of inter-agency cooperation in the treatment of dually-diagnosed individuals is described and illustrated.

Adult↗
PubMed2005

Welfare reform and interstate migration of poor families.

The thesis of this study is that as a result of increased inequalities in welfare rules, the 1996 welfare reform act not only enhanced incentives for poor families to move but also (and perhaps more important) created disincentives for them to stay in "race to the bottom" states. In testing this thesis, we evaluated the mediating and moderating roles of state economic development and family structure. We merged data from three main sources: the 1996-1999 panel of the Survey of Income and Program Participation, the Urban Institute's Welfare Rules Database, and state economic data from the Bureau of Labor Statistics. Modeling both destination (pull) and departure (push) effects of welfare policy measures and selected covariates in a nested discrete-time event-history migration analysis, we found robust support for the thesis that stringency in state welfare-eligibility and behavior-related rules stimulated interstate out-migration of poor families in the United States. However poor families were not drawn to states with relatively more-lenient welfare rules, although stringency in state welfare dollar benefits inhibited in-migration and state unemployment patterns may have conditioned the migration effects of welfare-reform rules on the choice of destination. Single mothers were not more directly affected by welfare-eligibility and behavior-related rules than were poor married couples.

Data Collection↗
PubMed2005

Financial incentives, cross-purposes, and moral motivation in health care provision.

Financial incentives and disincentives are fundamental to a category of proposals, usually characterised as forms of managed care, whereby the pecuniary interests of health care providers are directly affected by their clinical decision-making. Presently, Australian health care administrators and private insurers are adopting financial incentives as a means of ensuring provider compliance with 'health outcome' and cost-constraint objectives. To the extent that this has occurred, health-care relationships are transformed to emulate, more closely, a commercial transaction. This paper questions the ideological assumptions which inform the use of financial incentives in the health care domain and raises concerns with regard to the potential for financial incentives to undermine the moral integrity of clinical decision-making. It also challenges the legitimacy of rationing health care resources through the use of this measure, particularly when adopted by private insurers of health care.

Australia↗
PubMed2000

Erosion Control at Construction Sites: The Science-Policy Gap.

/ To test the effectiveness of Michigan's soil erosion control law, 30 construction sites were evaluated in the east-central part of the state. The analytical framework lumped nine best management practices (BMPs) most closely related to the law into three categories: slope stabilization, soil stabilization, and water management. All sites were in the land clearing or foundation/framing stage of construction and were evaluated within 2 days after a rainfall event. Only four of the sites performed above the mean of the scoring scale, with the categorical scoring of BMPs indicating the worst performance for slope stabilization measures. The poor results suggest a failure to integrate scientific knowledge of erosion control with policy. A fundamental problem is the lack of basic site data on soil, topography, and hydrology, resulting in the incorrect application of BMPs, such as staging, filter fences, and berms. The current institutional framework for soil erosion control also provides disincentives to mitigate local erosion problems.

Journal Article↗
PubMed2001

Early action to reduce greenhouse gas emissions before the commitment period of the Kyoto protocol: advantages and disadvantages.

Current "business as usual" projections suggest greenhouse gas emissions from industrialized nations will grow substantially over the next decade. However, if it comes into force, the Kyoto Protocol will require industrialized nations to reduce emissions to an average of 5% below 1990 levels in the 2008-2012 period. Taking early action to close this gap has a number of advantages. It reduces the risks of passing thresholds that trigger climate change "surprises." Early action also increases future generations' ability to choose greater levels of climate protection, and it leads to faster reductions of other pollutants. From an economic sense, early action is important because it allows shifts to less carbon-intensive technologies during the course of normal capital stock turnover. Moreover, many options for emission reduction have negative costs, and thus are economically worthwhile, because of paybacks in energy costs, healthcare costs, and other benefits. Finally, early emission reductions enhance the probability of successful ratification and lower the risk of noncompliance with the protocol. We discuss policy approaches for the period prior to 2008. Disadvantages of the current proposals for Credit for Early Action are the possibility of adverse selection due to problematic baseline calculation methods as well as the distributionary impacts of allocating a part of the emissions budget already before 2008. One simple policy without drawbacks is the so-called baseline protection, which removes the disincentive to early action due to the expectation that businesses may, in the future, receive emission rights in proportion to past emissions. It is particularly important to adopt policies that shift investment in long-lived capital stock towards less carbon-intensive technologies and to encourage innovation and technology development that will reduce future compliance costs.

Air Pollution↗
PubMed2006

Realigning economic incentives for depression care at UCSF.

Behavioral health carve-out arrangements create financial disincentives for primary care providers (PCPs) to treat depression. A novel collaboration between a primary care practice, a health insurer, and a managed behavioral health organization (MBHO) allows PCPs to receive reimbursement and schedule longer appointments to care for depressed patients. This article describes the details of the arrangement, and early results of this collaboration. Early results find that financial incentives are critical for implementation, but that time incentives do not appear to motivate PCPs. Sustainability of this model will require participation of multiple primary care practices, health insurers, and MBHOs.

California↗
PubMed2002

Changes in medicare reimbursement: impact on therapy for benign prostatic hyperplasia.

Medicare spending accounts for 17% of all health spending and therefore exerts a significant influence on health care spending policies. Medicare policies such as Diagnostic Related Groups and the Resource Based Relative Value System have resulted in profound changes in health care delivery in the United States. These resource-allocation methods are one of the major sources of controversies between managers, doctors, politicians, and social scientists. Financial disincentives associated with these resource-allocation policies have effectively rationed select therapies, particularly transurethral resection of the prostate (TURP). As a consequence, TURP, once the second most common surgical procedure billed to Medicare and comprising 38% of major surgical procedures performed by urologists, is increasingly challenged by medical therapy and minimally invasive surgical therapies that may be associated with lower efficacy and durability. This article examines the history of Medicare policies and their influence on TURP.

Health Care Costs↗
PubMed1985

Simple and complex antibody reactions in radioimmunoassay and the prediction of assay characteristics.

Radioimmunoassays are usually developed empirically since there have been few established rules which cover general RIA behaviour. Evidence is presented which enables the delineation of 2 types of RIA with distinct group characteristics. (1) Simple RIA, conforming to the law of mass-action kinetics, is a result of univalent interaction. Examples of simple RIA include hapten assays and those using a monoclonal antibody (McAb). (2) Complex RIA occurs when antigen reacts multivalently with a polyclonal antiserum (PcAs). The formation of multicomponent complexes between a large molecular weight antigen and a PcAs is demonstrated using gel exclusion chromatography. These complexes are resistant to dissociation and are responsible for higher affinity, greater sensitivity and slower equilibration times compared to simple RIA. The assignment of an assay to either the simple or complex RIA group is dependent upon either the molecular size of the antigen or the use of a McAb. The consequent predictability of RIA behaviour enables a more rational approach to optimal assay design than current theory allows. It is advocated that the inability of a McAb to form multicomponent complexes is a major disincentive to their indiscriminate adoption in RIA.

Antibodies, Monoclonal↗
PubMed1996

Abortion education for residents.

Planned Parenthood of New York City established a physician education program in first-trimester abortion using local anesthesia at its three clinics. This paper describes the program's technical and counseling skills curricula, individualized instruction, quality-assurance procedures, obstacles encountered, and solutions implemented. Major obstacles were slow initial recruitment, disincentives of off-site education, and scheduling difficulties. Solutions included grand rounds presentations at local hospitals to recruit residents, considerable flexibility in rotational scheduling, and expansion of instructional staff to include academic physicians as teachers. Since its inception in July 1993, 53 residents and attending physicians have been taught to perform induced abortions at Planned Parenthood, and 25 who completed the program are currently providing abortions around the nation. Planned Parenthood's experience in teaching residents from local hospitals to perform first-trimester abortion using local anesthesia may be valuable for those who wish to implement similar collaborative off-site educational programs.

Abortion, Induced↗
PubMed1988

Financial risk, hospital cost, complications and comorbidities (CCc) in non-CC stratified urology diagnostic related groups.

The federal Medicare Diagnosis Related Group payment mechanism is undergoing constant change. Significant interest has been generated at the health policy level regarding reimbursement for patients with complications and comorbidities. The purpose of this study was to analyze hospital resource consumption for patients in the seventeen urology non-complicating condition (CC) stratified Diagnostic Related Groups (DRGs), currently 45 percent of urology DRGs. We analyzed 185 Medicare patients in these non-CC stratified urology DRGs and found that patients with more CCs per patient had higher total hospital costs per patient, financial risk under DRGs, a greater percentage of outliers, and a higher mortality, than patients in these same DRGs with fewer CCs per patient. These findings suggest that the current DRG system is inequitable to some patients and certain hospitals vis-a-vis non-CC stratified urology DRGs. The Health Care Financing Administration has not significantly changed the complicating condition urology DRG classification, as of its recent May, 1988 legislation. Financial disincentives to treat these patients may affect both their access and quality of care in the future.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1989

Hospital costs, cancer patients, and gynecology diagnostic related groups.

This study of 115 Medicare gynecology patients in five noncancer-designated gynecology diagnostic related groups (DRGs) demonstrated that patients with a diagnosis of a malignancy (N = 52) had significantly higher hospital resource utilization compared to patients without a malignancy (N = 63) in these gynecology DRGs. Cancer patients had higher total hospital costs (P less than 0.001), longer hospital length of stay (P less than 0.01), significant financial losses under DRGs (P less than 0.01), greater percentage of outliers (P less than 0.05), greater severity of illness, and greater mortality (P less than 0.001) compared to noncancer patients in these same gynecology DRGs. These findings raise the question of whether hospitals will be adequately reimbursed by DRGs for many gynecology cancer patients. Disincentives for hospitals to treat gynecology cancer patients under the current DRG reimbursement system may affect both the access to and the quality of care.

Aged↗
PubMed1989

Public support for policy initiatives regulating high-fat food use in Minnesota: a multicommunity survey.

Public support of eight policies to regulate the sale and consumption of high-fat food was evaluated in a survey of 438 women and 383 men in seven Minnesota communities. The survey was part of the ongoing activities of the Minnesota Heart Health Program (MHHP). Respondents, when asked to indicate their level of support or opposition to each of eight policies, expressed general support for all but two. Women were consistently more supportive than men. Other sociodemographic characteristics and reported use of food and other substances were generally not predictive of support. Policies that would control conditions of sale or information about the product were the most strongly supported. Taxation as an incentive to food producers to provide alternatives to high-fat food or as a disincentive to consumers to purchase these foods was moderately supported. A proposal to limit sale of high-fat food to children was the most strongly opposed. The majority of respondents indicated that they felt the individual consumer, as opposed to the producer or retailer, is most responsible for problems associated with high-fat food use. The three communities which had received MHHP health promotion activities were significantly more supportive than the comparison communities on two of the eight proposals. There is a moderate level of support in the general public for additional policies to regulate the sale and consumption of high-fat foods. These policy level interventions, similar to policies common in the regulation of alcohol and tobacco use, may be a feasible strategy to help moderate use of potentially health-compromising food products.

Adolescent↗
PubMedDate not supplied

The neural basis of drug craving: an incentive-sensitization theory of addiction.

This paper presents a biopsychological theory of drug addiction, the 'Incentive-Sensitization Theory'. The theory addresses three fundamental questions. The first is: why do addicts crave drugs? That is, what is the psychological and neurobiological basis of drug craving? The second is: why does drug craving persist even after long periods of abstinence? The third is whether 'wanting' drugs (drug craving) is attributable to 'liking' drugs (to the subjective pleasurable effects of drugs)? The theory posits the following. (1) Addictive drugs share the ability to enhance mesotelencephalic dopamine neurotransmission. (2) One psychological function of this neural system is to attribute 'incentive salience' to the perception and mental representation of events associated with activation of the system. Incentive salience is a psychological process that transforms the perception of stimuli, imbuing them with salience, making them attractive, 'wanted', incentive stimuli. (3) In some individuals the repeated use of addictive drugs produces incremental neuroadaptations in this neural system, rendering it increasingly and perhaps permanently, hypersensitive ('sensitized') to drugs and drug-associated stimuli. The sensitization of dopamine systems is gated by associative learning, which causes excessive incentive salience to be attributed to the act of drug taking and to stimuli associated with drug taking. It is specifically the sensitization of incentive salience, therefore, that transforms ordinary 'wanting' into excessive drug craving. (4) It is further proposed that sensitization of the neural systems responsible for incentive salience ('for wanting') can occur independently of changes in neural systems that mediate the subjective pleasurable effects of drugs (drug 'liking') and of neural systems that mediate withdrawal. Thus, sensitization of incentive salience can produce addictive behavior (compulsive drug seeking and drug taking) even if the expectation of drug pleasure or the aversive properties of withdrawal are diminished and even in the face of strong disincentives, including the loss of reputation, job, home and family. We review evidence for this view of addiction and discuss its implications for understanding the psychology and neurobiology of addiction.

Adaptation, Physiological↗
PubMed1984

Impediments to recruitment in the Canadian National Breast Screening Study: response and resolution.

Eighteen months after the 1980 initiation of the Canadian National Breast Screening Study (NBSS) (a multicenter randomized controlled trial that will involve 90,000 women), the Toronto center experience such severe problems with recruitment that the study as a whole was jeopardized. Impediments to recruitment arose in five areas. The design of the protocol was criticized by some physicians and participants, a problem that could only be met by justifying the design. A second problem was a lack of understanding of the concept of screening and mistaken assumptions about what participation in the NBSS entailed. Thirdly, recruitment problems occurred at a time when the media were focusing much attention on the hazards of low-level ionizing radiation. Fourthly, women were found to have a variety of personal reasons for delaying or avoiding entry into the study. Finally, factors characteristic of the Canadian milieu such as universal health coverage may have acted as a disincentive to entry. To improve physician understanding, NBSS personnel made presentations at medical rounds and scientific meetings; articles were written for medical journals. To win support from the lay public, talks were given to recreation or work-based groups. Appearances on radio and television talk shows were sought out. Mass mailings to university staff and professional associations did not produce large responses, nor did advertisements on television, radio, or in newspapers. The distribution of a check insert in a government mailing gave rise to hundreds of appointments across Canada. However, for generating an ongoing adequate level of recruitment, the best measure has been the mailing of personally addressed letters to eligible women followed by a telephone call. Data on response rates, cost and women's attitudes toward the study are reported. By early 1983, Toronto met its recruitment target of 12,000.

Adult↗