State Medicaid nursing home reimbursement rates: adjusting for ancillaries

PURPOSE

State variation in inclusion of ancillary services in daily Medicaid nursing home reimbursement rates, versus covering ancillary costs outside of such rates, makes rate comparisons difficult. The purpose of this study is to adjust for inclusion of ancillaries when comparing Medicaid rates across states.

DESIGN AND METHODS

Data for 1987-1998 were drawn from a national survey of Medicaid reimbursement. Employing a random-effects model, the PANEL option in the LIMDEP software was used to estimate effects on state average Medicaid nursing facility constant-dollar rates of the inclusion in those rates of a set of ancillaries: physical therapy, occupational therapy, prescription drugs, nonprescription drugs, durable medical equipment (DME), medical supplies, and physician services.

RESULTS

Rates averaged higher when they included occupational therapy, physician services, nonprescription drugs, and both DME and medical supplies. Adjusting for the inclusion of ancillaries leads to a much different ranking of states than for unadjusted rates.

IMPLICATIONS

Public and industry policy makers should consider the inclusion of ancillaries in rates when considering the relative adequacy of rates across states.

Residential care supply and cognitive and physical problem case mix in nursing homes

OBJECTIVES

A rapid evolution has occurred in state policy and industry practices relative to assisted living and expanded use of residential care facilities for people with physical and cognitive frailty, yet relatively little is known about the interrelationship between this housing supply and nursing-home case mix.

METHODS

The association between residential care supply and the proportion of cognitively and physically impaired nursing facility residents was examined in more than 1,500 facilities in five states.

RESULTS

The proportion of nursing-home cases with only physical and cognitive impairment likely to be affected by emerging long-term care policy appears to be well under 10%. This effect is more persistent among admissions than continuing cases.

DISCUSSION

The findings raise caution about the optimistic assumptions of the interplay between residential care/assisted living policy and nursing-home use.

A review of 165 cases of transvaginal sacrospinous colpopexy performed by the Endo Stitch technique

The Endo Stitch technique has been in use in Geelong since 1994 as the method of performing transvaginal sacrospinous colpopexy (TSC). This article looks at the outcome of 165 of these procedures as assessed by a questionnaire. As the operation is technically easy, has a low complication rate and a high level of patient satisfaction we suggest that the Endo Stitch technique may be the method of choice for TSC.

Modulation of corneal endothelial hydration control mechanisms by Rolipram

Corneal stromal hydration is maintained by an active HCO3- transport mechanism located in the corneal endothelium. Whilst modulation of transport activity by changes in intracellular cAMP concentration have been noted, the site of effect is undefined. To resolve this question, the effects of Rolipram, a cAMP phosphodiesterase inhibitor, on endothelial physiology were determined. Addition of 0.1 mM Rolipram caused a threefold increase in intracellular cAMP with no change in cGMP. Associated with the increase in cAMP was a transient whole corneal thinning and a similarly transient increase in trans-endothelial potential difference, short-circuit current and resistance. The membrane potential hyperpolarized and the intracellular Na+ concentration decreased. The decreased intracellular Na+ was associated with an increased rate of Na+ extrusion between the endothelial cell and extracellular space. It is concluded that Rolipram increases the concentration of cAMP which activates the basolateral membrane Na+/K+-ATPase activity and increases net HCO3- transport. In addition there is a reduction in endothelial permeability which combined with the increase in pump activity may jointly explain the observed stromal thinning. The duplicity of responses indicates that if cAMP has a physiological role in regulating corneal hydration then it may operate on both the endothelial pump and the endothelial permeability.

Residential care supply, nursing home licensing, and case mix in four states

Simulation analyses quantify admission and continuing physical and cognitive impairment patient case-mix changes under two scenarios: with increases in residential care supply and with all nursing homes licensed only as skilled care facilities. Findings raise caution about the assumed interplay between residential care supply and nursing home use. The proportion of nursing home patients with only physical and cognitive impairment likely to be affected by current and emerging long-term care (LTC) policy was well under 25 percent of the nursing home population in each of the four study States. States varied in LTC supply and utilization controls.

The Queen Scallop Aequipecten opercularis: a new source of information on late Cenozoic marine environments in Europe

Few data exist on seasonal variation in the temperature (or other aspects of the environment) of late Cenozoic shelf seas in Europe. Ontogenetic records in the shell of Aequipecten opercularis, a widespread, fast-growing and typically well-preserved bivalve, are a potential source. Study of modern forms has shown that oxygen stable isotopes are incorporated in equilibrium with surrounding seawater (hence providing a faithful record of temperature) and data from late Holocene A. opercularis of the southern North Sea Basin (SNSB) indicate that extreme winter (as well as summer) temperatures are registered. Oxygen isotope data from apparently well-preserved, mid-Pliocene shells of the SNSB indicate seasonal temperatures similar to present, whereas microgrowth increment data suggest substantially warmer conditions, in accordance with other evidence. The balance of evidence thus implies cryptic diagenetic corruption of the isotopic temperature signature in mid-Pliocene shells. However, it would be premature to discount the possibility of cooler mid-Pliocene conditions than currently recognized. Ontogenetic variation in carbon isotopic composition within shells is minor and apparently unrelated to environment, but differences between mid-Pliocene, late Holocene and modern shells probably relate to changes in atmospheric CO2 concentration. Unlike certain taxa, seasonal variation is not evident in the strontium or magnesium contents of the A. opercularis shell, but may be displayed by other trace elements, hence affording (together with seasonal increment width variation) a means of independent temporal calibration of isotope profiles. Ontogenetic records of environment from A. opercularis can be complete (and, in the case of increment data, easily recovered) but are of short duration. They must be complemented by (less complete) records from longer lived taxa to obtain the fullest possible environmental history. Seasonal cycles in ontogenetic records afford a means of establishing age and growth rate, and can therefore provide information of value for evolutionary studies and management of living populations.

Infertility in female rabbits (Oryctolagus cuniculus) alloimmunized with the rabbit zona pellucida protein ZPB either as a purified recombinant protein or expressed by recombinant myxoma virus

Development of immunocontraceptives for wild rabbit populations requires selection of both effective antigens and effective delivery systems. Recombinant rabbit zona pellucida glycoprotein B (ZPB) produced in eukaryotic cells in vitro was an effective antigen and induced sustained infertility in 70% of female rabbits. This required two boosts and serum antibody titers of 12 800 or greater. Antibody titers in females were low after the initial immunization, as might be expected with a self-antigen; however, male rabbits had a strong antibody response, indicating that the protein was immunologically foreign. To develop a delivery system, ZPB was delivered by infection with a recombinant myxoma virus. In contrast to the results with ZPB protein, infection of rabbits induced a similar serum antibody response to ZPB in both sexes. This indicated that presentation of ZPB in the context of a virus infection was able to overcome tolerance in females. However, the antibody titers were lower than 12 800, and only 25% of female rabbits were infertile. This antibody response was boosted by injections of recombinant ZPB protein, after which 80% of female rabbits were infertile. Infertility was associated with antibody binding to zonae and varying degrees of ovarian pathology characterized by follicular degeneration and substantial depletion of primordial follicles. Oocyte and follicular degeneration appeared to be the principal mechanism of infertility and may be primarily induced by antibodies to ZPB.

Wearing Two Hats: Consumer & Provider

To change public attitudes toward people with mental illness, consumers need positive visibility and a strong community voice. We are making progress, although slowly, to eliminate the stigma surrounding mental illness. Progress can be attributed to the fact that the mentally ill are now living in our communities among us, and people are beginning to understand them more.

Parenting stress and mothers of young children with chronic illness: a cross-cultural study

This study examined the sources of parenting stress among mothers from Israel, Japan, Jordan, and the United States who had a young child with a chronic illness. The results indicated mothers from all four countries experienced high levels of child-focused and parent-focused stress that indicated a need for nursing intervention.

Cancer surveillance in the U.S.: can we have a national system?

Cancer-related services are consuming ever-increasing health resources; along with this trend, health care costs are rising. As health care planners, researchers, and policymakers formulate strategies to meet this challenge, they are looking to cancer registries and the health information system built around them as collectors of the most extensive information regarding cancer treatment in the U.S. Currently, there are multiple programs collecting and reporting data regarding cancer incidence, morbidity, mortality, and survival. This report profiles cancer surveillance efforts in the U.S. and describes the National Coordinating Council for Cancer Surveillance, which was organized in 1995 to facilitate a collaborative approach among the organizations involved.

Protein and cell engineering of components of the human immunoglobulin E receptor/effector system: applications for therapy and diagnosis

Adaptive immune responses characterised by the synthesis of antibodies of the immunoglobulin E (IgE) isotype play an important role in type I hypersensitivity disorders and parasitic infestations, diseases which have an significant socioeconomic impact world-wide. This paper considers potential applications of recent advances in our understanding of the origin of isotype specific immune responses which emerged as a result of cell and protein engineering studies on components of the human IgE/receptor/effector system. Furthermore, the identification of the receptor binding regions in IgE as a result of the development of a stable assay system has important applications for the design of rational therapeutic interventions in allergy and asthma, the treatment of mast cell tumours, and the establishment of procedures for the selective isolation of cells expressing the high-affinity receptor for IgE for functional studies.

Volume-controlled ventilation is made possible in infants by using compliant breathing circuits with large compression volume

We studied the weight dependency of set tidal volume (VTset) during volume-controlled ventilation of 80 infants (ASA physical status I-IV, 0.7-20 kg), including prematures, neonates, and exprematures, who were anesthetized for major and minor surgery, including abdominal, thoracic, and neurosurgical procedures. After neuromuscular blockade and endotracheal intubation, infant's lungs were ventilated with an Ohmeda 7800 volume-limited ventilator and either a pediatric or adult circle breathing system (PC or AC) or a Bain circuit (Ba) and a pediatric- or adult-sized bellows (PB or AB). Except for larger and older infants in the ACAB group, body weight, age, peak inspiratory pressure (PIP), ETCO2, and SPO2 did not differ among groups. Compression volume loss was large in the five circuits tested. We found that VTset/kg varied with weight in a curvilinear relationship where y represents volume added and x represents PIP (y = 175.02x-0.87; r2 - 0.87), whereby VTset is approximately 150-200 mL/kg for a 1-kg infant and approximately 25 mL/kg for infants > or = 10 kg. Ventilation was adequate in each infant, except for one with extremely poor pulmonary compliance. We conclude that large compression volumes associated with compliant breathing systems make possible the use of volume-controlled ventilators in small infants.

Internal calvarial bone distraction in rabbits with experimental coronal suture immobilization

Correction of craniosynostosis involves removal of the coronal suture to allow for expansion of the developing brain and normal craniofacial growth. Frequently, however, the site reossifies, restricts growth, and requires additional surgery. The present study was designed to assess the effects of an internal, subperiosteal calvarial distractor on suturectomy site patency and compensatory craniofacial growth changes in an experimental rabbit model of coronal suture synostosis. In the present study, 43 1 1/2-week-old rabbits were used. Amalgam markers were placed across the frontonasal, coronal, and anterior lambdoidal sutures in all animals. Twenty-nine rabbits underwent bilateral coronal suture immobilization using methyl methacrylate. Fourteen rabbits were left untreated and served as sham controls. At 6 weeks of age, the immobilized rabbits were divided into three groups: (1) immobilized (controls), (2) suturectomy, and (3) suturectomy and distraction. The distractors were activated percutaneously at an average of 0.6 mm/week for 5 weeks (3 mm total). Lateral head radiographs were taken at 1 1/2, 6, 12, and 18 weeks of age. Results revealed that, by 6 weeks of age, animals with coronal suture immobilization exhibited significantly (p < 0.01) reduced growth across the coronal suture, resulting in shorter and inferiorly rotated cranial vaults compared with sham controls. By 12 weeks of age, rabbits with distraction returned to normal (sham control) coronal suture marker separation, whereas rabbits with immobilized sutures and suturectomy only showed significantly reduced marker distances. Rabbits with distraction also exhibited greater anterior cranial base lengths compared with the other experimental groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin resistance, lipoproteins, body fat and hemostasis in nonobese men with angina and a normal or abnormal coronary angiogram

OBJECTIVES

The aim of this study was to compare metabolic risk factors in men with anginal chest pain and a normal or abnormal coronary angiogram with those in healthy men.

BACKGROUND

Risk factors for coronary heart disease, including lipoprotein abnormalities, hypertension and adiposity, may be metabolically interlinked, with insulin resistance and hyperinsulinemia being pivotal to these disturbances.

METHODS

Glucose and insulin metabolism, lipids and lipoproteins, hemostasis, blood pressure and body fat distribution were measured in 77 nonobese middle-aged men who had anginal chest pain (39 with an abnormal coronary angiogram and 38 with no detectable angiographic abnormality) and were compared with those of 40 healthy men of similar age and body mass index.

RESULTS

Patients with chest pain had higher insulin responses to an intravenous glucose challenge, lower insulin sensitivity, lower high density lipoprotein (HDL) and subfraction 2 cholesterol, lower apolipoprotein AI, higher triglycerides, greater android fat and higher systolic blood pressure at rest compared with levels in healthy control subjects (p < 0.05). Those with an abnormal coronary angiogram had lower tissue plasminogen activator levels, higher plasminogen activator inhibitor 1 levels and more android fat than did those with a normal angiogram (p < 0.05). Insulin sensitivity correlated positively with HDL (p < 0.05) and subfraction 2 (p < 0.001) cholesterol and negatively with triglycerides (p < 0.01), android fat proportion (p < 0.01) and systolic blood pressure (p < 0.05), whereas insulin response showed converse correlations.

CONCLUSIONS

These findings provide new evidence of the central role of insulin resistance and hyperinsulinemia in the development of risk factors associated with coronary heart disease.

Chronically ill children in self-care: issues for pediatric nurses

The self-care (or latchkey) arrangement for children with a chronic illness is an important topic for pediatric nurses. This article reviews the impact of self-care for children's development, examines the effectiveness of teaching self-care skills to latchkey children, and provides assessment and intervention information to help pediatric nurses who are working with parents and children with chronic illness who are in self-care.

Implementation of the postdischarge follow-up call in the patient care units

The Telephone Call Back System was implemented from October 1989 in the Inpatient and Ambulatory Care Units as a postdischarge follow-up and as an evaluation of the patients' hospital experience. Nurses called patients discharged from the Ambulatory Care Unit within 24 hours postdischarge and within 24-48 hours from the Inpatient Unit. Questions asked included present physical status, ocular discomfort, availability of assistance at home, and if there were any questions and concerns. For the year 1990, 77 percent of the patients discharged from the Ambulatory Care Unit were called and 71 percent were contacted. From the Inpatient Unit, 89 percent were called and 68 percent were contacted. Patient response required the following nursing interventions: review of discharge instructions, referral to an ophthalmologist and/or an internist, referral to a patient representative/social worker, reassurance on ocular signs and symptoms consistent with a normal postsurgical period, and patient teaching other than ophthalmic care. Patients discharged from the Inpatient Unit required more nursing intervention than patients discharged from the Ambulatory Care Unit. More than 99% of the patients discharged in both patient care units were satisfied with their hospital care. These results indicate the importance of postdischarge follow-up in the continuity of health care and in the transition from the health care institution to the home setting.

Limited value of the resting electrocardiogram in assessing patients with recent onset chest pain: lessons from a chest pain clinic

OBJECTIVE

To evaluate a clinic set up specifically to assess patients with recent onset chest pain, particularly those presenting with a normal resting electrocardiogram.

DESIGN

Retrospective review of case notes.

SETTING

Cardiac department of a tertiary referral cardiothoracic centre.

PATIENTS

250 consecutive patients with recent onset chest pain seen within 24 hours of general practitioner referral.

OUTCOME MEASURES

Clinical diagnosis and management.

RESULTS

40% of patients were seen within seven days of the onset of symptoms. Twenty seven per cent had non-cardiac symptoms and could be discharged while 60% were considered to have cardiac pain. Sixty six patients (26%) were admitted directly from the clinic and 48 of these underwent coronary angiography within three weeks. Seventy patients (28%) have so far undergone intervention (angioplasty or coronary artery surgery), 22 within one month of presentation. One hundred and nine patients (44%) presented with a normal resting electrocardiogram, 21 of whom were considered to have unstable angina. Forty one of these patients were investigated of whom 37 were found to have significant coronary disease and 26 have undergone intervention.

CONCLUSIONS

This experience highlights the inadequacy of a routine electrocardiogram reporting service in patients with recent onset of chest pain. An alternative facility offering immediate and complete cardiac assessment produced patient benefit with early diagnosis and intervention. Investigation of these patients, however, accounted for 5% of cardiac catheterisation laboratory throughput; this was a significant additional and unscheduled workload.

Frontal bone advancement and compensatory craniofacial growth changes in rabbits with experimental coronal suture immobilization

Recent clinical advances in the surgical correction of coronal suture synostosis involve the overcorrection of a frontal bone segment to allow for unrestricted expansion of the developing neurocapsular matrix. However, the effects of such large-scale calvarial repositioning on subsequent brain mass growth trajectories and compensatory cranio-facial growth changes is unclear. This study was designed to investigate this relationship in an experimental rabbit model of bilateral coronal suture synostosis. Amalgam markers were placed across the frontonasal, coronal, and anterior lambdoid sutures in thirty-one 1.5-week-old rabbits. Twenty-one animals underwent bilateral coronal suture immobilization using methyl-methacrylate. Ten animals were left untreated and served as sham controls. At 6 weeks of age, the coronal suture was released by frontal bone craniotomy or frontal bone craniotomy with a 6-mm frontal bone advancement. Lateral head radiographs were taken at 1.5, 6, 7, 9, 12, and 18 weeks of age. Results revealed that by 6 weeks of age, animals with coronal suture immobilization exhibited growth disturbances across the various sutures resulting in altered craniofacial and cranial vault shape compared to control animals. Following coronal suture release, animals that underwent craniotomy showed rapid restenosis, which resulted in significantly altered cranial vault shape and cranial orthocephalization by 18 weeks of age. Animals that underwent frontal bone advancement exhibited normal overall craniofacial growth by 18 weeks of age compared with control animals but did exhibit regional compensatory growth disturbances at the frontonasal and anterior lambdoid sutures, possibly related to neural tissue distension.(ABSTRACT TRUNCATED AT 250 WORDS)

Stability of school-age children's survey responses

School-age children may have low levels of response stability on many questions asked in survey research. This article incorporates evidence from a three-wave panel study into a discussion of some possible causes of low stability. In general, children's responses to questions of fact were more stable than responses to questions of opinion. The findings suggest that when questionnaires are carefully developed, school-age children are reliable respondents.