Performance of rural health clinics: an examination of efficiency and Medicare beneficiary outcomes

INTRODUCTION

In 2011, some 3800 Rural Health Clinics (RHCs) delivered primary care in underserved rural areas throughout the USA. To date, little research has been conducted to identify the variability in RHC performance. In an effort to address the knowledge gaps, a national, longitudinal study was conducted of a panel of 3565 RHCs. The goals of the study were to determine: (1) the relationship between two aspects of performance: efficiency and effectiveness; and (2) the factors that influence variation in RHC performance.

METHODS

A non-experimental study of RHC performance was conducted using 2 years of secondary data from multiple sources. A study panel of RHCs was formed. This panel was composed of all RHCs continuously in operation during the period 2006-2007. The study panel was divided into two subsets - one for the provider-based clinics; another for the independent clinics. The individual RHC was the unit of analysis throughout the study. Descriptive statistics were calculated for each subset. Bivariate analyses was conducted of the relationships between the clinic characteristics and the performance outcome measures, as well as the interrelationships between various clinic characteristics using χ², t-tests, Cramer's V, Pearson correlation, and Spearman correlation statistics. Next, using covariance structure analysis, the interrelationships were examined among the context (community or demographic factors), design (organizational structure and other mediating factors), and performance (efficiency and effectiveness) of RHCs. Three hypotheses were tested: (1) the effectiveness of RHCs is positively influenced by efficiency; (2) there is a reciprocal relationship between RHC efficiency and effectiveness; and (3) large RHCs are more efficient than small RHCs.

RESULTS

To test the hypotheses that effectiveness of RHCs is positively influenced by efficiency and that there is a reciprocal relationship between efficiency and effectiveness, two covariance structure models were developed and revised: one for independent and one for provider-based RHCs. However, the revised models were not supported by the data. To test the hypothesis that large RHCs are more efficient than small ones, two additional efficiency-based structural equation models were constructed (one for independent RHCs and another for provider-based RHCs). Both of these models were supported by the data (independent model: χ² = 13.8, df = 8, p = 0.088, relative χ² = 1.723, adjusted goodness of fit index [AGFI] = .981, root mean square error of approximation [RMSEA] = .034; provider-based model: χ² = 19.011, df = 8, p = 0.015, relative χ² = 2.376, AGFI = .978, RMSEA = .043).

CONCLUSION

This study examined the relationship between efficiency and effectiveness of RHCs. In addition, it identified several factors that influence the variation in RHC performance. The study has implications for optimizing RHC performance, providing quality services to rural populations, and enhancing the value of RHC data. The present is a critical time in the history of RHCs as they transition to meet the goals and expectations of the US health system reform. Additional research is needed to quantify and trend RHCs' contribution to the rural health delivery system in order to optimize their service to rural populations.

Assessment of Kalman filter bias-adjustment technique to improve the simulation of ground-level ozone over Spain

The CALIOPE air quality modelling system has been used to diagnose ground level O(3) concentration for the year 2004, over the Iberian Peninsula. We investigate the improvement in the simulation of daily O(3) maximum by the use of a post-processing such as the Kalman filter bias-adjustment technique. The Kalman filter bias-adjustment technique is a recursive algorithm to optimally estimate bias-adjustment terms from previous measurements and model results. The bias-adjustment technique improved the simulation of daily O(3) maximum for the entire year and the all the stations considered over the whole domain. The corrected simulation presents improvements in statistical indicators such as correlation, root mean square error, mean bias, and gross error. After the post-processing the exceedances of O(3) concentration limits, as established by the European Directive 2008/50/CE, are better reproduced and the uncertainty of the modelling system, as established by the European Directive 2008/50/CE, is reduced from 20% to 7.5%. Such uncertainty in the model results is under the established EU limit of the 50%. Significant improvements in the O(3) timing and amplitude of the daily cycle are also observed after the post-processing. The systematic improvements in the O(3) maximum simulations suggest that the Kalman filter post-processing method is a suitable technique to reproduce accurate estimate of ground-level O(3) concentration. With this study we evince that the adjusted O(3) concentrations obtained after the post-process of the results from the CALIOPE system are a reliable means for real near time O(3) forecasts.

Indoor radon measurements in the city of Valencia

The indoor radon risk in Valencia (Spain) was studied more than twenty years ago in two surveys using different methodologies and leading to contradictory results. We report here on new indoor radon measurements with the charcoal canister technique, which confirm the low average level of indoor radon in the city, with a geometrical mean of 24 Bq/m(3) and an arithmetic mean of 27 Bq/m(3).

Use of the LightCycler SeptiFast test for rapid etiologic diagnosis of nosocomial infection in gynecological sepsis

A new molecular biology technique was used in 2 subjects with systemic inflammatory response syndrome and negative blood cultures, in which broad-spectrum antibiotics were administered, without a visible improvement. Case 1: A 33-year-old female patient with a diagnosis of septic shock originating in the abdomen was admitted in a bad general state, presenting with systemic inflammatory response. The patient's general condition did not improve. As an alternative, we used molecular biology. Candida krusei was reported and the patient responded well to the treatment. Case 2: A woman in the 36th week of pregnancy, with diabetes mellitus and secondary renal insufficiency, presented with fever and hematological alterations. The patient's progress was slow and accompanied by persistent fever, bandemia and leukopenia, as well as signs of multiple organ dysfunction. The SeptiFast test identified Enterobacter cloacae/aerogenes as the cause of the disorder. However, the patient died 24 h after the antibiotics were changed.

Cardiovascular risk factors in primary Sjögren's syndrome: a case-control study in 624 patients

We evaluated the prevalence and clinical significance of cardiovascular risk factors in a large series of patients with primary Sjögren’s syndrome (SS), focusing on the possible association with clinical and immunological SS features, the therapies administered, and the impact on cardiovascular disease. The study cohort included 312 patients fulfilling the 2002 classification criteria for primary SS, consecutively evaluated and followed in our department between 1984 and 2009. The control group consisted of 312 age- and sex-matched patients without systemic autoimmune diseases followed during the study period in a primary care centre.

In comparison with the age- and sex-matched control group, patients with primary SS showed a higher frequency of diabetes mellitus (27% versus 13%, p < 0.001) and hypertriglyceridaemia (22% versus 15%, p = 0.023), and a lower frequency of hypertension (30% versus 46%, p < 0.001) and smoking (19% versus 31%, p < 0.001). The adjusted, multivariate analysis showed that SS patients with at least three cardiovascular risk factors had a higher mean age at SS diagnosis (p < 0.001), a higher frequency of liver involvement (p = 0.01) and central nervous system involvement (p = 0.001), higher mean levels of C-reactive protein (CRP, p = 0.001), a lower percentage of circulating gamma globulins (p = 0.001), and had received corticosteroids more frequently (p = 0.003) in comparison with patients without cardiovascular risk factors. Patients who had received corticosteroids showed a higher frequency of hypertension (37% versus 25%, p = 0.032), diabetes mellitus (37% versus 21%, p = 0.002), and hypertriglyceridaemia (33% versus 15%, p < 0.001).

Patients with primary SS showed a twofold higher prevalence of diabetes mellitus and a 1.5-fold higher prevalence of hypertriglyceridaemia in comparison with primary care patients. Corticosteroid use was closely associated with cardiovascular risk factors. These results suggest that cardiovascular risk factors should be taken into account in the management of patients with primary SS and show the importance of recognizing and controlling both traditional and SS-related modifiable risk factors.

Different role of cAMP dependent protein kinase and CaMKII in H3 receptor regulation of histamine synthesis and release

Histamine H(3) autoreceptors induce a negative feedback on histamine synthesis and release. While it is known that cAMP/cAMP dependent protein kinase (PKA) and Ca(2+)/CaMKII transduction pathways mediate H(3) effects on histamine synthesis, the pathways regulating neuronal histamine release are poorly known. Given the potential use of H(3) ligands in cognitive diseases, we have developed a technique for the determination of H(3) effects on histamine synthesis and release in brain cortical miniprisms. Potassium-induced depolarization effects were impaired by blockade of calcium entry through N and P/Q channels, as well as of CaMKII, but release was not affected by activators or inhibitors of the cAMP/PKA pathway (1-methyl-3-isobutylxanthine (IBMX), N6,2'-O-dibutyryladenosine 3',5'-cyclic monophosphate sodium salt (db-cAMP) or myristoyl PKA inhibitor peptide 14-22 (PKI(14-22)). In contrast, forskolin stimulated histamine release, although independently of PKA. Stimulation of histamine H(3) receptors with the agonist imetit markedly reduced the depolarization increase of histamine release, apparently through P/Q calcium channel inhibition. The H(3) antagonist/inverse agonist thioperamide modestly stimulated histamine release. Thioperamide effect on release was not modified by the PKA inhibitor PKI(14-22), but it was blocked by the CaMKII inhibitor KN-62. These results indicate that H(3) autoreceptors regulate neuronal histamine release (1) independently of the cAMP/PKA cascade, and (2) through modulation of calcium entry and CaMKII activation during depolarization.

[Validity of a telephone survey for determining the prevalence of atopic dermatitis and its seasonal variation in Spain]

BACKGROUND

Atopic dermatitis is a eczematous disease of the skin with onset during childhood and subsequent flares. The UK Working Party (UKWP) defined the diagnostic criteria normally used for atopic dermatitis. The objective of this study was to assess the prevalence of atopic dermatitis according to these criteria.

METHODS

This was a 2-phase cross-sectional, epidemiologic computer-assisted telephone survey. Parents of children aged 14 years or less participated in the first phase to determine the prevalence of atopic dermatitis in Spain. In the second phase, 6 months later, parents of children with diagnosis of atopic dermatitis according to the UKWP diagnostic criteria in phase 1 were interviewed to assess seasonal variations in disease activity between the 2 phases.

RESULTS

In total, 1979 parents participated; 8.6 % of the children (95 % confidence interval, 7.4 %-9.8 %) were diagnosed with atopic dermatitis by telephone. Of these, 49.2 % had a family history of atopy and 41.3 % had been diagnosed with atopic dermatitis by a physician. Diagnosis by the physician and that made by interview agreed in 75.3 % of these cases. Of the factors associated with atopic dermatitis, it was found that increased body temperature, periods of stress, dust, use of/contact with wool or fiber clothes, and use of certain soaps and hygiene products showed seasonal variations.

CONCLUSIONS

The estimated prevalence of atopic dermatitis in children between 0 and 14 years old in Spain was 8.6 %. Certain factors associated with disease flares showed seasonal variations.

Interaction of environmental moisture with powdered green tea formulations: effect on catechin chemical stability

Green tea and tea catechins must be stable in finished products to deliver health benefits; however, they may be adversely affected by tea processing/storage conditions and the presence of other components. The objective of this study was to determine the effects of storage relative humidity (RH) and addition of other ingredients on catechin stability in simulated dry beverage mixtures. Samples of green tea powder alone and mixed with sucrose, citric acid, and/or ascorbic acid were prepared and stored in desiccators at 22 degrees C and 0-85% RH for up to 3 months. Epicatechin, epigallocatechin, epicatechin gallate, and epigallocatechin gallate were determined by high-performance liquid chromatography (HPLC). Formulation and the interaction of formulation and RH significantly promoted catechin degradation ( P < 0.0001). The chemical degradation of total and individual catechins in green tea powder formulations was significantly increased ( P < 0.0001) by exposure to increasing RH, and the degradation was exacerbated at > or = 58% RH by the presence of powdered citric acid and at > or = 75% RH by the presence of ascorbic acid. Catechins degraded the most in formulations containing both acids. Although catechin chemical stability was maintained at < or = 43% RH in all samples stored at 22 degrees C for 3 months, caking was observed in samples at these relative humidities. These results are the first to demonstrate that addition of other dry components to tea powders may affect catechin stability in finished dry blends and highlight the importance of considering the complex interplay between a multicomponent system and its environment for developing stable products.

Correlation Between Mast Cell Density and Myocardial Fibrosis in Congestive Heart Failure Patients

Besides the well-established role of mast cells in allergic reactions as an important source of vasoactive and proinflammatory products, they have been related to tissue fibrosis and remodelling processes. In a heart failure (HF) animal model, mast cells were shown to synthesize transforming growth factor beta1 and basic fibroblast growth factor in myocardial tissue and were localized to an area with fibrosis. Our objective was to quantify mast cell density in left ventricles from patients with congestive heart failure who were candidates for transplantation and to analyze whether they showed a correlation with the fibrosis level of the same area.

METHODS

We obtained myocardial biopsies from 20 patients with end-stage HF secondary to idiopathic dilated cardiomyopathy (iDCM) undergoing heart transplantation and 15 controls (donors without cardiopathy). Mast cells were detected by immunohistochemistry with a human mast cell chymase antibody and fibrosis levels measured with picrosirius red staining of collagen fibrils with later quantification by morphometry.

RESULTS

The patients mean age was 51 +/- 3 years. Fibrosis levels in the myocardial sections from patients with congestive HF was three-fold higher than those in control myocardium (12.41 +/- 1.7% vs 3.98 +/- 0.63%, P < .001). Mast cell density correlated with the collagen fraction and could be fitted to a linear regression curve: collagen fraction = 0.78 + 0.05 mast cell density (n = 33, P < .005, R2 = 0.28).

CONCLUSION

The elevated collagen fraction present in failing hearts may be the cause of increased stiffness and loss of elasticity that is detected in patients with end-stage HF. Due to the mast cells capacity to synthesize vasoactive and fibrogenic products and the correlation between their density and fibrosis levels, they probably play a role in the ventricular remodelling in HF.

Epidemiology of Ancylostoma spp. in the endangered Iberian lynx (Lynx pardinus) in the Doñana National Park, south-west Spain

The epidemiology of Ancylostoma spp. was studied in the endangered Iberian lynx (Lynx pardinus) in the Doñana National Park, south-west Spain. Faecal samples were collected throughout a complete annual cycle (August 1997 to September 1998). The overall egg prevalence of Ancylostoma spp. was 57.8%. The pattern of abundance of Ancylostoma spp. eggs in faeces was overdispersed. Juvenile lynx demonstrated a statistically higher prevalence and abundance of Ancylostoma spp. than in adults. These levels of egg output (maximum 21195 epg), as previously reported in free ranging large felid cubs, could be close to disease involvement. The potential pathogenicity of hookworms and the influence of individual and ecological factors on hookworm transmission in the Iberian lynx from the Doñana National Park population are discussed.