Toward estimating the impact of changes in immigrants' insurance eligibility on hospital expenditures for uncompensated care

BACKGROUND: The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 gave states the option to withdraw Medicaid coverage of nonemergency care from most legal immigrants. Our goal was to assess the effect of PRWORA on hospital uncompensated care in the United States. METHODS: We collected the following state-level data for the period from 1994 through 1999: foreign-born, noncitizen population and health uninsurance rates (US Census Current Population Survey); percentage of teaching hospitals (American Hospital Association Annual Survey of Hospitals); and each state's decision whether to implement the PRWORA Medicaid bar for legal permanent residents or to continue offering nonemergency Medicaid coverage using state-only funds (Urban Institute). We modeled uncompensated care expenditures by state (also from the Annual Survey of Hospitals) in both univariate and multivariable regression analyses. RESULTS: When measured at the state level, there was no significant relationship between uncompensated care expenditures and states' percentage of noncitizen immigrants. Uninsurance rates were the only significant factor in predicting uncompensated hospital care expenditures by state. CONCLUSIONS: Reducing the number of uninsured patients would most surely reduce hospital expenditures for uncompensated care. However, data limitations hampered our efforts to obtain a monetary estimate of hospitals' financial losses due specifically to the immigrant eligibility changes in PRWORA. Quantifying the impact of these provisions on hospitals will require better data sources

Acute ischemic heart disease and interventional cardiology: a time for pause

BACKGROUND: A major change has occurred in the last few years in the therapeutic approach to patients presenting with all forms of acute coronary syndromes. Whether or not these patients present initially to tertiary cardiac care centers, they are now routinely referred for early coronary angiography and increasingly undergo percutaneous revascularization. This practice is driven primarily by the angiographic image and technical feasibility. Concomitantly, there has been a decline in expectant or ischemia-guided medical management based on specific clinical presentation, response to initial treatment, and results of noninvasive stratification. This 'tertiarization' of acute coronary care has been fuelled by the increasing sophistication of the cardiac armamentarium, the peer-reviewed publication of clinical studies purporting to show the superiority of invasive cardiac interventions, and predominantly supporting (non-peer-reviewed) editorials, newsletters, and opinion pieces. DISCUSSION: This review presents another perspective, based on a critical reexamination of the evidence. The topics addressed are: reperfusion treatment of ST-elevation myocardial infarction; the indications for invasive intervention following thrombolysis; the role of invasive management in non-ST-elevation myocardial infarction and unstable angina; and cost-effectiveness and real world considerations. A few cases encountered in recent practice in community and tertiary hospitals are presented for illustrative purposes The numerous and far-reaching scientific, economic, and philosophical implications that are a consequence of this marked change in clinical practice as well as healthcare, decisional and conflict of interest issues are explored. SUMMARY: The weight of evidence does not support the contemporary unfocused broad use of invasive interventional procedures across the spectrum of acute coronary clinical presentations. Excessive and unselective recourse to these procedures has deleterious implications for the organization of cardiac health care and undesirable economic, scientific and intellectual consequences. It is suggested that there is need for a new equilibrium based on more refined clinical risk stratification in the treatment of patients who present with acute coronary syndromes

Regional variability in peatland burning at mid-to high-latitudes during the Holocene

Northern peatlands store globally-important amounts of carbon in the form of partly decomposed plant detritus. Drying associated with climate and land-use change may lead to increased fire frequency and severity in peatlands and the rapid loss of carbon to the atmosphere. However, our understanding of the patterns and drivers of peatland burning on an appropriate decadal to millennial timescale relies heavily on individual site-based reconstructions. For the first time, we synthesise peatland macrocharcoal records from across North America, Europe, and Patagonia to reveal regional variation in peatland burning during the Holocene. We used an existing database of proximal sedimentary charcoal to represent regional burning trends in the wider landscape for each region. Long-term trends in peatland burning appear to be largely climate driven, with human activities likely having an increasing influence in the late Holocene. Warmer conditions during the Holocene Thermal Maximum (∼9–6 cal. ka BP) were associated with greater peatland burning in North America's Atlantic coast, southern Scandinavia and the Baltics, and Patagonia. Since the Little Ice Age, peatland burning has declined across North America and in some areas of Europe. This decline is mirrored by a decrease in wider landscape burning in some, but not all sub-regions, linked to fire-suppression policies, and landscape fragmentation caused by agricultural expansion. Peatlands demonstrate lower susceptibility to burning than the wider landscape in several instances, probably because of autogenic processes that maintain high levels of near-surface wetness even during drought. Nonetheless, widespread drying and degradation of peatlands, particularly in Europe, has likely increased their vulnerability to burning in recent centuries. Consequently, peatland restoration efforts are important to mitigate the risk of peatland fire under a changing climate. Finally, we make recommendations for future research to improve our understanding of the controls on peatland fires

Ovarian Aging and Hormone Replacement Therapy: Hormonal Levels, Symptoms, and Attitudes of African-American and White Women

OBJECTIVES: To characterize reproductive hormone levels, symptoms, and attitudes related to menopause among healthy, menstruating white and African-American women aged 44 to 49 years. DESIGN: Pilot study; cross-sectional survey. SETTING: Community-based convenience sample of women in the Philadelphia metropolitan area. PARTICIPANTS: Thirty-three African-American and 35 white women. MEASUREMENTS: The survey instrument collected demographic data, medical and reproductive history, health practices and behaviors. It included previously validated function, depression, and quality-of-life instruments, and a Menopause Attitude Scale that included two factors, attitudes toward the menopause and attitudes toward medical therapy. Anthropometric measurements were taken at enrollment, and reproductive hormones and daily symptom logs were followed over two menstrual cycles. MAIN RESULTS: The two groups were comparable in mean age (African-American 46.2 years, white 46.9 years). Serum levels of estradiol, follicle-stimulating hormone, dihydroepiandrosterone-sulfate, and progesterone were comparable. Symptoms were similar in type and frequency. However, the African-American women had significantly more positive attitudes toward menopause, were more likely to rely on family for information about menopause, and were less likely to have been recommended hormone replacement therapy by their physicians. A majority of women in each group expressed satisfaction with the care they had received. CONCLUSIONS: Perimenopausal African-American and white women have different expectations of menopause and the role of medical care in menopause. This bears directly on women’s acceptance of hormone replacement therapy. Conclusions are limited by the small sample size and convenience nature of the study population: further work with larger samples is needed to confirm these apparent differences

Geographic Variation in Health Care Utilization and Outcomes in Veterans with Acute Myocardial Infarction

OBJECTIVES: To examine regional variation in health care utilization and outcomes during acute and chronic care of veterans following acute myocardial infarction (AMI), identifying potentially modifiable variables and processes of care that influence patient outcomes. METHODS: Using national VA databases, we identified all veterans hospitalized at any VA Medical Center (VAMC) for AMI between October 1990 and September 1997. Demographic, inpatient, outpatient, mortality, and readmission data were extracted for 4 regions: Northeast, South, Midwest and West. Multivariable Cox proportional hazards regression models, controlled for comorbidity, were used to assess predictors of time to death and readmission. RESULTS: We identified 67,889 patients with AMI. Patient demographic characteristics by region were similar. Patients in the Northeast had more comorbid conditions and longer lengths of stay during the index AMI hospitalization. Region of the country independently predicted time to death, with lower risk of death in the Northeast (hazard ratio [HR] = 0.875; 95% confidence interval [95% CI], 0.834 to 0.918; P < .0001) and West (HR = 0.856; 95%CI, 0.818 to 0.895; P = .0001) than in the South. Patients in the Northeast and West also had more cardiology or primary care follow-up within 60 days and at 1 year post-discharge than patients in the South and Midwest. Outpatient follow-up accounted for a significant portion of the variation in all-cause mortality. CONCLUSION: Substantial geographic variation exists in subsequent clinical care and outcomes among veterans hospitalized in VAMCs for AMIs. Outpatient follow-up was highly variable and associated with decreased mortality. Further studies are needed to explore the causes of regional variation in processes of care and to determine the most effective strategies for improving outcomes after AMI