Rapid thinning of the Late Pleistocene Patagonian Ice Sheet followed migration of the Southern Westerlies.

Here we present the first reconstruction of vertical ice-sheet profile changes from any of the Southern Hemisphere's mid-latitude Pleistocene ice sheets. We use cosmogenic radio-nuclide (CRN) exposure analysis to record the decay of the former Patagonian Ice Sheet (PIS) from the Last Glacial Maximum (LGM) and into the late glacial. Our samples, from mountains along an east-west transect to the east of the present North Patagonian Icefield (NPI), serve as 'dipsticks' that allow us to reconstruct past changes in ice-sheet thickness, and demonstrates that the former PIS remained extensive and close to its LGM extent in this region until ~19.0 ka. After this time rapid ice-sheet thinning, initiated at ~18.1 ka, saw ice at or near its present dimension by 15.5 ka. We argue this rapid thinning was triggered by a combination of the rapid southward migration of the precipitation bearing Southern Hemisphere (SH) westerlies and regional warming.

Functional overexpression of wild-type p53 correlates with alveolar cell differentiation in the developing human lung.

At 15 weeks after conception (a.c.), the human pulmonary acinus is lined by distal low-columnar and more proximal cuboidal cells that are successive stages in alveolar type II cell differentiation (pseudoglandular period of lung development). From 16 weeks a.c. onward, there are also 'flatter' cells that are intermediate stages in the differentiation of cuboidal type II cells into squamous type I cells (canalicular period). We investigated the role of wild-type p53 protein and the proliferation marker Ki-67 in the differentiation of type II and type I cells in these two periods. Serial sections from fetal lungs (n = 30) were immunoincubated with antibodies against p53 and Ki-67. The presence of prospective type II and type I cells was confirmed using immunohistochemistry for surfactant protein SP-A as a differentiation marker and light and electron microscopy. The p53 and Ki-67 positive nuclei were quantified per alveolar cell phenotype (i.e., low-columnar; cuboidal; flatter). The occurrence of cell apoptosis was studied using propidium iodide (PI) and 4',6'-diamino-2-phenylindol dihydrochloride (DAPI) staining. The combined increase in p53 expression and decrease in Ki-67 expression during alveolar epithelial cell differentiation suggests that wild-type p53 protein plays a role in the differentiation of alveolar type II and type I cells in the human lung, and that this function is mediated through cell cycle arrest. The rare incidence of apoptotic nuclei in alveolar type II cells, together with their absence in alveolar type I cells, supports the view that p53 is involved in the differentiation, rather than the death, of alveolar epithelial cells.

Medical care use by treated and untreated substance abusing medicaid patients.

Medicaid reimbursement costs for county residents at least 18 years old who used a treatment service (n = 1043) and residents who were Medicaid enrollees with a substance abuse diagnosis but who did not receive treatment (n = 2125) were compared. Untreated patients were more likely to be male (47% vs. 39%), white (56% vs. 45%), and older (39.7 yrs. +/- 13 SD vs. 35.5 yrs +/- 10 SD). The average monthly Medicaid costs ($257) for the untreated were higher in the year prior to identification than were costs ($207) for the treated. The monthly costs in the six months following identification were $761 for the untreated and $373 for the treated. The costs in the next six months returned to near the original for the treated ($224), while those for the untreated remained higher at $340. Medicaid enrollees with untreated substance abuse pose a significant cost to the Medicaid system.

Measuring the costs of primary care education in the ambulatory setting.

In 1995, the authors obtained cost, operations, and educational activity data from 98 ambulatory care sites across the United States in which primary care teaching was occurring and compared those data with the corresponding data from 84 ambulatory care sites where no teaching was going on. The teaching sites in the sample were found to have 24-36% higher operating costs than the non-teaching sites. This overall difference in costs is approximately the same difference in costs earlier estimated for university teaching hospitals compared with non-teaching hospitals. These costs are shared by all involved in the ambulatory education process: sponsors, sites, and faculty. In a related finding, the authors discovered that 30-50% of all ambulatory care sites thought not to be involved in education are in fact teaching at a high level of involvement. Further research into not only the costs but the value of education in the clinical setting is encouraged. The authors also hope that the publication of this report will encourage accrediting bodies and professional organizations to improve the information available about ambulatory care training in general.

Estimating the cost of primary care training in ambulatory settings.

The Balanced Budget Act of 1997 legislated the idea of reimbursing ambulatory sites for training medical professionals. However, very little is known about the costs of training in such settings. This paper assesses the cost of primary care training in ambulatory settings. Selection models were used to separate the cost of teaching from the cost of infrastructural differences between teaching and non-teaching sites. A probit equation modelled the likelihood of an ambulatory site having a teaching programme and a cost function related total medical practice costs to clinical output, the presence of a health professions educational programme, the price of resources used, characteristics of the medical practice and location. Data on 184 community health centres (CHCs), group practices, health maintenance organizations (HMOs) and outpatient clinics were used. Teaching sites were found to have 36% higher operating costs than their non-teaching counterparts: 38% of these higher costs were due to infrastructural differences and 62% were the 'pure' costs of teaching, i.e. the costs of teaching the net of infrastructural effects.

Understanding the value added to clinical care by educational activities. Value of Education Research Group.

In an era of competition in health care delivery, those who pay for care are interested in supporting primarily those activities that add value to the clinical enterprise. The authors report on their 1998 project to develop a conceptual model for assessing the value added to clinical care by educational activities. Through interviews, nine key stakeholders in patient care identified five ways in which education might add value to clinical care: education can foster higher-quality care, improve work satisfaction of clinicians, have trainees provide direct clinical services, improve recruitment and retention of clinicians, and contribute to the future of health care. With this as a base, an expert panel of 13 clinical educators and investigators defined six perspectives from which the value of education in clinical care might be studied: the perspectives of health-care-oriented organizations, clinician-teachers, patients, education organizations, learners, and the community. The panel adapted an existing model to create the "Education Compass" to portray education's effects on clinical care, and developed a new set of definitions and research questions for each of the four major aspects of the model (clinical, functional, satisfaction, and cost). Working groups next drafted proposals to address empirically those questions, which were critiqued at a national conference on the topic of education's value in clinical care. The next step is to use the methods developed in this project to empirically assess the value added by educational activities to clinical care.

Hospital participation in community partnerships to improve health.

BACKGROUND: The core business of hospitals now requires, for both competitiveness and quality improvement reasons, that hospitals move beyond their physical and conceptual walls to form community partnerships. THE HOSPITAL'S ROLE AS A PARTNER IN COMMUNITY-BASED HEALTH IMPROVEMENT SYSTEMS: Hospitals, as organizations that are significant health care, social, and economic institutions in their communities, should play a leading role in mobilizing resources for such community-level health improvement efforts. MOVING OUTSIDE THE WALLS TO IMPROVE QUALITY: Three examples of extending hospital efforts into the community demonstrate that improvement of a problem involving hospital care can derive from a collaborative, community-based activity. In Boston, infection control--once a standard, strictly in-house procedure--has been forced by altered patterns of hospital use to become a largely community-based process. In Chicago, a variety of health care providers and community representatives have worked effectively to reduce mortality and morbidity in a single disease (asthma) model. In Akron, Ohio, Lifelink program hospitals, working together with community agencies and groups in a door-to-door neighborhood program, improved the effectiveness of prenatal care and the quality of birth outcomes. CONCLUSION: Efforts to work with community groups to improve health status should not be simply an optional do-good endeavor, as they have often been in the past, but rather an essential part of quality improvement and good business practice. Marketplace incentives will increasingly reward hospitals that are able to form successful community partnerships.

Understanding the costs of ambulatory care training.

While patient care has been shifting to the ambulatory setting, the education of health care professionals has remained essentially hospital-based. One factor discouraging the movement of training into community-based ambulatory settings is the lack of understanding of what the costs of such training are and how these costs might be offset. The authors describe a model for ambulatory care training that makes it easier to generalize about to quantify its educational costs. Since ambulatory care training does not exist in a vacuum separate from inpatient education, the model is compatible with the way hospital-based education costs are derived. Thus, the model's elements can be integrated with comparable hospital-based training cost elements in a straightforward way to allow a total-costing approach. The model is built around two major sets of variables affecting cost. The first comprises three types of costs--direct, indirect, and infrastructure--and the second consists of factors related to the training site and factors related to the educational activities of the training. The model is constructed to show the various major ways these two sets of variables can influence training costs. With direct Medicare funding for some ambulatory-setting-based education pending, and with other regulatory and market dynamics already in play, it is important that educators, managers, and policymakers understand how costs, the characteristics of the training, and the characteristics of the setting interact. This model should assist them. Without generalizable cost estimates, realistic reimbursement policies and financial incentives cannot be formulated, either in the broad public policy context or in simple direct negotiations between sites and sponsors.

Financial incentives in residency recruiting for primary care: scope, characteristics, and students' perceptions.

BACKGROUND: One response to the decline in interest among medical students in residency training in primary care has been the offering, by residency programs and hospitals, of financial recruitment incentives to medical students during their residency interviews. Few data on the breadth and effectiveness of this practice have been available. METHOD: To gain insight into how hospitals and/or programs offered incentives, the authors compared 1990 and 1992 survey data on this topic from the members of the Association of American Medical Colleges' Council of Teaching Hospitals (AAMC/COTH) with 1992 data from the members of the Association for Hospital Medical Education (AHME), employing responses to identical questionnaire items. Complementary data on students' experiences with recruitment incentives in 1991 and 1992 were also analyzed. These data have been collected since 1991 in the Medical School Graduation Questionnaire (GQ) of the AAMC's Section for Educational Research, but little or no information had been available on medical students' perceptions of the effectiveness of these incentives. Therefore, one of the authors surveyed members of the classes of 1992 at four Midwestern medical schools about their residency interviewing experiences, including their reactions to financial incentives they encountered. RESULTS: The outcomes from these surveys indicate that, as expected, family practice, internal medicine, and pediatrics were the specialties most likely to offer financial incentives; that a wide variety of recruitment incentives was available to students; that the proportion of programs and hospitals offering such incentives was increasing (e.g., from 37% in the 1990 COTH survey to 54% in the 1992 survey); and that a large majority (79%) of students who encountered these incentives viewed them as at least somewhat effective in persuading them to consider matching with the programs that offered them. CONCLUSION: The prevalence and persuasiveness of financial incentives raise a number of serious questions, including whether competition for residents will divert funds from improving educational quality to recruitment.

Factors contributing to the variability of direct costs for graduate medical education in teaching hospitals.

Medicare's support of graduate medical education includes funds allocated to the direct costs of graduate medical education: housestaff stipends and benefits, faculty costs, and related educational costs such as classroom space. As reimbursed through the mechanism called the direct graduate medical education (DGME) pass-through, these direct costs have been reported to vary widely from one teaching hospital to another, with little explanation for this variation being available. Based on a national survey of 69 teaching hospitals--principally affiliated community teaching hospitals--the author suggests that a major cause for the variation in these costs might be found in their faculty-expenses component. It is further suggested that economies of scale may provide some clue as to the variability of these costs. The author also reports lower DGME costs for the survey sample than for the national sample, and suggests that the fact that community teaching hospital faculties include a significant volunteer component may account for some of these savings.