Using a family-based structure to detect the effects of genomic inbreeding on embryo viability in Holstein cattle.

Recent evidence has suggested that some of the decline in reproductive ability in dairy cattle has been caused by embryonic death. The current study compared expected genomic inbreeding from sire-dam mating pairs to genomic inbreeding from live progeny in an attempt to determine how embryonic inbreeding may affect fertility. A total of 11,484 Holstein cattle with 43,485 SNP markers and pedigree information were available for analysis. A total of 412 sire-dam-progeny trios in which all animals had reliable genotypes were discovered. After removal of trios because of parentage errors, 374 remained for analysis. Additionally, a total of 3,031 animals comprising 3,906 genotyped full-sibling pairs were available for comparison. Expected genomic inbreeding measures were calculated by predicting homozygosity independently per SNP (FPHE) in sire-dam mating pairs and by simulating progeny using phased haplotype information (FROHE and FPHE). Actual genomic inbreeding measures were calculated using the percent homozygosity of all SNP (FPH) and using runs of homozygosity (FROH). Average FPHE values (62.8±0.78%) were slightly lower than FPH (63.1±1.12%), when considering each SNP independently. After phasing haplotypes, FPHE (62.5±0.83%) was again slightly lower than FPH (62.7±1.16%), and FROHE (3.46±1.54%) was slightly lower than FROH (3.53±2.17%). Results suggest increases in expected genomic inbreeding do not explain a large effect on embryo viability at average levels of expected inbreeding. Higher variation in FROH values was present with sire-dam mating pairs exhibiting high FROHE, which may suggest high levels of genomic inbreeding are required for a noticeable effect on overall embryo viability. Genomic inbreeding between full siblings was also compared with moderate correlations (0.47-0.52) present. Overall, expected genomic inbreeding measures were calculated, but results did not suggest a large effect of expected inbreeding on embryo viability.

Inter-laboratory assessment of a harmonized zebrafish developmental toxicology assay - progress report on phase I.

This report provides a progress update of a consortium effort to develop a harmonized zebrafish developmental toxicity assay. Twenty non-proprietary compounds (10 animal teratogens and 10 animal non-teratogens) were evaluated blinded in 4 laboratories. Zebrafish embryos from pond-derived and cultivated strain wild types were exposed to the test compounds for 5 days and subsequently evaluated for lethality and morphological changes. Each of the testing laboratories achieved similar overall concordance to the animal data (60-70%). Subsequent optimization procedures to improve the overall concordance focused on compound formulation and test concentration adjustments, chorion permeation and number of replicates. These optimized procedures were integrated into a revised protocol and all compounds were retested in one lab using embryos from pond-derived zebrafish and achieved 85% total concordance. To further assess assay performance, a study of additional compounds is currently in progress at two laboratories using embryos from pond-derived and cultivated-strain wild type zebrafish.

Effects of changing Medicaid fees on physician participation and enrollee access.

This paper assesses the effects of Medicaid fee changes on physician participation, enrollee access, and shifts in the site of ambulatory care using several natural experiments in Maine and Michigan. We use Medicaid claims and enrollment data to measure these outcomes. The reimbursement changes included substantial percentage changes in fees, however the value of the Medicaid fee improvements relative to the private market eroded very rapidly in the months following the interventions. Although the fee increases did not improve the outcome measures, they might have prevented conditions from worsening.

The changing landscape of health care financing and delivery: how are rural communities and providers responding?

Rural communities have not kept pace with the recent dramatic changes in health care financing and organization. However, the Medicare provisions in the Balanced Budget Act of 1997 will require rural providers to participate in the new systems. Case studies revealed the degree of readiness for change in six rural communities and charted their progress along a continuum, as reflected in three sets of activities: the development of networking; the creation of new strategies for managing patient care; and the adoption of new methods for contracting with health insurers. Some communities had constructed highly integrated systems, whereas others were just beginning to change their billing practices; a few were signing contracts for capitated care, in contrast to those that were resisting discounts in current fee structures. These six rural areas still have considerable ground to cover before their health care organization and financing reach the levels achieved by urban communities.

State-sponsored programs for the uninsured: is there adverse selection?

Risk contracting by states for coverage of previously uninsured populations has been hampered by uncertainty regarding likely claims experience. This study reports on the utilization experience of two state programs offering subsidized coverage in commercial managed care organizations to low-income and previously uninsured people. Program participants used services similarly to people enrolled through large employer benefit plans. There was no evidence of pent-up demand or an unusual level of chronic illness. Similarly, there was little evidence of underutilization, although dissatisfaction and reported barriers to service were more frequent among nonwhite enrollees.

Rural models for integrating primary care and mental health services.

This paper presents findings from a study designed to identify and describe models for integrating primary care and mental health services in rural communities. Data were obtained from telephone interviews with staff at rural primary care sites around the country. Findings are based on the responses of 53 primary care organizations in 22 states. The authors identify four integration models--diversification, linkage, referral and enhancement--which appear to exist in combination, rather than as pure types. The proposed analytic framework outlines aspects of integration that are readily amenable to study.

Satisfaction with practice in a rural state: perceptions of nurse practitioners and nurse midwives.

Data from nurse practitioners and certified nurse midwives are used to explore contributions to primary care in a rural state and how regulatory restrictiveness and other factors affect satisfaction with practice (N = 151). Satisfaction is high, especially with home communities and professional aspects of work, including collaboration with physicians. However, many feel limited by regulations and are less satisfied, especially those with a master's degree and those in organizational versus office practice sites. Reducing restrictive regulations, reevaluating practice structures, and providing for full scope of practice and other incentives consistent with rising educational levels can increase access to care.

The role of health services research in developing state health policy.

As their responsibility for health policy making grows, states are pursuing a variety of strategies for getting the research and analytical assistance they need, including expanding their relationships with university-based health services research and policy analysis programs. These collaborations raise a number of questions about the fit between states' analytic needs and universities' interest and capacity, and about the appropriate role of the university research organization in the often highly politicized state environment. This paper discusses these questions in light of case studies of universities involved in state health policy in five states: Maryland, Minnesota, North Carolina, Washington, and Wisconsin.

Managerial responses to Medicaid prospective payment in the nursing home sector.

The United States must soon address long-term care policy. Policymakers have sought cost containment through reimbursement policies that contain incentives for efficiency. Nursing facility administrators were surveyed twice following a significant change in Maine's Medicaid reimbursement policy to determine the effects of the change on their managerial practices. The administrators responded to some of the policy changes as profit maximizers, including instituting cost controls and benefiting from incentives. In other areas, such as staffing, staff pay, and accepting heavy care patients, the administrators did not seem to behave entirely as expected. Insights from organizational theory are useful for explaining some of the other behaviors. As long-term care reform is undertaken, a policy framework should include aspects of the internal environment of nursing facilities, such as administrator goals and organizational structure and mission.

Legislative and policy strategies for supporting rural health network development: lessons from the 103rd Congress.

There was considerable support in most major health reform bills considered by the 103rd Congress for the development of rural integrated service networks. The demise of comprehensive health reform, together with the pace of current market-driven changes in the health care system, suggests the need to assess the impact of specific policy strategies considered in the last Congress on rural integrated service network development. Toward this end, this article evaluates the rural health policy strategies of the major bills in relation to three essential preconditions for the development of rural integrated service networks: (1) the need for a more stable financial base for rural providers; (2) the need for administrative, service and clinical capacity to mount a successful network; and finally, (3) the need for appropriate market areas to ensure fair competition among networks and plans. Key policy strategies for supporting rural network development include reform of insurance and payment policies, expansion of targeted support and technical assistance to the underserved, limited-capacity rural areas, and policies governing purchasing groups or alliances that will ensure appropriate treatment of rural providers and networks.

An expert panel approach to assessing the rural implications of health care reform: the case of the Health Security Act.

The policy arena is hungry for objective information regarding the potential effects of comprehensive national and state health care reform. Such information reduces the dependence of policy-makers on information generated solely by advocacy groups and serves as a checkpoint for such information. Unfortunately, the academic community is often unable to mobilize its resources quickly enough to help meet this information need. This article describes one model for overcoming this difficulty. When the time frame is especially short, academic expertise can be brought together in the form of an expert panel. However, for such an approach to be effective, it must be carefully configured and orchestrated. Critical ingredients include much preparatory groundwork, a well-defined framework and methodology for conducting the policy analysis, and a professional facilitator. The Rural Policy Research Institute used such an approach to analyze President Clinton's Health Security Act shortly after the initial blueprint was released (but before the legislative language was released). The consensus of the expert panel was that the Health Security Act would, on balance, represent an improvement over today's rural reality. However, a number of troubling aspects were noted. First, the Act's emphasis on primary care and nonphysician providers is a double-edged sword. While these are precisely the types of providers needed in rural areas, the short-run effect may be to create increased competition for such providers from urban areas.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of prospective reimbursement on nursing home costs.

OBJECTIVE: This study evaluates the effect of Maine's Medicaid nursing home prospective payment system on nursing home costs and access to care for public patients. DATA SOURCES/STUDY SETTING: The implementation of a facility-specific prospective payment system for nursing homes provided the opportunity for longitudinal study of the effect of that system. Data sources included audited Medicaid nursing home cost reports, quality-of-care data from state facility survey and licensure files, and facility case-mix information from random, stratified samples of homes and residents. Data were obtained for six years (1979-1985) covering the three-year period before and after implementation of the prospective payment system. STUDY DESIGN: This study used a pre-post, longitudinal analytical design in which interrupted, time-series regression models were estimated to test the effects of prospective payment and other factors, e.g., facility characteristics, nursing home market factors, facility case mix, and quality of care, on nursing home costs. PRINCIPAL FINDINGS: Prospective payment contributed to an estimated $3.03 decrease in total variable costs in the third year from what would have been expected under the previous retrospective cost-based payment system. Responsiveness to payment system efficiency incentives declined over the study period, however, indicating a growing problem in achieving further cost reductions. Some evidence suggested that cost reductions might have reduced access for public patients. CONCLUSIONS: Study findings are consistent with the results of other studies that have demonstrated the effectiveness of prospective payment systems in restraining nursing home costs. Potential policy trade-offs among cost containment, access, and quality assurance deserve further consideration, particularly by researchers and policymakers designing the new generation of case mix-based and other nursing home payment systems.

The effects of variations in AFDC and Medicaid eligibility on prenatal care use.

Despite substantial evidence linking improved pregnancy outcomes with receipt of prenatal care and recent improvements in prenatal care utilization, specific subpopulations continue to receive less than adequate care. The study reported here examined the effects on prenatal care utilization of differences among states in AFDC and Medicaid eligibility policies. The study was based on information obtained from birth certificates and a mailed questionnaire to stratified random samples of all women experiencing live births during specified periods in four states. States were selected to provide comparisons between two states with liberal AFDC and Medicaid eligibility standards--Wisconsin and Colorado--and two states--Maine and Texas--which had more restrictive standards at the time data were collected. Study findings generally indicate that more liberal AFDC/Medicaid eligibility standards improve the adequacy of prenatal care among low income women. They also suggest, however, that the often lengthy eligibility process may actually pose barriers to care.

Comparison of surgical methods in the treatment of dissociated vertical deviation.

The effectiveness of 3- to 5-mm recession of the superior rectus muscle with and without posterior fixation sutures was compared with 7- to 9-mm superior rectus muscle recessions in 228 patients with dissociated vertical deviation. We examined the patients at intervals ranging from six months to three years, and the results were classified as corrected, improved, or failed. Superior rectus muscle recessions of 3 to 5 mm were the least successful treatment. When 3- to 5-mm recession was combined with posterior fixation, the short-term results were more encouraging but the failure rate after three years was nearly the same in both groups (59% and 55%, respectively). The best results (P = .021) were achieved with 7- to 9-mm recessions. After three years the dissociated vertical deviation of most patients treated with this technique remained corrected or improved.

Developing consumer-centered quality assurance strategies for home care. A case management model.

Despite a growing interest in home care quality assurance, models for effective quality assurance systems are in short supply. This article describes such a model, developed after a literature review; interviews with business leaders and with home care consumers and their families; and focus groups with consumers, case managers, and home health nurses. The Consumer-Centered, Negotiated Model for Home Care Quality integrates quality assurance into the case management process, focusing on the entire plan of care, not simply individual services. In this model, quality assurance is a regular and ongoing process, utilizing standards that are consumer-oriented, specific, and measurable.