Primary cesarean section rates in uninsured, Medicaid and insured populations of predominantly rural northern New England.

Many studies in the United States during the past two decades have reported consistently lower cesarean section rates in women of lower socioeconomic status as defined by census tract, insurance status, or maternal level of educational attainment. This study sought to determine whether cesarean section rates in predominantly rural northern New England are lower for lower, compared with higher socioeconomic groups, as they are reported nationally and in more urban areas. Age-adjusted, primary cesarean section rates for privately insured, Medicaid and uninsured women were calculated using 1990 to 1992 uniform hospital discharge data for Maine, New Hampshire and Vermont. Age-adjusted cesarean section rates for insured women (15.71 percent) were significantly higher than those for Medicaid (14.35 percent) and uninsured (12.85 percent) women. These differences in the cesarean section rate between the insured and poorer populations in northern New England are much less than those reported elsewhere in the country.

Relationship between rates and outcomes of operative treatment for lumbar disc herniation and spinal stenosis.

BACKGROUND: Population-based variations in rates of operations for the treatment of lumbar disc herniation and spinal stenosis are well known. This variability may occur in part because of differences in the threshold at which physicians recommend an operation, reflecting uncertainty about the optimum use of an operative procedure. To the best of our knowledge, no previous reports have indicated whether differences in population-based rates of operative treatment are associated with patient outcomes. METHODS: The Maine Lumbar Spine Study is an ongoing prospective study of 655 patients who had a herniated lumbar disc or spinal stenosis. The patients were enrolled by their physicians, who provided baseline demographic and treatment-related data. The patients completed baseline and follow-up questionnaires that focused on symptoms, function, satisfaction, and quality of life. Small-area variation analysis was used to develop three distinct so-called spine service areas in Maine. The outcomes (usually at four years; minimum, two years) were compared among these areas, in which a total of 250 patients had been managed operatively and had answered questionnaires. RESULTS: Population-based rates of operative treatment derived from statewide data that had been collected over five years in the state of Maine ranged from 38 percent below to 72 percent above the average rate in the state (a greater than fourfold difference). The outcomes for the patients who had been managed by surgeons in the lowest-rate area were superior to those for the patients in the two higher-rate areas. Seventy-nine percent (fifty-seven) of seventy-two patients in the lowest-rate area had marked or complete relief of pain in the lower extremity compared with 60 percent (eighteen) of thirty patients in the highest-rate area. The improvements in the Roland disability score (p < or = 0.01), quality of life (p < or = 0.01), and satisfaction (p < or = 0.05) were significantly greater among the patients in the lowest-rate area. The patients in the higher-rate areas generally had less severe symptoms and findings at baseline than those in the lowest-rate area did. CONCLUSIONS: Higher population-based rates of elective spinal operations may be associated with inferior outcomes. This variability is possibly related to differences in physicians' preferences with regard to recommending an operation and in their criteria for the selection of patients. Physicians cannot assume that their outcomes will be the same as those of others, and therefore they need to evaluate their own results.

Maine Carpal Tunnel Study: small area variations.

As is the case for all elective procedures, small area variations occur in rates of surgery for carpal tunnel syndrome. A 1993 analysis of Maine data demonstrates that carpal tunnel release rates across population-based service areas varied 3.5-fold, from 0.82 to 2.87 per thousand. Four areas had rates significantly higher and 2 were significantly lower than the state average of 1.44 per thousand. Among many potential factors influencing variations, physician practice patterns appear to be the major contributor.

Changing physician behavior: the Maine Medical Assessment Foundation.

Methods to produce change in physician practice patterns are of increasing importance to payers and regulators as well as to physicians themselves. Because some of the strategies being adopted occur without physician input and participation, they have aroused concern in the medical community. We describe the methods used and results achieved by the Maine Medical Assessment Foundation, a nonprofit education and research organization, that has been active in practice pattern analysis since the late 1970s. The foundation has successfully engaged clinicians in a program of systematic assessment of medical care provided to residents of Maine. Significant change in practice patterns has been documented. Physicians have become active participants in the process of voluntary self-assessment, education, and quality improvement.

Do physicians do what they say? The inclination to test and its association with coronary angiography rates.

OBJECTIVE: Efforts to evaluate variations in cardiac procedures have focused on patient factors and differences in health care delivery systems. We wanted to assess how physicians' inclination to test patients with coronary artery disease influences utilization patterns. SETTING AND SUBJECTS: Physicians and the populations of Maine, New Hampshire, and Vermont. DESIGN: We conducted a survey of 263 family practitioners, internists, and cardiologists residing in 57 hospital service areas in Maine, New Hampshire, and Vermont. Using patient scenarios, we assessed the clinicians' inclinations to test during the evaluation of patients with coronary artery disease. Self-reported testing intensities were used to create three indices: a Catheterization Index, an Imaging Exercise Tolerance Test (ETT) Index, and Nonimaging ETT Index. Using administrative data, age- and gender-adjusted population-based coronary angiography rates were calculated. Physicians were assigned to low (2.9/1,000), average (4.2/1,000), and high (5.8/1,000) coronary angiography rate areas, based on where they practice. Analysis of variance techniques were used to assess the relation of the index scores to the population-based coronary angiography rates and to physician specialties. RESULTS: There was a positive relationship between the population-based coronary angiography rates and the self-reported scores of the Catheterization Index (p < .005) and the Imaging ETT Index (p = .01), but none was found for the Non-imaging ETT Index (p = .10). These relationships were evident in subanalyses of cardiologists and internists, but not of family practitioners. CONCLUSIONS: Self-reported testing intensity by physicians is related to the population-based rates of coronary angiography. This relationship cuts across specialties, suggesting that there is a "medical signature" for the evaluation of patients with coronary artery disease.

The relationship between the supply of cardiac catheterization laboratories, cardiologists and the use of invasive cardiac procedures in northern New England.

OBJECTIVES: Utilization rates of coronary angiography and cardiac revascularization have been found to vary between areas. This study addresses the relationship between resource supply and procedure rates. METHODS: We compared the association of per capita catheterization laboratories, per capita cardiologists and multi-provider markets (where more than one hospital offers coronary angiography services) with the utilization rates for angiography and cardiac revascularization in northern New England, USA. Administrative data were used to capture invasive cardiac procedures. Small area analyses were used to create coronary angiography service areas. Linear regression methods were used to measure associations between the resource supply and utilization rates. RESULTS: Variation in the use of invasive cardiac procedures was strongly associated with the population-based availability of catheterization facilities and multi-provider markets and unrelated to cardiologist supply or need (as reflected in the hospitalization rates for myocardial infarction). In the multivariate model, an increase of 1 catheterization laboratory per 100,000 population was associated with an increase in the angiography rate of 1.62 per 1000 population; those service areas with multi-provider markets were associated with an additional increase in the angiography rate of 1.27 per 1000 population (R2 = 0.84, P = 0.0006). There was a moderately strong relationship between the catheterization laboratories per capita and the revascularization rates (R2 = 0.43, P = 0.029). Angiography rates were highly associated with cardiac revascularization rates: an increase in the angiography rate of 1 per 1000 population was associated with a 0.46 per 1000 increase in the cardiac revascularization rate (R2 = 0.85, P = 0.0001). CONCLUSIONS: Our work suggests that current efforts to address variation in cardiac procedures through activities such as appropriateness criteria, guidelines and utilization review are misdirected and should be redirected towards capacity, in this case the supply of catheterization facilities.

Transgenic plantlets of 'Chancellor' grapevine (Vitis sp.) from biolistic transformation of embryogenic cell suspensions.

Transgenic plantlets of 'Chancellor' grapevine (Vitis L. complex interspecific hybrid) were produced via biolistic transformation. Embryogenic cell suspensions were bombarded with 1 µm tungsten particles coated with pBI426 which encodes a fusion peptide between ß-glucuronidase (GUS) and neomycin phosphotransferase II (NPTII). The fusion peptide is under the control of a double 35S Cauliflower Mosaic Virus promoter and a leader sequence from Alfalfa Mosaic Virus. The cells were placed on kanamycin-containing media (10, 25 or 50 mg/l) 2 d after bombardment. Activated charcoal reduced cell browning. Embryos were first observed on selective media 14-29 weeks after bombardment. More than 1600 clusters of embryos were germinated and/or assayed for GUS. Of 621 embryos assayed for GUS expression, 182 (29.3%) were positive. PCR confirmed the presence of the NPTII gene in all 5 GUS-positive and 2 GUS-negative (bombarded) embryos tested. In germination experiments, 15% of the embryo clusters produced at least one plant with normal shoot growth. Of 164 normal plants assayed for GUS expression, 37 (22.6%) were positive. The NPTII gene was amplified by PCR in 1 (of 1) GUS-positive and 4 (of 5) GUS-negative bombarded plants, but not in non-bombarded control plants. Southern blotting confirmed integration of the NPTII gene in all 3 of the GUS and PCR-NPTII positive plants tested. Biolistics is an efficient method for transformation of 'Chancellor' and should be applicable to other important grape cultivars.

Phosphinothricin stimulates somatic embryogenesis in grape (Vitis sp. L.).

The effect of phosphinothricin concentration on embryo production from an embryogenic callus of 'Chancellor' (Vitis L. complex interspecific hybrid) was tested. Embryogenic callus was cultured on medium supplemented with nine phosphinothricin concentrations (0, 0.1, 0.5, 1, 1.5, 2, 3, 5, and 10 mg/l). The highest number of embryos per plate was observed at 0.5 mg/l phosphinothricin. The use of phosphinothricin to stimulate embryo production did not affect embryo germination and plantlet formation. Three germination techniques were compared. Embryo dehydration or growth on Transfergelsolidified medium gave higher germination rates than chilling treatments. Most germinated somatic embryos produced secondary embryos from the hypocotyl after a few weeks of culture. Regardless of the germination technique, the plantlet conversion rate was very low.

A survey of students' attitudes toward medical school and factors motivating them to become physicians.

During the 1981-1982 academic year a study was undertaken to assess medical students' opinions on various occupational/personal/demographic issues. Results demonstrated that a typical USD School of Medicine student was family medicine oriented, wanted to enter private practice, and viewed his/her calling into medicine as primarily altruistic in nature.

Dealing with geographic variations in the use of hospitals. The experience of the Maine Medical Assessment Foundation Orthopaedic Study Group.

Orthopaedists and other physicians in Maine organized the Maine Medical Assessment Foundation to deal with the problem of variations in the rates of hospitalization for orthopaedic conditions. Five musculoskeletal injuries and five orthopaedic procedures were selected for study. The variation in decision-making by orthopaedists was least for fractures of the ankle and fractures of the hip and was greatest for fractures of the forearm, derangement of the knee, and lumbosacral sprain. The rates in an area tended to be consistently high or low for the same treatments. The major reasons for the variations appeared to be related to lack of agreement about optimum treatment. Feedback of data to physicians on variations in patterns of practice reduced the variations.

Informed inquiry into practice variations: the Maine Medical Assessment Foundation.

This paper reports on the development of a successful physician organized and driven medical assessment program, the Maine Medical Assessment Foundation. Responding to the issues and challenges presented by practice pattern variation in the state of Maine, eight physician specialty study groups have been developed in the state over the past ten years. Working in a confidential, educational, non-regulatory format, study groups have had remarkable success in providing feedback of epidemiologic data on area variations to practitioners. This process has succeeded in modifying practice patterns, resulting in marked improvements in quality of care and decreases in apparently excessive utilization of health care resources. Simultaneously, physicians have become supporters of the process of small area analysis and they have joined in community based outcomes research projects. This successful program can be a model for other areas.

The next baby: parents' responses to perinatal experiences subsequent to a stillbirth.

This study examines the responses experienced in the perinatal period by parents who have had an infant subsequent to a stillbirth. Interview findings from eight couples in a stillbirth study group (SSG) who had this experience and eight couples in a comparison group (CG) whose live-born children were delivered at similar time intervals as the SSG were compared. In contrast to a comparison group, half of the SSG mothers did not make preparations for their babies until after delivery and seven of eight SSG mothers wanted the hospital staff to recognize their previous loss and give them special understanding. The parents in the SSG reported that because of their loss, they were likely to spend more time (p less than 0.01), to be more attentive to fussing (p less than 0.01), and to hold their babies more (p less than 0.01). Over half of the SSG parents also noted that after having another baby, they experienced greater relaxation, happiness, and closeness with their spouse. After their subsequent baby, the SSG parents observed that thinking about the stillbirth was easier, but resented being told by others to feel grateful.

Practice environment is associated with obstetric decision making regarding abnormal labor.

Nonmedical factors affecting obstetric decisions regarding abnormal labor were investigated in Maine, a rural state. Obstetricians were questioned about practice structure, hospital services, anesthesia support, and legal liability. Cesarean section rates specific for abnormal labor, based on hospital discharge summaries in the previous two years, correlated inversely with improved night coverage support, 24-hour blood bank availability, and more adequate anesthesia services. Neither the payment differential between vaginal and cesarean delivery nor previous legal liability were associated with increased cesarean rates for abnormal labor. We conclude that improved ancillary services may lead to lower dystocia-specific cesarean section rates.

Reproductive and developmental effects on rats after prenatal, postnatal, or pre- and postnatal exposure to the hypotensive agent losulazine.

Losulazine was administered orally to 21 bred Sprague-Dawley rats per group at 0, 4, and 8 mg/kg/day by three dosing schedules: gestation day 15 until term (prenatal section); postnatal days 1 to 21 (postnatal section); and gestation day 15 until postnatal day 21 (pre- and postnatal section). Dams were allowed to deliver and the number of live and dead pups recorded. Each pup was sexed and weighed on days 0, 4, and 21. Also, pinna detachment and eye opening were monitored. Randomly selected offspring were allowed to mature and then cohabited for assessment of reproductive performance. Dam body weight gain during dosing was reduced in the high dose group of the pre- and postnatal section. Treated dams in the postnatal and pre- and postnatal sections had litters with reduced body weight, delayed development, and decreased survival. In the F1 mating portion of the postnatal and pre- and postnatal sections, F1 offspring from losulazine-treated dams had reduced body weights over the entire study. A dose-related decrease was found for both the percentage of F1 males that bred and the conception rate of bred F1 females. All F1 females entered estrus at least once, and those that conceived delivered normal litters. Neither microscopic examination of F1 male reproductive organs nor analyses of serum prolactin, luteinizing hormone (LH), and testosterone levels indicated the cause of impaired fertility. Thus, although prenatal exposure only did not result in adverse effects, postnatal exposure to losulazine via lactation affected offspring growth, development, and reproductive capacity.

Parental response to perinatal death. Mother-father differences.

Depression and social interaction of mothers and fathers following a perinatal loss were studied using the questionnaire responses of 58 married couples. In the first six weeks following their loss, differences observed in responses of mothers and fathers are most apparent. During this time, mothers have more depressive symptoms, more often would like others to open a conversation with them about the baby, and are more likely to find their spouse helpful. At a mean of 25 months after the death, mothers' and fathers' differences with respect to depression become less apparent. However, fathers with more depressive symptomatology have increasing needs for social interaction and do not perceive that their marriage has grown stronger. Maternal depression has no correlation with perceptions of marital strength. Family counseling should reflect the possible variations in timing of the grief reaction and potential capabilities of parents to be supportive of one another.