The care of HIV-infected adults in rural areas of the United States.

OBJECTIVE: This study describes the population of HIV-infected adults receiving care in rural areas of the United States and compares HIV care received in rural and urban areas. METHODS: Interviews were conducted with a nationally representative sample of 367 HIV-infected adults receiving health care in rural areas and 2806 HIV-infected adults receiving health care in urban areas of the contiguous United States. RESULTS: We estimate that 4800 HIV-infected persons received medical care in rural areas during the first half of 1996. Patients in rural HIV care were more likely than patients in urban HIV care to receive care from providers seeing few (<10) HIV-infected patients (38% vs. 3%; p <.001). Rural care patients were less likely than urban care patients to have taken highly active antiretroviral agents (57% vs. 73%; p <.001) or Pneumocystis carinii pneumonia prophylactic medication when indicated (60% vs. 75%; p =.006). CONCLUSIONS: Few American adults received HIV care in rural areas of the United States. Our findings suggest ongoing disparities between urban and rural areas in access to high-quality HIV care.

Breast cancer action plan for Kentucky.

In 1998, Governor Paul E. Patton established the Kentucky Breast Cancer Task Force (KBCTF) to assess and make recommendations on the availability, accessibility, utilization, quality, and outcomes of breast cancer services across the spectrum of disease. Over a two-year period, the KBCTF reviewed the state of breast cancer control in Kentucky and made recommendations for reducing breast cancer morbidity and mortality. To achieve the provision of optimal breast cancer care, the KBCTF recommended universal adoption of professionally accepted guidelines for breast cancer treatment, pain management, and distress management. To better coordinate public education on breast cancer, the KBCTF recommended the development of a standardized packet of public education materials for dissemination through regional networks of "cancer control partners." KBCTF members also requested the Kentucky Cancer Program to investigate the feasibility of establishing a centralized mammography registry to gather more complete data on screening mammography programs.

Who receives Ryan White CARE Act services? A demographic comparison of CARE act clients and the general AIDS population.

This study examines the extent to which health and social service providers funded by the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act serve women, minorities, and other vulnerable populations emphasized by the legislation. Demographic characteristics of AIDS-diagnosed clients served by CARE Act-funded providers in four metropolitan areas and two states are compared with Centers for Disease Control and Prevention estimates of AIDS prevalence. Clients of CARE Act-funded providers tend to reflect the demographics of local HIV/AIDS epidemics. Where differences exist, CARE Act clients are more likely to be women and minorities and less likely to be injecting drug users. CARE Act-funded providers are effectively reaching most medically underserved populations.

Prenatal HIV prevention practices in a low seroprevalence state.

The purpose of this study was to build understanding of prenatal HIV counseling and testing practices in low seroprevalence states. Responses from a 1998 population-based survey of Kentucky prenatal care providers (67% response; 312 analyzed) were compared with findings from patient focus groups. Sixty-two percent of clinicians said they routinely counsel prenatal patients with risk factors, but only 46% routinely counsel patients without risk factors. The proportions routinely offering HIV testing to patients with and without risk factors were 94% and 84%, respectively. Prenatal patients identified "fear of a positive test result" as the major barrier to test acceptance. This fear was fueled by lack of knowledge regarding the benefits of early detection. The study concludes that achieving universal prenatal HIV testing will require new strategies, such as the distribution of a standardized protocol, that address clinicians' concerns about "time burdens" without depriving patients of the opportunity to receive individualized counseling.

Benchmarking organ procurement organizations: a national study.

OBJECTIVE: An exploratory examination of the technical efficiency of organ procurement organizations (OPOs) relative to optimal patterns of production in the population of OPOs in the United States. DATA SOURCES: A composite data set with the OPO as the unit of analysis, constructed from a 1995 national survey of OPOs (n = 64), plus secondary data from the Association of Organ Procurement Organizations and the United Network for Organ Sharing. STUDY DESIGN: The study uses data envelopment analysis (DEA) to evaluate the technical efficiency of all OPOs. PRINCIPAL FINDINGS: Overall, six of the 22 larger OPOs (27 percent) are classified as inefficient, while 23 of the 42 smaller OPOs (55 percent) are classified as inefficient. Efficient OPOs recover significantly more kidneys and extrarenal organs; have higher operating expenses; and have more referrals, donors, extrarenal transplants, and kidney transplants. The quantities of hospital development personnel and other personnel, and formalization of hospital development activities in both small and large OPOs, do not significantly differ. CONCLUSIONS: Indications that larger OPOs are able to operate more efficiently relative to their peers suggest that smaller OPOs are more likely to benefit from technical assistance. More detailed information on the activities of OPO staff would help pinpoint activities that can increase OPO efficiency and referrals, and potentially improve outcomes for large numbers of patients awaiting transplants.

Hospital development and the performance of organ procurement organizations.

With more than 56,000 patients on the national waiting list for organ transplants and relatively little growth in the number of donors, organ procurement organizations now recognize the need to aggressively market their services and the range of donor procurement opportunities to hospital personnel. This study examines the types and levels of hospital development activities being conducted by organ procurement organizations, the characteristics of organ procurement organizations that are more involved in hospital development, and the relationship between hospital development and organ procurement. Results from a national survey indicate that, as of the mid-1990s, organ procurement organizations had not made major investments in hospital development despite an increased recognition of the importance of these activities. Organ procurement organizations whose directors were more committed to hospital development exhibited higher levels of hospital development activity. Efforts to formalize hospital development activities through the establishment of a hospital development department and evaluation standards were associated with more organs procured per donor.

Integrating learning into integrated delivery systems.

Integrated delivery systems that promote learning and flexibility will be better prepared to face the challenges imposed by a complex and competitive environment. The integration of learning into these systems requires a shared vision, facilitative leadership, and highly functioning communication channels within an organic structure. Strategies that promote positive attitudes toward change are necessary for learning as is the provision of resources, training, incentives, and rewards that support learning, and feedback on how new administrative and clinical practices advance the mission and goals of the system.

Service needs and networks of rural women with HIV/AIDS.

Despite the fact that one of every 16 women with AIDS in the United States lives in a rural area, little is known about their demographic and epidemiologic characteristics, service needs, social support networks, or service utilization patterns. This article reports key findings from case studies of services to rural women with HIV/AIDS in southwest Georgia, northwest Mississippi, southeastern South Carolina, south Texas, and south-central Washington. Despite the growing numbers of HIV-positive women in these areas, many primary care physicians lack training in the diagnosis and treatment of HIV infection in women, and multidisciplinary protocols for the "shared care" of HIV-positive pregnant women are still being developed. Concerns about confidentiality and the lack of health insurance and transportation pose major access barriers. The findings suggest a need for new kinds of rural initiatives that embed HIV prevention and care into broader programs of educational and economic development.

A typological approach to the study of rural HIV service delivery networks.

Despite the rapid growth of AIDS cases in nonmetropolitan areas, little is known about the characteristics and needs of HIV-positive rural residents or how rural areas are responding to the epidemic. This paper proposes a typology for distinguishing among rural environments and examining variations in HIV service networks. The typology identifies three dimensions that have a major effect on the development of rural HIV service networks: degree of rurality, the prevalence of AIDS, and the epidemiological and demographic characteristics of the infected populations. Data from four case studies are used to illustrate how variations in rural environments can affect the organization and delivery of HIV/AIDS care. The typology contributes to public policy discussions by identifying key attributes of rural environments that influence program planning and implementation and the transferability of service delivery models.

A time to gain, a time to lose: new directions for western European HIV/AIDS alliances.

The complex and varied needs of people with HIV/AIDS have prompted major changes in the way that health care is organized and delivered. In the USA, the Netherlands and the UK, many HIV service providers have formed alliances to better coordinate policies and programs. These structural reforms have been accompanied by extensive reforms in the financing of health services. Drawing upon case studies of seven HIV/AIDS alliances in the Netherlands and the UK, the article examines how alliances are adapting their missions, organizational structures and functions to be responsive to changing community attitudes and the gradual elimination of earmarked HIV/AIDS funding. The case studies suggest strategies for maintaining interorganizational cooperation around public health issues in unstable and competitive funding environments.

Interorganizational exchanges as performance markers in a community cancer network.

OBJECTIVE: This study examines how "strategic partnerships" between community-based consortia of oncologists and hospitals (CCOPs) and clinical cooperative groups emerge, develop, and influence patient accruals (i.e., the number of patients enrolled in clinical trials) over time. DATA SOURCES AND STUDY SETTING: Study analyses are based on 65 pairwise relationships that 38 CCOPs established with eight clinical cooperative groups in September 1983 and maintained through February 1989. Data are drawn from grantee applications and progress reports. STUDY DESIGN: The study examines how different types of CCOP-cooperative group exchange relate to one another and to CCOP patient accruals over six time points. Key independent variables include resource dependence, information exchange (i.e., meeting attendance and committee membership), and protocol exchange (i.e., the number of different protocols used). DATA COLLECTION METHODS: Data extracted from secondary sources were entered in a data base. PRINCIPAL FINDINGS: The number of CCOP physicians and support staff who attend cooperative group meetings during the first two years of a clinical research partnership has a significant influence on meeting attendance and protocol use in later years. Two-thirds or more of the variance in patient accruals at each time point can be explained by the number of different protocols used and the number of CCOP representatives serving on cooperative group committees (or attending cooperative group meetings). CONCLUSIONS: The findings highlight the importance of historical relationships and anticipated resource dependence in shaping initial exchange patterns. They also suggest that strategic partnerships need to emphasize structures and processes that encourage early involvement in collaborative activities and that reward participants for maintaining high levels of interaction.

States' responses to Title II of the Ryan White CARE Act.

Title II of the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act of 1990 provides formula-based grants to States to help them improve the quality, availability, and organization of health care and support services for people with human immunodeficiency virus (HIV) infection. This article reviews State expenditures during the first year of CARE Act funding (April 1991-March 1992) within the context of Title II guidelines and the federally funded grant programs that preceded and helped shape Title II. The authors also discuss future challenges that require development of resources, the assessment of program impact, and the evaluation of the quality and appropriateness of HIV-related services. Ninety-one percent of the $77.5 million awarded to States during fiscal year 1991 went for the provision of medical and support services through HIV care consortia, drug reimbursement programs, home and community-based care programs, and health insurance initiatives. The remaining monies were used for planning, evaluation, and program administration. Forty States allocated $38.9 million for the establishment of HIV care consortia to assess service needs and to develop comprehensive continuums of health and support services in the areas most affected by HIV disease. Fifty States allocated an additional $28.3 million for the continuation or expansion of FDA-approved drug therapies for low-income people with HIV infection. Twenty-five States allocated $2.2 million for the provision of home- and community-based health services, and 16 States allocated $1.3 million for programs that help low-income people with HIV infection to purchase or maintain health insurance coverage.

Legislative interventions to increase access to screening mammography.

Although numerous studies have established that breast cancer mortality can be significantly reduced through early detection, only a small percentage of women obtain screening mammograms at intervals recommended by the National Cancer Institute, the American Cancer Society, and other major medical organizations. This paper examines the importance of cost as a barrier to routine screening and the state legislative movement to make screening mammography a basic health insurance benefit. Mammography "knowledge, attitudes, and behavior" studies offer conflicting findings on the extent to which cost enters into the decision to have a mammogram. Women seldom report cost as a major reason for postponing or failing to have a mammogram; yet, descriptive studies show a consistently positive relationship between income and mammography use. State mammography reimbursement laws vary greatly with respect to whether screening mammography is a required or optional benefit, payment limits, and eligibility and referral requirements. Although state-specific data on the percentage of women with private health insurance are not available, 1987 National Medical Expenditure Survey estimates for U.S. Census geographic divisions suggest that the New England, East North Central, West North Central, Middle Atlantic, and Mountain states have the highest percentages of women who are privately-insured and, thus, potentially eligible for legislated mammography benefits. Access to screening mammography also is likely to be influenced by the proportion of employer-sponsored health plans that are self-insured and, therefore, exempt from minimum benefit mandates and the extent to which women are aware of the screening coverage.

Synthesis and in vitro characterization of novel amino terminally modified oxotremorine derivatives for brain muscarinic receptors.

A series of novel 2-substituted acetylenic pyrrolidines and piperidines related to oxotremorine (1) were prepared and evaluated in vitro as muscarinic cholinergic agents at brain M1 and M2 receptors. One analogue, 3-(2-oxo-1-pyrrolidinyl)-1-[2(R)-pyrrolidinyl]-1-propyne hydrogen oxalate (6a), was found to be a partial agonist producing a PI hydrolysis response at cortical M1 receptors approximately 3-fold larger than that produced by 1. The intrinsic activity profile of 6a at brain muscarinic receptors is similar to those of azetidine oxo analogue 2 and dimethylamino oxo analogue. All three compounds are partial M1 agonists and full M2 agonists; however, the profile of 6a in binding studies is significantly different. While 2 and 3 exhibit large M2 selectivities ranging between 8-fold to several hundred-fold, the binding profile of 6a shows almost no subtype selectivity.

Organizing for cancer control. The diffusion of a dynamic innovation in a community cancer network.

This paper examines the diffusion of a "dynamic" innovation--research on the prevention and control of cancer--in a community cancer network. By analyzing the social structures and communication strategies of network members, as well as the attributes of the innovation, the authors explain why this innovation is diffusing more slowly than its "formed" counterpart--research on the treatment of cancer.

Strategic approaches to cancer control research in NCI-funded research bases.

Although the Community Clinical Oncology Program (CCOP) of the National Cancer Institute (NCI) has always encouraged research on cancer prevention and control issues, the clinical cooperative groups and cancer centers that serve as CCOP "research bases" were not required to conduct cancer control research until June 1987. This article draws upon case studies of six cooperative groups and two cancer centers to examine how CCOP research bases have defined cancer control research to be compatible with their missions, restructured roles and relationships to facilitate protocol development and implementation, and routine cancer control research to make prevention and control studies an accepted component of their scientific programs. Three "deliberate" or "emergent" strategies are found to be associated with the earlier resolution of problems and more rapid assimilation of cancer control studies into research base agendas. These strategies include (1) proactive planning, such as the early formation of a Cancer Control Research Committee (CCRC) and the identification of "idea champions" to promote cancer prevention and control research; (2) a staged approach to defining and introducing cancer control research; and (3) the creation of multiple "bridging" mechanisms to link cancer prevention and control studies with ongoing research activities. Research bases were most successful in building investigator commitment to cancer control research when they framed research questions within an accepted scientific paradigm, sought out and supported investigators with an interest in cancer prevention and control questions, created CCRCs with broadly representative memberships, and widely publicized ideas for prevention and control studies.

Paths and pacemakers: innovation diffusion networks in multihospital systems and alliances.

This article examines the role of multihospital systems and alliances as "innovation carriers." Drawing upon studies of interpersonal and interorganizational communications networks, the authors suggest how membership in a system or alliance, as well as network characteristics, affects innovation practices in general acute care hospitals.

A simple, non-chromatographic procedure to purify immunoglobulins from serum and ascites fluid.

A simple, two-step procedure to purify the immunoglobulin G (IgG) fraction from mammalian sera and ascites fluid is described. In the first step, albumin and other non-IgG proteins are precipitated with caprylic acid (octanoic acid). In the second, the IgG fraction is precipitated with ammonium sulfate. Factors influencing the precipitation of serum proteins by caprylic acid are described, as are procedural modifications to purify the IgG fraction from sera with a high lipid content. The procedure can be used to purify the IgG fraction of serum from rabbit, sheep, goat, horse, rat and mouse, as well as monoclonal antibodies from mouse ascites fluid. Greater than 80% of the IgG in rabbit serum could be isolated by this procedure, with a purity equal to rabbit IgG purified by anion-exchange chromatography. In addition to its simplicity and low cost, the procedure described offers several advantages over other methods to purify IgG.