VELOCITY-RESOLVED [C ii] EMISSION AND [C ii]/FIR MAPPING ALONG ORION WITH HERSCHEL.

We present the first ~7.5'×11.5' velocity-resolved (~0.2 km s-1) map of the [C ii] 158 µm line toward the Orion molecular cloud 1 (OMC 1) taken with the Herschel/HIFI instrument. In combination with far-infrared (FIR) photometric images and velocity-resolved maps of the H41α hydrogen recombination and CO J=2-1 lines, this data set provides an unprecedented view of the intricate small-scale kinematics of the ionized/PDR/molecular gas interfaces and of the radiative feedback from massive stars. The main contribution to the [C ii] luminosity (~85 %) is from the extended, FUV-illuminated face of the cloud (G0>500, nH>5×103 cm-3) and from dense PDRs (G≳104, nH≳105 cm-3) at the interface between OMC 1 and the H ii region surrounding the Trapezium cluster. Around ~15 % of the [C ii] emission arises from a different gas component without CO counterpart. The [C ii] excitation, PDR gas turbulence, line opacity (from [13C ii]) and role of the geometry of the illuminating stars with respect to the cloud are investigated. We construct maps of the L[C ii]/LFIR and LFIR/MGas ratios and show that L[C ii]/LFIR decreases from the extended cloud component (~10-2-10-3) to the more opaque star-forming cores (~10-3-10-4). The lowest values are reminiscent of the "[C ii] deficit" seen in local ultra-luminous IR galaxies hosting vigorous star formation. Spatial correlation analysis shows that the decreasing L[C ii]/LFIR ratio correlates better with the column density of dust through the molecular cloud than with LFIR/MGas. We conclude that the [C ii] emitting column relative to the total dust column along each line of sight is responsible for the observed L[C ii]/LFIR variations through the cloud.

Treatment process in prison therapeutic communities: motivation, participation, and outcome.

Although the largest effects of prison-based therapeutic community (TC) programs are associated with entry into aftercare, only a minority of prisoners volunteer for these aftercare programs. The study addresses the gap in our knowledge concerning these low rates of voluntary entry. A theoretical formulation of the TC process involving the effect of the interaction of clients' motivation and participation in the activities of the TC on entry into aftercare was tested on a sample of 110 volunteers in a prison-based TC for whom there were client and staff ratings of 3-month participation and 12-month follow-up data on relapse and recidivism. Path analyses support a model in which the interaction of motivation and 3-month participation ratings have a direct effect on the selection of aftercare, and aftercare has a direct effect on relapse and recidivism. The use of a combination of enhanced motivation and early program participation as a means of increasing the utilization and effectiveness of aftercare is discussed.

A client-treatment matching protocol for therapeutic communities: first report.

The present study is the first report on a client-treatment matching protocol (CMP) to guide admissions to residential and outpatient substance abuse treatment settings. Two cohorts, a field test sample (n = 318) and cross-validation (n = 407) sample were drawn from consecutive admissions to nine geographically distributed multisetting therapeutic communities (TCs). A passive matching design was employed. Clients received the CMP on admission, but agencies were "blind" to the CMP treatment recommendation (i.e., match) and assigned clients to treatment by the usual intake procedures. Bivariate and logistical regression analyses show that positive treatment dispositions (treatment completion or longer retention in treatment)) were significantly higher among the CMP-matched clients. The present findings provide the empirical basis for studies assessing the validity and utility of the CMP with controlled designs. Though limited to TC-oriented agencies, the present research supports the use of objective matching criteria to improve treatment.

Discovery of water vapour around IRC+10216 as evidence for comets orbiting another star.

Since 1995, planets with masses comparable to that of Jupiter have been discovered around approximately 60 stars. These planets have not been seen directly, but their presence has been inferred from the small reflex motions that they gravitationally induce on the star they orbit; these motions result in small periodic wavelength shifts in the stellar spectrum. The presence of analogues of the smaller bodies in our Solar System cannot, however, be determined using this technique, because the induced reflex motions are too small-so an alternative approach is needed. Here we report the observation of circumstellar water vapour around the ageing carbon star IRC+10216; water is not expected in measurable quantities around such a star. The only plausible explanation for this water is that the recent evolution of IRC+10216, which has been accompanied by a prodigious increase in its luminosity, is causing the vaporization of a collection of orbiting icy bodies-a process considered in an earlier theoretical study.

Operations for peptic ulcer disease: paradigm lost.

Over the past several decades, the pharmacologic and endoscopic treatment of peptic ulcer disease (PUD) has dramatically improved. To determine the effects of these and other changes on the operative management of PUD, we reviewed our surgical experience with gastroduodenal ulcers over the past 20 years. A computerized surgical database was used to analyze the frequencies of all operations for PUD performed in two training hospitals during four consecutive 5-year intervals beginning in 1980. Operative rates for both intractable and complicated PUD were compared with those for other general surgical procedures and operations for gastric malignancy. In the first 5-year period (1980 to 1984), a yearly average of 70 upper gastrointestinal operations were performed. This experience included 36 operations for intractability, 15 for hemorrhage, 12 for perforation, and seven for obstruction. During the same time span, 13 resections were performed annually for gastric malignancy. By the most recent 5-year interval (1994 to 1999), the total number of upper gastrointestinal operations had declined by 80% (14 cases), although the number of operations for gastric cancer had changed only slightly. Operations decreased most markedly for patients with intractability, but the prevalence of operations for bleeding, obstruction, and perforation was also decreased. We conclude that improved pharmacologic and endoscopic approaches have progressively curtailed the use of operative therapy for PUD. Elective surgery is now rarely indicated, and emergency operations are much less common. This changed paradigm poses new challenges for training and suggests different approaches for practice.

The effect of selective contracting on hospital costs and revenues.

OBJECTIVE: To examine the effects of selective contracting on California hospital costs and revenues over the 1983-1997 period. DATA SOURCES/STUDY SETTING: Annual disclosure data and discharge data sets for 421 California general acute care hospitals from 1980 to 1997. ANALYSIS: Using measures of competition developed from patient-level discharge data, and financial and utilization measures from the disclosure data, we estimated a fixed effect multivariate regression model of hospital costs and revenues. FINDINGS: We found that hospitals in more competitive areas had a substantially lower rate of increase in both costs and revenues over this extended period of time. For-profit hospitals lowered their costs and revenues after selective contracting was initiated relative to the cost and revenue levels of not-for-profit hospitals. The Medicare PPS has also led high-cost hospitals to lower their costs. CONCLUSIONS: The more competitive the hospital's market, the greater degree to which it has had to lower the rate of increase in costs. A similar pattern exists with regard to hospital revenues. Both of these trends appear to result from the growth of selective contracting. It remains unclear to what extent these cost reductions were the result of increased efficiency or of reduced quality. Since hospital cost growth is sensitive to the competitiveness of its market, antitrust enforcement is a critical element in any cost containment policy.

Can cost shifting continue in a price competitive environment?

Both Medicare and Medicaid are reducing payments to hospitals, and there is widespread concern that hospitals may respond by increasing prices to privately insured patients. Theoretical models of hospital behaviour have ambiguous predictions as to whether, and under what circumstances, hospitals will shift costs to private payers. This paper extends previous theoretical models and then tests empirically using data from California for the 1983-1991 period, a time of increasingly intense price competition. Hospitals did increase their prices to private payers in response to reductions in Medicare rates; they had far smaller and generally insignificant responses to changes in Medicaid reimbursement. Hospital ownership and the competitiveness of the hospital market both affected this behaviour, but there was no significant change over time. The results suggest the need to broaden our models of hospital behaviour to 'embed' them in their local markets.

Motivation for treatment in a prison-based therapeutic community.

Current research concludes that participation in postprison aftercare is critical to the effectiveness of prison-based therapeutic community (TC) treatment. This conclusion makes it imperative to understand the client determinants of retention in prison treatment, particularly continuance in postprison aftercare. Currently, however, little data exist as to client predictors of seeking and remaining in prison-based TCs or entering postrelease aftercare. In the present study, significant relationships were obtained between initial motivation (i.e., Circumstances, Motivation, Readiness [CMR] scores), retention, aftercare, and outcomes in a sample of substance abusers treated in a prison-based TC program. Implications are discussed for theory, research, and treatment policy.

Therapeutic communities. Enhancing retention in treatment using "Senior Professor" staff.

Evaluation research documents a firm relationship between retention and treatment outcomes among substance abusers in therapeutic communities (TCs). However, most admissions leave treatment prematurely, particularly in the first months after admission. This paper reports findings from a controlled study that assessed the efficacy of an intervention to reduce early dropout in a residential TC. In the "Senior Professor" (SP) intervention, the most experienced clinical and managerial staff in a TC program were utilized to conduct program induction seminars during the first weeks of admissions, traditionally the period of the highest rate of dropout. Rates of short-term retention (30 days of treatment) were compared for the experimental cohort (N=362), who received the intervention, and a cohort of admissions (N=243), who received standard or non-enhanced treatment. Findings showed that the SP intervention significantly reduced the likelihood of early dropout compared with controls. The enhanced effects are most evident for the new inductees with the lowest levels of motivation. Some theoretical and clinical implications are discussed as to the utilization of experienced staff to increase retention among new inductees with relatively lower motivational levels, who are at greatest risk for early dropout.

Therapeutic communities: diversity in treatment elements.

This study addresses the need to describe the diversity of therapeutic community (TC) programs. The Survey of Essential Elements Questionnaire (SEEQ) was used to develop a typology of TC programs based on 19 programs that identified themselves as traditional or modified TCs in the Drug Abuse Treatment Outcome Studies (DATOS). These traditional and modified TCs differed in adherence to the elements of TC treatment, on operational characteristics, and in client mix. Differences in treatment philosophy and approach included the emphasis on self-reliance, and the use of work as a therapeutic agent for traditional TCs. There were also trends for traditional TC programs to utilize community-as-method, provide educational and vocational training, and include family members as part of therapy. Modified programs showed a greater tendency to rely on counselors. Implications of the findings for program quality, health care policy, and research are discussed.

Market power and hospital pricing: are nonprofits different?

Dramatic changes in hospitals' operating environments are leading to major restructuring of hospital organizations. Hospital mergers and acquisitions are increasing each year, and conversions by hospitals to different forms of ownership also are continuing apace. Such changes require policymakers and regulators to develop and implement policies to ensure that consumers' interests are protected. An important consideration in this process is the impact on the price of hospital care following such transactions. This paper reviews empirical evidence that mergers that reduce competition will lead to price increases at both merging hospitals and their competitors, regardless of ownership status. We show that nonprofit and government hospitals have steadily become more willing to raise prices to exploit market power and discuss the implications for antitrust regulators and agencies that must approve nonprofit conversions.

Clarifying the nature of therapeutic community treatment. The Survey of Essential Elements Questionnaire (SEEQ).

This study reports on the extent to which Therapeutic Community (TC) agencies share a common set of beliefs about the essential elements of TC treatment. The Survey of Essential Elements Questionnaire (SEEQ), a TC theory-based instrument, was used in a field survey of 59 directors of agencies identified as TCs through their membership in Therapeutic Communities of America (TCA). Results showed a high degree of concordance in the perceived importance of a common set of treatment elements identified as essential to the TC modality. Two clusters of TC-oriented agencies, identified as Traditional and Modified, were determined based on beliefs in the importance of the elements. Results were seen as validating the TC formulation from which the SEEQ items were drawn. Implications on the potential use of the SEEQ as a means of codifying TC treatment for research, training, and quality assurance are discussed.

The changing effects of competition on non-profit and for-profit hospital pricing behavior.

Has the nature of hospital competition changed from a medical arms race in which hospitals compete for patients by offering their doctors high quality services to a price war for the patients of payors? This paper uses time-series cross-sectional methods on California hospital discharge data from 1986-1994 to show the association of hospital prices with measures of market concentration changed steadily over this period, with prices now higher in less competitive areas, even for non-profit hospitals. Regression results are used to simulate the price impact of hypothetical hospital mergers.

Price competition and hospital cost growth in the United States (1989-1994).

In recent years, most health care markets in the United States (US) have experienced rapid penetration by health maintenance organizations (HMOs) and preferred provider organizations (PPOs). During this same period, the US has also experienced slowing health care costs. Using a national database, we demonstrate that HMOs and PPOs have significantly restrained cost growth among hospitals located in competitive hospital markets, but not so in the case of hospitals located in relatively concentrated markets. In relative terms, we estimate that HMOs have contained cost growth more effectively than PPOs.

Motivation and readiness for therapeutic community treatment among adolescents and adult substance abusers.

A growing body of research has demonstrated the importance of motivation and readiness among drug abusers in seeking, complying with, and remaining in treatment. To date, however, there is little research on these factors among adolescent substance abusers. The present study reports findings from a large scale investigation of motivation and readiness differences across adolescent (range = 14-18 years, n > 1000) and adult (range = 19-26 + years, n > 1400) admissions to residential therapeutic communities (TCs). Data were collected with an instrument assessing circumstances, motivation, readiness, and suitability for TC treatment (i.e., CMRS). Results showed that: (1) there is a significant positive linear relationship between CMRS scores and age; (2) the CMRS scores were the largest and most consistent predictors of short term retention across all age groups. Although confined to TC samples, the present findings support clinical observations that adolescent drug abusers are less motivated to change or ready for treatment than adults; and they confirm the importance of motivational and readiness factors in the treatment process, regardless of age.

A profile of uncompensated hospital care, 1983-1995.

This DataWatch examines national trends in the provision of uncompensated hospital care. It shows that rapid growth from 1983-1986 was followed by modest growth through 1990, a time during which managed care was becoming established in some regions. There was then another spurt in uncompensated care from 1991-1993, a period that corresponds to sizable increases in disproportionate-share payments. Uncompensated care growth again slowed through 1995. The increase in uncompensated care levels after 1988 appears not to have kept pace with growth in hospital expenses or the number of uninsured. However, the trend data do not suggest a large-scale reduction of effort.

Motivation and readiness for therapeutic community treatment among cocaine and other drug abusers.

There is currently little empirical research on the effect of motivation and readiness on the treatment of different groups of substance abusers. In the present study, the CMRS scales are used to assess motivation and readiness for treatment of a large sample of primary alcohol, marijuana, heroin, cocaine, and crack cocaine abusers admitted to a long-term residential therapeutic community. Findings show few significant differences in overall retention or initial motivation and readiness. Initial motivation and readiness scores persist as significant predictors of short-term retention in treatment across most groups. Findings support the TC perspective that the substance abuse problem is the person, not the drug of choice, and are consistent with prior research emphasizing the importance of dynamic rather than fixed variables as determinants of retention.

Differentiation and specialization in the California hospital industry 1983 to 1988.

This article examines changes in the service mix of California hospitals as part of their response to shifts in the system of reimbursement between 1983 and 1988. The Hospital Discharge Data Set and the Annual Hospital Disclosure Report produced by California Office of Statewide Health Planning and Development were used in this study. Characteristics of inpatient hospital services in California before and after the introduction of new reimbursement mechanisms (including the Medicare Prospective Payment System [PPS] and the growth of selective contracting plans) were compared. The factors that influence two measures of hospital service mix, one focusing on specialization and the other on differentiation, were studied. The factors included hospital characteristics and changes in hospital reimbursement. Variables describing a hospital's service mix and the level in its market were constructed from data in the annual discharge abstracts. Data pertaining to average hospital costs and reimbursements under the Medicare PPS were drawn from a file containing a 20% sample of hospital stay records for the year of PPS. Other hospital data, such as ownership and bed size, were taken from the California Annual Disclosure Report data set. The results indicate that completion among hospitals tended to increase differentiation whereas higher financial PPS pressure is associated with increased specialization. Hospitals tend to adopt some high visibility services offered by their competitors while filling market niches selectively overall. It also appears that the cost savings expected for specialization may prevail only for narrowly defined services. Study of subsequent data sets should show whether the cost containment strategies used by the hospitals to achieve these results have been maintained over a period of sustained financial pressure.

Can managed care plans control health care costs?

The health insurance sector has been transformed in the past fifteen years, with managed care replacing indemnity insurance as the norm. This transformation was intended to change the nature of competition in the health care system so that market forces could be used to control costs. Empirical studies have shown that this objective has been met, as areas with high managed care penetration have tended to have much lower rates of increase in their costs. Creating a more efficient health care system will require additional efforts to produce useful measures of quality and to maintain competitive markets.

State health care expenditures under competition and regulation, 1980 through 1991.

OBJECTIVES: This paper examines health expenditure growth under two alternative policy approaches: competition-based managed care and state government rate regulation. METHODS: Data are presented on cumulative growth in real per capita health expenditures between 1980 and 1991 so as to compare California, a state with a pro-competitive policy, with the US average and with four states with established regulation programs. RESULTS: Real per capita expenditures for hospital services in the United States grew 54% between 1980 and 1991, while in California the growth was half the national rate, or 27%. Real per capita expenditures for physician services and drug expenditures in the United States grew by 82% and 65%, respectively, while in California these expenditures increased only 58% and 41%, respectively. California's growth rate was below that of all four regulatory states for all measures of health care cost inflation. CONCLUSIONS: On the basis of these findings, a properly structured competitive approach could play a significant role in controlling health expenditures in the United States.