Association Between Perceived Social Support and Depressive Symptoms Among Community-Dwelling Older Chinese Americans

Purpose: This study examined the association between social support and depressive symptoms among U.S. Chinese older adults. Methods: Data were from the Population Study of Chinese Elderly in Chicago (PINE) study. Independent variables were positive and negative perceived social support (PSS). Dependent variable was depressive symptoms. Multinomial logistic regression analyses were performed. Results: A total of participants were 3,157 Chinese older adults with the mean age of 72.8 years (range 60-105 years). After controlling for confounding factors, Chinese older adults with higher positive PSS were 12% (odds ratio [OR] = 0.88, 95% confidence interval [CI] = [0.85, 0.92]) and 18% (OR = 0.82, 95% CI = [0.79, 0.86]) less likely to report mild and moderate-severe depressive symptoms, respectively, compared to reporting minimal depressive symptoms; On the contrary, Chinese older adults with higher negative PSS were 34% (OR = 1.34, 95% CI = [1.24, 1.46]) and 38% (OR = 1.38, 95% CI = [1.26, 1.52]) more likely to report mild and moderate-severe depressive symptoms, respectively. Discussion: The study findings corroborate previous research that social support is significantly associated with depressive symptoms. Our findings reinforce the importance of developing strategies to utilize positive social support and limit negative support in practice for the depressed older adults. Further studies should be conducted to better understand the associations between different dimensions of social support and depression among U.S. Chinese older adults.

An Early Look at the Association Between State Medicaid Expansion and Disparities in Cardiovascular Diseases: A Comprehensive Population Health Management Approach

Cardiovascular disease (CVD) is one of the most prevalent chronic diseases nationally and disproportionately affects low-income individuals. There are substantial disparities on CVD outcomes that stem from the lack of health insurance among low-income populations. The Affordable Care Act expands Medicaid health insurance to low-income populations, and aims to increase the utilization of health, social, and economic preventive services to reduce health disparities and prevent chronic diseases. The authors analyzed data from the 2014 Behavioral Risk Factor Surveillance System to understand the potential impact of Medicaid expansion on disparities in CVD among low-income populations. Logistic regression models examined the association between CVD self-reported outcomes among low-income adults with incomes at or below 138% of the federal poverty level in states that have chosen to expand Medicaid and those states choosing not to expand, controlling for socioeconomic, demographic, behavioral, social, and health variables that affect CVD. Overall, the results show that adults in Medicaid expansion states have significantly lower odds of experiencing poor heart health compared to those in non-Medicaid expansion states (odds ratio = 0.767, 95% confidence interval 0.667-0.882). Additionally, significant findings were found between the association of CVD and demographic, socioeconomic, health, and health behavioral covariates. Policy makers should consider policies, systems, and interventions that increase access to a comprehensive set of preventive, population health, and socioeconomic services targeting the key determinants of CVD and other outcomes when expanding Medicaid and designing state plans and waivers.

The Impact of Tobacco-Free School Policies on Youth Smoking Rates in Florida Public School Districts

BACKGROUND

Developing and implementing policies to curb and prevent youth tobacco use is of the utmost importance. In Florida, public school districts were authorized to develop tobacco-free school policies through an amendment to the Florida Clean Indoor Air Act in 2011. The purpose of this study is to determine the impact of tobacco-free school policies on smoking rates among youth in Florida.

METHODS

Analysis of covariance (ANCOVA) and a multiple regression analysis were used to determine whether the comprehensiveness and enforcement of tobacco-free school policies affect the youth smoking rates within Florida public school districts. The 2010 and 2014 youth smoking rates were calculated based on the Florida Youth Tobacco Survey results.

RESULTS

The 2010 youth smoking rate and the inclusion of the enforcement component with provision of cessation resources were statistically significant predictors of the 2014 youth smoking rate. However, the comprehensiveness level of a policy and the inclusion of an enforcement component were not statistically significant predictors.

CONCLUSIONS

The inclusion of an enforcement component with provision of cessation resources is important in efforts to reduce youth smoking rates. The content of the tobacco-free school policies seems to be less relevant to their effectiveness than the enforcement of the policies.

MICA/B genotyping of Tujias from Zhangjiajie, Hunan Province, China

One hundred eighty-seven Tujia individuals from Zhangjiajie, Hunan Province, China were genotyped at the MICA and MICB loci using polymerase chain reaction-sequence specific priming and sequencing-based typing methods. MICA and MCB genotypes are consistent with expected HW proportions. These genotype data are available in the Allele Frequencies Net Database.

Association between Elder Mistreatment and Suicidal Ideation among Community-Dwelling Chinese Older Adults in the USA

BACKGROUND

Elder mistreatment and suicidal ideation are important public health concerns among aging populations. However, very few studies have been conducted to explore the association between elder mistreatment and suicidal ideation.

OBJECTIVES

To examine the association between elder mistreatment and suicidal ideation among Chinese older adults in the USA.

METHODS

Guided by a community-based participatory research approach, in this study we conducted in-person interviews with Chinese older adults aged 60 years and older in the Greater Chicago area from 2011 to 2013. Elder mistreatment was assessed by a 10-item instrument derived from the Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST) and the Vulnerability to Abuse Screening Scale (VASS). Suicidal ideation was assessed by the ninth item of the Patient Health Questionnaire-9 (PHQ-9) and the Geriatric Mental State Examination-Version A (GMS-A).

RESULTS

Overall, 3,159 Chinese older adults participated in this study, and their mean age was 72.8 years. After controlling for age, gender, education, income, medical comorbidities, depressive symptoms, and social support, elder mistreatment was significantly associated with 2-week suicidal ideation (OR 2.46, 95% CI 1.52-4.01) and 12-month suicidal ideation (OR 2.46, 95% CI 1.62-3.73). With respect to gender differences, the study found that the association remained significant for older women but not for older men after adjusting for all confounding factors.

CONCLUSION

As the largest epidemiological study conducted among Chinese older adults in the USA, this study suggests that elder mistreatment is significantly associated with 2-week and 12-month suicidal ideation in older women but not in older men. Longitudinal studies should be conducted to explore the mechanisms through which elder mistreatment links with suicidal ideation.

The impact of demographic and perceptual variables on a young adult's decision to be covered by private health insurance

BACKGROUND

The large number of uninsured individuals in the United States creates negative consequences for those who are uninsured and for those who are covered by health insurance plans. Young adults between the ages of 18 and 24 are the largest uninsured population subgroup. This subgroup warrants analysis. The major aim of this study is to determine why young adults between the ages of 18 and 24 are the largest uninsured population subgroup.

METHODS

The present study seeks to determine why young adults between the ages of 18 and 24 are the largest population subgroup that is not covered by private health insurance. Data on perceived health status, perceived need, perceived value, socioeconomic status, gender, and race was obtained from a national sample of 1,340 young adults from the 2005 Medical Expenditure Panel Survey and examined for possible explanatory variables, as well as data on the same variables from a national sample of 1,463 from the 2008 Medical Expenditure Panel Survey.

RESULTS

Results of the structural equation model analysis indicate that insurance coverage in the 2005 sample was largely a function of higher socioeconomic status and being a non-minority. Perceived health status, perceived need, perceived value, and gender were not significant predictors of private health insurance coverage in the 2005 sample. However, in the 2008 sample, these indicators changed. Socioeconomic status, minority status, perceived health, perceived need, and perceived value were significant predictors of private health insurance coverage.

CONCLUSIONS

The results of this study show that coverage by a private health insurance plan in the 2005 sample was largely a matter of having a higher socioeconomic status and having a non-minority status. In 2008 each of the attitudinal variables (perceived health, perceived value, and perceived need) predicted whether subjects carried private insurance. Our findings suggest that among those sampled, the young adult subgroup between the ages of 18 and 24 does not necessarily represent a unique segment of the population, with behaviors differing from the rest of the sample.

Job and Professional Leaving Among Newly Licensed RNs: A Structural Equation Model

With more than 50% of the nursing workforce close to retirement, it is especially important to keep younger nurses in nursing jobs and careers. This study empirically tests a structural equation model of registered nurse (RN) intent to leave the job and profession using data from a survey of newly licensed RNs (NLRNs). Job demands, difficulties and control, intent to leave the job, and intent to leave the profession were latent variables. A number of direct, indirect, and mediating relationships were modeled. Measurement models for all latent variables and the structural model had good fit. The final model showed a path from job demands, difficulties, and control to job satisfaction to intent to leave the job to intent to leave the profession. The results suggest that the process of an NLRN intending to leave the job and profession involves a number of mediators between the work environment and this intent.

The Hospital Work Environment And Job Satisfaction of Newly Licensed Registered Nurses

In prior studies, newly licensed registered nurses (NLRNs) described their job as being stressful. Little is known about how the hospital work environment affects their job satisfaction. A random sample of NLRNs were surveyed to assess the influence of hospital work environment on job satisfaction. Perceptions of greater job difficulty, job demands, and patient load were significantly related to lower job satisfaction. In contrast, being White, working 12-hour shifts, working more hours, and having more job control, greater professional tenure, and a perception of a better initial orientation were significantly related to higher job satisfaction.

LDL-C levels in US patients at high cardiovascular risk receiving rosuvastatin monotherapy

BACKGROUND

Statin therapy is recommended as the first-line pharmacotherapeutic approach for lowering LDL-C levels in patients at high cardiovascular risk.

OBJECTIVE

To assess LDL-C levels among patients at high cardiovascular risk treated with rosuvastatin monotherapy.

METHODS

This retrospective cohort study used patient records from the GE Centricity Electronic Medical Records (GE Centricity EMR) database and administrative claims data from Humana Medicare to identify patients at high cardiovascular risk with a first prescription for rosuvastatin monotherapy (index date) from January 1, 2008 through December 31, 2010. Eligible adult patients had an International Classification of Diseases, Ninth Revision (ICD-9) diagnosis or a Current Procedural Terminology (CPT) procedure code indicating coronary heart disease or atherosclerotic vascular disease, ≥1 LDL-C measurement 3 to 12 months after the index date, and continuous data during 1-year baseline and 1-year follow-up. Mean LDL-C levels and distribution of patients around <70 mg/dL and <100 mg/dL thresholds overall and by daily rosuvastatin dose were assessed.

RESULTS

Among 6004 GE Centricity EMR patients (mean [SD] age, 66 [10] years; 56% men) and 11,320 Humana Medicare patients (mean [SD] age, 74 [8] years; 44% men) who met selection criteria, the most frequently prescribed rosuvastatin dose was 10 mg, and the mean (SD) follow-up LDL-C level was 89 (37) mg/dL for GE Centricity EMR patients and 92 (36) mg/dL for Humana Medicare patients. Overall, lower mean LDL-C levels were observed as rosuvastatin dose increased. However, less than one-third of GE Centricity EMR and Humana Medicare patients had an LDL-C level <70 mg/dL, and approximately two-thirds had an LDL-C level <100 mg/dL.

CONCLUSION

More effective lipid-lowering strategies, such as statin up-titration or combination therapy, may be needed to achieve therapeutic goals in a substantial proportion of high-risk patients.

Limitations of real-world treatment with atorvastatin monotherapy for lowering LDL-C in high-risk cardiovascular patients in the US

BACKGROUND

Guidelines endorse statin therapy for lowering low-density lipoprotein cholesterol (LDL-C) to recommended levels, in patients with cardiovascular disease (CVD) risk, if needed, after lifestyle changes. Atorvastatin is a common statin with greater LDL-C lowering efficacy than most other statins; its availability in generic form will likely increase its use. This study assessed attainment of guideline-recommended LDL-C levels in high-risk CVD patients treated with atorvastatin monotherapy.

METHODS

Analyses of two retrospective US cohorts of patients who received a prescription for atorvastatin monotherapy between January 1, 2008 and December 31, 2010 (index date defined as first prescription date) in the GE Centricity Electronic Medical Record (EMR) (N=10,693) and Humana Medicare (N=16,798) databases. Eligible patients were ≥18 years, diagnosed with coronary heart disease or atherosclerotic vascular disease, with ≥1 LDL-C measurement between 3 months and 1 year postindex date, and continuously enrolled for 1 year prior to and following the index date.

RESULTS

Of the eligible patients, 21.8%, 29.6%, 29.9%, and 18.7% (GE Centricity EMR) and 25.4%, 32.9%, 27.8%, and 14.0% (Humana Medicare) received 10, 20, 40, and 80 mg doses of atorvastatin, respectively. The mean ± standard deviation (SD) follow-up LDL-C levels were 2.1±0.8 mmol/L (83±30 mg/dL) and 2.3±0.8 mmol/L (88±31 mg/dL) for the GE Centricity EMR and Humana Medicare cohorts, respectively. Regardless of dose, only 28.3%-34.8% of patients had LDL-C levels <1.8 mmol/L (<70 mg/dL), and 72.0%-78.0% achieved LDL-C <2.6 mmol/L (<100 mg/dL) in both cohorts. As many as 41% and 13% of patients had LDL-C levels ≥0.5 mmol/L (≥20 mg/dL) above LDL-C 1.8 mmol/L (70 mg/dL) and 2.6 mmol/L (100 mg/dL), respectively, in both cohorts; these percentages were generally similar across atorvastatin doses.

CONCLUSION

In this real-world US setting, a large number of high-risk CVD patients did not attain guideline-recommended LDL-C levels with atorvastatin monotherapy. More than 65% of the patients had LDL-C levels >1.8 mmol/L (>70 mg/dL), and of these, 30%-40% had LDL-C levels ≥0.5 mmol/L (≥20 mg/dL) above this, regardless of dose. This suggests that more effective lipid-lowering strategies, such as statin uptitration, switching to a higher efficacy statin, and/or combination therapy, may be required to achieve optimal LDL-C lowering in high-risk patients.

Impact of health literacy on medication adherence: a systematic review and meta-analysis

OBJECTIVE

To systematically review the literature and estimate the effect size of the relationship between health literacy and medication adherence through meta-analysis.

DATA SOURCES

Databases searched included Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982-2013), International Pharmaceutical Abstracts (IPA; 1970-2013), MEDLINE OVID (1966-2013), PubMed (1966-2013), PsycInfo (1966-2013), and Web of Science (1966-2013).

STUDY SELECTION AND DATA EXTRACTION

Inclusion criteria were as follows: English language; published through May 1, 2013; medication adherence as the outcome variable; use of validated measures of health literacy and medication adherence; availability of a direct (not mediating) relationship between health literacy and medication adherence; and identifiable effect size and statistical significance of the relationship. Exclusion criteria were as follows: duplicated results, irrelevant results, conference abstracts, proceeding papers, books, dissertations, reviews, editorial letters, continuing education units, or book reviews. Data included author, publication year, disease area, sample size, sampling method, location, study design, effect size of the relationship between health literacy and medication adherence, and measures of health literacy and medication adherence.

DATA SYNTHESIS

There is a small statistically significant and positive association between health literacy and medication adherence. In the conservative results, the unweighted and weighted correlation coefficients were 0.081 and 0.056 with P values <0.001. In the less conservative results, the unweighted and weighted correlation coefficients were 0.088 and 0.072.

CONCLUSIONS

The relationship between health literacy and medication adherence is statistically significant but weak. It is plausible that health literacy has a mediator relationship with other adherence determinants. Future research should explore such relationships.

Gaps in nurse staffng and nursing home resident needs

Trends in nurse staffing levels in nursing homes from 1997 to 2011 varied across the category of nurse and the type of nursing home. The gaps found in this study are important to consider because nurses may become overworked and this may negatively affect the quality of services and jeopardize resident safety. Nursing home administrators should consider improving staffing strategically. Staffing should be based not only on the number of resident days, but also allocated according to particular resident needs. As the demand for nursing home care grows, bridging the gap between nurse staffing and resident nursing care needs will be especially important in light of the evidence linking nurse staffing to the quality of nursing home care. Until more efficient nursing care delivery exits, there may be no other way to safeguard quality except to increase nurse staffing in nursing homes.

Improving nursing home resident integrity by optimizing interpersonal communication skills in clinical staff

In this article the authors discuss the prevalence of resident abuse and reported violations of care deficiencies and resident maltreatment in nursing homes in the United States. The number of nursing homes in the United States that are cited with abuse violations has increased in recent years. While the authors recognize that treatments (both positive and negative) received by residents are sometimes related to factors other than staff's lack of knowledge and poor attitudes, their purpose in this analysis is to enhance resident integrity through the improvement of staff interpersonal communication skills. In doing so, innovative strategies and specific interpersonal communication theories are examined as educational methods to confront and resolve care deficiencies and elevate and enrich residents' integrity, satisfaction, and outcomes.

China: awakening giant developing solutions to population aging

As the world's most populous country with the largest aging population and a rapidly growing economy, China is receiving increased attention from both the Chinese government and the governments of other countries that face low fertility and aging problems. This unprecedented shift of demographic structure has repercussions for many aspects of development including economic growth, social welfare, elder care, and other public welfare issues in China. Balancing population aging and economic growth requires innovative strategies and represents both challenges and opportunities for China.

Nursing home research in Jinan, China: a focus group approach

This qualitative research using the focus group approach has gathered pertinent perceptions from the stakeholders in Chinese elderly care environment, including community-based and institutionalised elderly, medical providers, administrators and governmental officials. The study found that the elderly are willing to live in nursing homes when they are not in good physical condition and are dependent on others for their activities of daily living. The utilisation of nursing home care has gained acceptance in the community as more elders recognise its advantages. The elderly study subjects expressed interest in the service environment, as well as the cultural and recreational activities in nursing homes. Most participants were satisfied with the quality of nursing care. Administrators and providers in the nursing homes agreed that skilled nursing facilities appear to be more competitive because they require more licensed providers and other professional staff members. A majority of nursing homes face serious financial difficulties.

Structural equation modeling of the proximal-distal continuum of adherence drivers

OBJECTIVES

Nonadherence to prescription medications has been shown to be significantly influenced by three key medication-specific beliefs: patients' perceived need for the prescribed medication, their concerns about the prescribed medication, and perceived medication affordability. Structural equation modeling was used to test the predictors of these three proximal determinants of medication adherence using the proximal-distal continuum of adherence drivers as the organizing conceptual framework.

METHODS

In Spring 2008, survey participants were selected from the Harris Interactive Chronic Illness Panel, an internet-based panel of hundreds of thousands of adults with chronic disease. Respondents were eligible for the survey if they were aged 40 years and older, resided in the US, and reported having at least one of six chronic diseases: asthma, diabetes, hyperlipidemia, hypertension, osteoporosis, or other cardiovascular disease. A final sample size of 1072 was achieved. The proximal medication beliefs were measured by three multi-item scales: perceived need for medications, perceived medication concerns, and perceived medication affordability. The intermediate sociomedical beliefs and skills included four multi-item scales: perceived disease severity, knowledge about the prescribed medication, perceived immunity to side effects, and perceived value of nutraceuticals. Generic health beliefs and skills consisted of patient engagement in their care, health information-seeking tendencies, internal health locus of control, a single-item measure of self-rated health, and general mental health. Structural equation modeling was used to model proximal-distal continuum of adherence drivers.

RESULTS

The average age was 58 years (range = 40-90 years), and 65% were female and 89% were white. Forty-one percent had at least a four-year college education, and just under half (45%) had an annual income of $50,000 or more. Hypertension and hyperlipidemia were each reported by about a quarter of respondents (24% and 23%, respectively). A smaller percentage of respondents had osteoporosis (17%), diabetes (15%), asthma (13%), or other cardiovascular disease (8%). Three independent variables were significantly associated with the three proximal adherence drivers: perceived disease severity, knowledge about the medication, and perceived value of nutraceuticals. Both perceived immunity to side effects and patient engagement was significantly associated with perceived need for medications and perceived medication concerns.

CONCLUSION

Testing the proximal-distal continuum of adherence drivers shed light on specific areas where adherence dialogue and enhancement should focus. Our results can help to inform the design of future adherence interventions as well as the content of patient education materials and adherence reminder letters. For long-term medication adherence, patients need to autonomously and intrinsically commit to therapy and that, in turn, is more likely to occur if they are both informed (disease and medication knowledge and rationale, disease severity, consequences of nonadherence, and side effects) and motivated (engaged in their care, perceive a need for medication, and believe the benefits outweigh the risks).

Determinants of health insurance coverage rates for young adults: an analytical literature review

This chapter summarizes the major determinants of health insurance coverage rates among young adults. Socioeconomic status, demographics, actual and perceived health status, perceived value, and perceived need are all examined in order to determine what the literature reveals regarding each variable and how each variable impacts a young adult's decision to purchase health insurance. Results indicate that socioeconomic status, demographics, perceived value, and perceived need were the most significant determinates of health insurance status of young adults. A conceptual framework is also examined and used to illustrate theoretical implications. Managerial implications for marketing health plans to young adults are also addressed. Finally, policy implications concerning the new Patient Protection and Affordable Care Act are addressed.

Explaining the efficiency of local health departments in the U.S.: an exploratory analysis

No study to date has analyzed the efficiency at which local health departments (LHDs) produce public health services. As a result, this study employs data envelopment analysis (DEA) to explore the relative technical efficiency of LHDs operating in the United States using 2005 data. The DEA indicates that the typical LHD operates with about 28% inefficiency although inefficiency runs as high as 69% for some LHDs. Multiple regression analysis reveals that more centralized and urban LHDs are less efficient at producing local public health services. The findings also suggest that efficiency is higher for LHDs that produce a greater variety of services internally and rely more on internal funding. However, because this is the first study of LHD efficiency and some shortcomings exist with the available data, we are reluctant to draw strong policy conclusions from the analysis.

Changes in nursing home staffing levels, 1997 to 2007

A positive relationship has been demonstrated between the quality of care delivered in nursing homes and the quality of nursing staff providing the care. The general perception, however, is that there is a decline in registered nurses' staff hours in nursing homes. The primary objective of this study is to investigate whether the levels of registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants (NAs) as well as skill mix has changed in nursing homes between the years 1997 and 2007. A descriptive research design was employed on data derived from Online Survey Certification and Reporting System database. After accounting for facility size and ownership, it was found that more nursing homes have increased-rather than decreased-LPN and NA hours per resident day between 1997 and 2007. On the other hand, more nursing homes have decreased-rather than increased-RN hours per resident day and skill mix during the same time period.

Has the Medicare prospective payment system led to increased nursing home efficiency?

RESEARCH OBJECTIVE

To assess the impact of recent Medicare prospective payment system (PPS) changes on efficiency in skilled nursing homes.

DATA SOURCE/STUDY SETTING

Medicare Cost Reports (MCR), On-line Survey Certification and Reporting System (OSCAR), Area Resource Files (ARF), a Centers for Medicare and Medicaid Services (CMS) hospital wage index website, a Consumer Price Index (CPI) database, and a survey of state Medicaid reimbursement rates. The sample was 8,361 nursing homes in the Medicare Cost Report databases from the years 1997 to 2003.

STUDY DESIGN

Data-envelopment analyses (DEA) calculated efficiency scores for three separate DEA models: unadjusted, acuity-adjusted, and acuity-and-quality-adjusted efficiency. The efficiency scores from these models were regressed on the Medicare PPS changes (the Balanced Budget Act [BBA], the Balanced Budget Refinement Act [BBRA] and the Benefits Improvement and Protection Act) and other organizational and market explanatory variables using a panel-data truncated regression.

PRINCIPAL FINDINGS

Mean values for all efficiency measures decreased over time, the acuity-quality-adjusted efficiency measures decreasing the most. All policy variables were significantly negatively related to all efficiency measures. Higher nurse staffing was negatively related to efficiency in all but the acuity-quality-adjusted model. Other explanatory variables varied in their relationships to the efficiency variables.

CONCLUSIONS

The results suggest that the reimbursement policy changes had a significantly negative impact on efficiency. Higher nurse staffing contributed to lower efficiency only when efficiency was not adjusted for quality. Various organizational and market factors also played significant roles in all efficiency models.

Facility service environments, staffing, and psychosocial care in nursing homes

Using 2003 Online Survey Certification and Reporting (OSCAR) data for Medicare and Medicaid certified facilities (N = 14, 184) and multinomial logistic regression this study investigated if (1) psychosocial care quality was better in facilities where State requirements for qualified social services staffing exceeded Federal minimum regulations and (2) facility service environments are associated with psychosocial care quality. For-profit status and higher percentage of Medicaid residents are associated with lower quality. Staffing, market demand, and market competition are associated with better quality. Psychosocial care quality is more associated with payer status and market forces and less with regulatory requirements.

Effects of institutional mechanisms on nursing home quality

This study explores institutional mechanisms explaining the variation in nursing home quality. A two-level panel design with the national data is conducted. Structural equation modeling is employed to examine the main and interaction effects of institutional factors on nursing home quality at both facility and state levels. The findings indicate that the quality of nursing homes is more responsive to regulatory and payment constraints than to normative and mimetic mechanisms. The potential demand for care, Medicaid reimbursement rate, and occupancy rate are positively associated with nursing home quality. An interaction effect between the regulatory mechanism and nurse staffing is statistically significant. The findings lend support to the importance of multi-level analysis of nursing home quality.

Predictors of resident outcome improvement in nursing homes

The effects of contextual characteristics and nursing-related factors on the overall quality improvement of resident outcomes, measured by a weighted index in incidents of pressure ulcers, physical restraints, and catheter use in nursing homes, were investigated by autoregressive latent trajectory modeling of panel data (1997-2003). Findings show that in the initial study period, nursing homes with a smaller bed size, being for-profit, caring for more Medicare residents, having residents with lower acuity levels, being located elsewhere than the South, having a high level of nurse staffing, and certified with lower frequencies of nursing care deficiencies had better quality. The intercept factor, representing the baseline of quality, was well predicted by six of the eight contextual and facility characteristics variables, and the slope trajectory of quality was only weakly predicted by them. The improved quality in resident outcomes was associated with facilities having fewer nursing care deficiency citations than their counterparts.

Minimum nurse staffing ratios for nursing homes

The authors explored minimum nurse staffing ratios for nursing homes using production function simulations. Minimum levels of registered nurse hours per resident day were 0.31, 1.83, and 3.3 at 50%, 75%, and 90% levels of quality respectively. These results suggest that efficiency-oriented minimum nurse staffing points exist, and could be used to inform policymakers and nursing home administrators on better resource allocation and health care delivery.

The Measurement of Nursing Home Quality: Multilevel Confirmatory Factor Analysis of Panel Data

This study examined the validity of a measurement model of nursing home quality by using multilevel confirmatory factor analysis. Based on Mullan and Harrington's (2001) facility-level quality measurement model, a two-level analysis (facility and state) of the measurement model were performed. Two research questions were asked: (1) Can the measurement model developed at the facility-level be applied to state-level nursing home quality measurement? (2) Is the measurement model of nursing home quality stable over time? Panel data of 1997 and 2001, from the national OSCAR database, were used to test the assumptions. The results show that the state-level measurement model fits the data better than the facility-level model does. When the indicator "assessment" was removed from the state-level measurement model, a better-fitted measurement model was found. The two-level measurement model is relatively stable over time, demonstrating the construct validity of this measurement model.

Observation by an air-shower array in Tibet of the multi-TeV cosmic-ray anisotropy due to terrestrial orbital motion around the Sun

We report on the solar diurnal variation of the galactic cosmic-ray intensity observed by the Tibet III air shower array during the period from 1999 to 2003. In the higher-energy event samples (12 and 6.2 TeV), the variations are fairly consistent with the Compton-Getting anisotropy due to the terrestrial orbital motion around the Sun, while the variation in the lower-energy event sample (4.0 TeV) is inconsistent with this anisotropy. This suggests an additional anisotropy superposed at the multi-TeV energies, e.g., the solar modulation effect. This is the highest-precision measurement of the Compton-Getting anisotropy ever made.

Observation of Multi-TeV Gamma Rays from the Crab Nebula using the Tibet Air Shower Array

The Tibet experiment, operating at Yangbajing (4300 m above sea level), is the lowest energy air shower array, and the new high-density array constructed in 1996 is sensitive to gamma-ray air showers at energies as low as 3 TeV. With this new array, the Crab Nebula was observed in multi-TeV gamma-rays and a signal was detected at the 5.5 sigma level. We also obtained the energy spectrum of gamma-rays in the energy region above 3 TeV which partially overlaps those observed with imaging atmospheric Cerenkov telescopes. The Crab spectrum observed in this energy region can be represented by the power-law fit dJ&parl0;E&parr0;&solm0;dE=&parl0;4.61+/-0.90&parr0;x10-12&parl0;E&solm0;3 TeV&parr0;-2.62+/-0.17 cm-2 s-1 TeV-1. This is the first observation of gamma-ray signals from point sources with a conventional air shower array using scintillation detectors.

Restriction primer extension method of labeling oligonucleotide probes and its application to the detection of Hb E genes

A new method for labeling oligonucleotides was developed to obtain high specific activity of radioactive probes. In an oligonucleotide molecule, two sequences were designed. One sequence, the 5', contains 19 nucleotides and serves as a template for probe synthesis. The second sequence, 3', contains a consensus sequence which forms a Pst I site after forming a complementary strand with the primer. In the presence of E. coli DNA polymerase I (Klenow fragment), alpha-32P dNTP and other dNTPs, a radioactive labeled oligonucleotide was synthesized by the primer extension method. After Pst I digestion, the probe was different from its template in length by 4 bp and could be separated from each other on urea-polyacrylamide gel electrophoresis (PAGE). A radioactive oligonucleotide probe with extremely high specific activity up to 10(10) dpm/micrograms could be obtained by the use of this method. The oligonucleotide probes have been used for the detection of the Hb E mutation in this report.

First-trimester prenatal diagnosis of severe alpha-thalassemia

By means of chorion biopsy together with restriction endonuclease analysis of fetal DNA, first trimester diagnoses were successfully made in 33 fetuses at risk for Bart's hydrops fetalis. Seven pregnancies with Hb H or hydrops fetalis were therapeutically terminated before 4 1/2 months of gestation. Of the 26 pregnancies intended to continue, 18 have come to term with normal deliveries; one with threatened abortion was terminated at the end of the first trimester and, seven are progressing normally.

Alpha-1-antitrypsin types in five Chinese national minorities

The frequencies of alpha-1-antitrypsin alleles were determined for five Chinese national minorities: Uigur, Korean, Mongolian, Chuang, and Li. PI S and PI Z alleles are not found in the five populations studied. PI ETOK allele is present in Korean, Mongolian, and Chuang populations, and Etokyo is a very common alpha-1-antitrypsin variant in Chinese. Other alleles which occur in more than one of the minorities are PI X (Mongolian and Chuang) and PI M4 (Korean and Uigur). The high frequency of PI M4 in the Uigur population suggests a probably Occidental origin of this nationality.

Geographical variability of alpha-1-antitrypsin alleles in China: a study on six Chinese populations

Alpha-1-antitrypsin phenotypes of six Chinese Han populations (20 degrees-45 degrees N. latitude) were determined. The frequency of allele M2 increases from North to South China. The north-south change of M2 appears to be mainly at the expense of alleles M1 and M3. Geographical variability of other variants was also observed. In the northern populations, the most common variants are M4 and Etokyo; in the southern populations, Pweishi, a variant which can not be distinguished electrophoretically from Pyasugi. These results form a distribution pattern of alpha-1-antitrypsin alleles in China.