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OBJECTIVE: The objective of this paper is to provide empirical guidance by comparing the performance of six different area-level SDoH measurement approaches in predicting patient referral to a social worker and hospital admission after a primary care visit. METHODS: We compared the performance of six area-level SDoH measurement approaches in predicting patient referral to a social worker and hospital admission after a primary care visit using random forest classification algorithm. Data came from 209,605 patient encounters at a federally qualified health center. Models with each area-based measurement approach were compared against the patient-level data only model using area under the curve, sensitivity, specificity, and precision. RESULTS: Addition of area-level features to patient-level data improved the overall performance of models predicting need for a social worker referral. Entering area-level measures as individual features resulted in highest model performance. CONCLUSION: Researchers seeking to include area-level SDoH measures in risk prediction may be able to forego more complex measurement approaches.

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Recent studies have added to our knowledge regarding the mechanisms of calcium crystal deposition. Calcium pyrophosphate dihydrate (CPPD) crystal deposition is associated with elevated levels of PPi in joints. Cyclic compression of cartilage transiently elevated ATP levels in culture media. Extracellular ATP may be hydrolyzed by nucleoside triphosphate pyrophosphohydrolase (NTPPPH), yielding an elevated PPi concentration. CPPD crystal deposition increases with age. Nitric oxide may alter cartilage matrix by interfering with chondrocyte mitochondrial function and ATP production. Transglutaminase in adult, but not young, porcine articular chondrocytes was able to activate latent transforming growth factor beta, a potent stimulus to PPi production. Basic calcium phosphate crystals are more likely to form in a milieu of reduced PPi concentration. The ank gene mutation results in higher intracellular PPi concentration and lower extracellular concentration. The ANK protein is thought to be a transmembrane protein necessary for transport of PPi out of cells. A mutation that results in reduced synthesis of NTPPPH PC-1 caused infantile wrist and ankle periarticular calcification and vascular calcification.

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OBJECTIVE: The authors examine the extent and nature of managed care plans participating in local public health activities. METHODS: In 1998, the authors surveyed the directors of all US local health departments serving jurisdictions of at least 100,000 residents to collect information about public health activities performed in their jurisdictions and about organizations participating in the activities. Multivariate logistic and linear regression models were used to examine organizational and market characteristics associated with managed care plan participation in public health activities. RESULTS: Managed care plans were reported to participate in public health activities in 164 (46%) of the jurisdictions surveyed, and to contribute to 13% of the public health activities performed in the average jurisdiction. Plans appeared most likely to participate in public health activities involving the delivery or management of personal health services and the exchange of health-related information. Managed care participation was more likely to occur in jurisdictions with higher HMO penetration, fewer competing plans, and larger proportions of plans enrolling Medicaid recipients. Participation was positively associated with the overall scope and perceived effectiveness of local public health activities. CONCLUSIONS: Although plans participate in a narrow range of activities, these contributions may complement the work of public health agencies.

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OBJECTIVES: This study examines organizational characteristics and market conditions likely to influence collaborative relationships between public health agencies and community medical care providers. METHODS: Public health directors in 60 US counties were surveyed by telephone concerning their relationships with area community hospitals (n = 263) and community health centers (n = 85). Multivariate models were used to estimate the effects of organizational and market characteristics on collaboration. RESULTS: Collaboration was reported among 55% of the hospitals and 64% of the health centers. Certain forms of collaboration were more likely in markets characterized by higher HMO penetration and lower HMO competition. CONCLUSIONS: Targeted efforts to facilitate collaboration may be required in settings where institutional and market incentives are lacking.

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Efforts are under way to develop a performance measurement monitoring system for state and local public health systems and to develop a strategic planning tool for local public health systems. The development of these measures is being based on the Essential Public Health Services. This article provides the rationale for why the Essential Services offer a good framework for identifying, analyzing, and evaluating public health activities. The article also reviews the history of local public health and the development and application of the Essential Public Health Services and their predecessor frameworks such as the core functions, the organizational practices, and the essential elements.

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As part of the developmental process for the National Public Health Performance Standards Program, the CDC convened a group of experts in the fields of public health practice and research to evaluate key conceptual and methodological issues involved in measuring the performance of public health organizations. Participants engaged in a nominal group process and an electronic polling exercise designed to elicit expert opinions about these issues. Results revealed broad consensus around the need for measurement systems that support quality improvement and accountability applications, with scientific investigation viewed as an important but secondary objective of measurement. Substantial variation was observed in perceptions about the importance of specific measurement concepts and methods. Results highlight the need for performance measurement systems to reflect multiple organizational perspectives in their design and implementation.

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In the Americas, health sector reforms are facing the challenge of strengthening the steering and leadership role of health authorities. An important part of that role consists of fulfilling the essential public health functions (EPHFs) that are incumbent on all levels of government. For that, it's crucial to improve public health practice, as well as the instruments used to assess the current state of public health practice and the areas where it needs to be strengthened. For that purpose, the Pan American Health Organization has started an initiative called "Public Health in the Americas," with the objective of defining and measuring EPHFs, as a way of improving public health practice and strengthening the leadership provided by health authorities at all levels of government. This article summarizes conceptual and methodological aspects of defining and measuring EPHFs. The article also analyzes the implications that measuring performance on these public health roles, responsibilities, and activities would have for improving public health practice in the Americas.

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BACKGROUND: Relatives of breast cancer patients often face substantial uncertainty and psychological stress regarding their own health risks and optimal strategies for prevention and early detection. Efficacious educational and counseling interventions are rarely evaluated for their potential adoption and use in medical practice settings. This study evaluates a health education program for first-degree relatives of breast cancer patients based on the program's potential for being adopted and used by medical practices affiliated with cancer centers. METHODS: A randomized, controlled trial was implemented in four community hospital-based medical practices. After 9 months, clinical and administrative staff at each practice were given self-administered surveys. Of 90 staff members recruited to respond, useable responses were received from 60 (67%), including 13 physicians (31%), 43 nurses (98%), and four program managers (100%). Participants made self-reports of program awareness, program support, perceived program performance, likelihood of program adoption and use, and barriers to adoption. RESULTS: A strong majority of respondents (80%) reported that all or most staff agreed with the need for the program. Perceived program performance in meeting goals was generally favorable but varied across sites and across staff types. Overall, 56% of respondents indicated that their practices were likely or highly likely to adopt the program in full. The likelihood of adoption varied substantially across sites and across program components. CONCLUSIONS: Evaluating the potential for program adoption offers insight for tailoring preventive health interventions and their implementation strategies to improve diffusion in the field of practice.

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Spatial memory deficits have been reported following prenatal alcohol exposure and animal studies have demonstrated hippocampal vulnerability to alcohol. This study examined spatial memory in children diagnosed with fetal alcohol syndrome (FAS) or fetal alcohol effects (FAE) and matched controls. Spatial memory was examined with location recall measures. Since visual perceptual skills and nonspecific memory impairment could impact spatial memory, tasks assessing perception and verbal memory were administered. Analyses revealed group differences on perceptual and verbal and spatial memory tasks. There was no significant difference in spatial memory once perceptual and verbal memory task performance was taken into account, suggesting that differences in spatial memory were not solely attributable to a material specific memory deficit.

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Growth in managed care enrollment potentially creates incentives for health plans to become involved in public health activities, such as health promotion and disease prevention interventions, and care for vulnerable populations. Using cross-sectional data from 60 diverse markets, this study explores the extent to which health maintenance organizations (HMOs) form cooperative alliances with local public health agencies to perform such activities. Results from multivariate models suggest that the incentives for cooperation vary substantially with health plan ownership and market structure. In view of recent HMO industry trends, these findings raise questions about the ability of alliances to integrate the practice of public health and medicine on a broad national scale, as some proponents suggest they do.

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Nonsteroidal antiinflammatory drugs (NSAIDs) are the most frequently prescribed class of medication for arthritis and other musculoskeletal disorders. NSAIDs block prostaglandin production, thereby reducing pain and inflammation, but may also cause significant side effects, particularly ulcers in stomach and duodenum. Some risk factors include age, previous history of ulcer, and high dose of NSAID. Synthetic prostaglandins, H2 blockers, and proton pump inhibitors have been employed to reduce risks with varying degrees of success. New NSAIDs that block only prostaglandins at sites of inflammation (COX-2 selective NSAIDs) may be significantly safer than traditional NSAIDs.

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BACKGROUND: Many health care organizations have begun to pursue collaborative approaches for addressing community-level health issues. To understand how these community health alliances develop and operate, a descriptive study was conducted within a nationally selected group of 60 local communities and supplemented by detailed case studies in 8 communities. ALLIANCE MODELS: A broad array of organizations were found to participate in community health alliances. Moreover, alliances were found to vary considerably. Strategically, alliances focused on one of three primary objectives: acquiring needed organizational knowledge and skills; addressing common resource needs; and pursuing a shared organizational mission. Functionally, alliances were observed in the areas of service delivery, planning and policy development, surveillance and assessment, and education and outreach. Structurally, alliances were found to operate through one of four interorganizational arrangements; informal collaboration, contractual agreements, shared governance, and shared ownership. ALLIANCE DEVELOPMENT: Organizational characteristics such as ownership type, organizational proximity, and market share appear to be important in the development of community health alliances. Community and market characteristics--including health resource availability, HMO penetration, and market consolidation--also appear to be influential in alliance development. Longitudinal observations suggest that alliances evolve over time in response to changing community health needs and organizational objectives. ALLIANCE MANAGEMENT: Several managerial tasks appear to be important to successful alliance operations, including developing a shared vision of collaboration; devising explicit strategies for addressing participation constraints; ensuring the compatibility of organizational incentives; managing communication and information flows across organizations; and developing appropriate processes for performance monitoring. CONCLUSIONS: The observed variation in alliance structures and functions appears healthy rather than problematic, as organizations develop arrangements to fit community needs, organizational capacities, and market conditions.

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Throughout the past decade, growing attention has focused on ways to monitor the performance of local public health organizations and ensure the adequacy of their services. We surveyed representatives of the nation's state health agencies during 1997 to examine their processes for local public health performance assessment. Eighty-eight percent of agencies reported some involvement in assessment activities. Of these agencies, 50 percent reported having an assessment process that was currently operative. States reported using a diversity of assessment methods. Results suggest that states are developing performance assessment processes that are tailored to local resources, needs, and priorities.

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OBJECTIVE: To examine the intracellular calcium response to basic calcium phosphate (BCP) crystals in fibroblasts. DESIGN: In this study, intracellular calcium [Ca2+]i levels in fibroblasts were determined using the photoactive dye, fura-2. Interruption of these responses was accomplished by either removal of Ca2+ from the extracellular medium or addition of ammonium chloride that inhibits intracellular dissolution of BCP crystals by alkalinizing phagolysosomes. The effects of such interruptions on BCP induction expression of proto-oncogenes were demonstrated by the Northern blot analysis. RESULTS: Addition of media containing BCP crystals yielded an immediate 10-fold rise of [Ca2+]i over the baseline level in human fibroblasts. This peak was derived mostly from extracellular calcium and was not seen when BCP crystals in calcium-free media were added to fibroblasts. The [Ca2+]i concentration returned to the baseline level within 8 min. A second rise of [Ca2+]i started at 60 min and continued to increase up to at least 3 h. This peak was derived from intracellular dissolution of phagocytosed crystals and almost completely inhibited by 10 mM ammonium chloride. CONCLUSION: The initial transient [Ca2+]i increase probably serves as a second messenger leading to activation of early cellular responses such as c-fos expression which is important in BCP crystal-induced mitogenesis. The second, slower and more sustained rise of [Ca2+]i probably initiates other cellular processes needed for fibroblast mitogenesis.

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This article provides a framework for analyzing how downsizing and reengineering have affected healthcare organizations. These approaches are reviewed, and key tools that have been used, such as across-the-board cuts, reorganizing, and redesigning, are described. Examples are drawn from healthcare as well as other business sectors. The consequences of cost reduction strategies for an organizations's performance in terms of costs, quality of services, and satisfaction of consumers and employees are explored. The case is made that an organization's context--that is, its culture, level of trust, and leadership--is an important factor that influences the effect of cost-cutting strategies. Characteristics of organizations where downsizing has a better chance of succeeding also are described.

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The spondyloarthropathies represent a heterogeneous group of arthropathies including ankylosing spondylitis, reactive arthritis with Reiter syndrome as one subtype, arthritis associated with inflammatory bowel disease, arthritis associated with psoriasis, and juvenile spondyloarthritis. These conditions are linked by several common features: inflammatory arthritis involving the back, a high prevalence of HLA-B27, frequent tendon/ligament insertion inflammation, and several common extra-articular manifestations (iritis, skin lesions). Although not uncommon, these types of arthritis are more difficult to recognize than other types of arthritis such as osteoarthritis and rheumatoid arthritis.

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