RESUMO
Evidence points to the existence of two coexisting inefficiencies in mental health care resource allocation: those with need receive too limited or no care while those with no apparent need receive services. In addition to reducing costs, managed mental health care is expected to reallocate treatment resources to those with greater need for services. However, there are no empirical findings regarding this issue. This study tests whether managed mental health care has had a differential impact by level of need. Data consist of three waves of a community sample with a control group. The study finds that managed care has not succeeded in reallocating resources from the unlikely to the definite "needers."
Assuntos
Alocação de Recursos para a Atenção à Saúde/economia , Programas de Assistência Gerenciada/economia , Transtornos Mentais/economia , Serviços de Saúde Mental/economia , Avaliação das Necessidades/economia , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Transtornos Mentais/reabilitação , Pessoa de Meia-Idade , Porto RicoRESUMO
OBJECTIVES: Health care reforms associated with managed care may adversely affect the health care safety net for disadvantaged populations. This study compared changes in health care use among poor and nonpoor individuals enrolled in managed care. METHODS: Data from 3 waves of a random community sample were collected on approximately 3,000 adults. Changes in use of mental health services were assessed in a pretest-posttest, quasi-experimental design. RESULTS: Managed care increased use of specialty services among the nonpoor while maintaining the same level of use for the poor in the public sector. CONCLUSIONS: Reallocation of mental health services may be a result of expanding Medicaid eligibility.
Assuntos
Reforma dos Serviços de Saúde/organização & administração , Acessibilidade aos Serviços de Saúde/organização & administração , Programas de Assistência Gerenciada/organização & administração , Serviços de Saúde Mental/organização & administração , Pobreza/estatística & dados numéricos , Adolescente , Adulto , Idoso , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Modelos Logísticos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Inovação Organizacional , Avaliação de Programas e Projetos de Saúde , Setor Público , Porto Rico , Inquéritos e QuestionáriosRESUMO
This paper estimates the impact of managed care on use of mental health services by residents of low-income areas in Puerto Rico. A quasi-experimental design evaluates the impact of a low capitation rate on a minority population using three waves of data from a random community sample. Results indicate that two years after introducing managed care, privatization of mental health services had minimal impact on use. Advocates had hoped health care reform would increase access in comparison to access seen within the public system, while opponents feared profit motives would lead to decreased access. Neither forecast turned out to be correct. The question remains as to how to improve access for the poor with low capitation rates.
Assuntos
Capitação , Serviços Comunitários de Saúde Mental/estatística & dados numéricos , Serviços Contratados/organização & administração , Reforma dos Serviços de Saúde , Programas de Assistência Gerenciada/estatística & dados numéricos , Medicaid/organização & administração , Adolescente , Adulto , Idoso , Serviços Comunitários de Saúde Mental/organização & administração , Feminino , Acessibilidade aos Serviços de Saúde/organização & administração , Pesquisa sobre Serviços de Saúde , Humanos , Masculino , Programas de Assistência Gerenciada/organização & administração , Transtornos Mentais/terapia , Pessoa de Meia-Idade , Áreas de Pobreza , Privatização , Porto Rico , Transtornos Relacionados ao Uso de Substâncias/terapiaRESUMO
Immunization of cattle with native MSP1 induces protection against Anaplasma marginale. The native immunogen is composed of a single MSP1a protein and multiple, undefined MSP1b polypeptides. In addition to the originally sequenced gene, designated msp1beta(F1), we identified three complete msp1beta genes in the Florida strain: msp1beta(F2), msp1beta(F3), and msp1beta(F4). Each of these polymorphic genes encodes a structurally unique MSP1b protein, and unique transcripts can be identified during acute A. marginale rickettsemia. The structural polymorphism is clustered in discrete variable regions, and each MSP1b protein results from a unique mosaic of five variable regions. Although each of the MSP1b proteins in the Florida strain contains epitopes recognized by serum antibody induced by protective immunization with the native MSP1 complex, the variable regions also include epitopes expressed by some but not all of the MSP1b proteins. These data support testing recombinant vaccines composed of the multiple antigenically and structurally unique MSP1b proteins combined with MSP1a in order to mimic the efficacy of native MSP1 immunization.
Assuntos
Anaplasma/genética , Bacteriemia/genética , Proteína 1 de Superfície de Merozoito/genética , Sequência de Aminoácidos , Aminoácidos/metabolismo , Anaplasma/metabolismo , Animais , Anticorpos/sangue , Anticorpos/metabolismo , Linfócitos B/imunologia , Bacteriemia/metabolismo , Bovinos , Clonagem Molecular , Sequência Conservada , Epitopos , Expressão Gênica , Proteína 1 de Superfície de Merozoito/metabolismo , Modelos Genéticos , Dados de Sequência Molecular , Polimorfismo Genético , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Homologia de Sequência de Aminoácidos , Transcrição GênicaRESUMO
A competitive enzyme-linked immunosorbent assay using recombinant major surface protein 5 (rMSP5-cELISA) of Anaplasma marginale was validated in a naturally infected cattle herd in an area of eastern Oregon where A. marginale is endemic. The true positive and negative A. marginale infection status of 235 randomly selected cattle was determined by using a nested PCR (nPCR) coupled with msp5 sequence analysis and hybridization. Judgment of the reliability of the nPCR and hybridization for detection of persistent infections was based on three observations. First, the nPCR was able to detect as few as 30 infected erythrocytes per ml. Second, the nPCR was able to consistently detect low levels of rickettsemia in seven carrier cattle experimentally infected with A. marginale. Third, msp5 sequence analysis showed >95% identity among 30 nPCR amplicons from cattle naturally infected with field strains of A. marginale. The nPCR and hybridization identified 151 infected and 84 uninfected cattle among the 235 animals tested. With a cutoff point of 28%, the rMSP5-cELISA showed a sensitivity of 96% and a specificity of 95%. These results indicate that the rMSP5-cELISA can sensitively and specifically detect cattle with naturally acquired persistent A. marginale infections and suggest that it is an excellent assay for epidemiological studies, eradication programs, and regulation of international cattle movement.
Assuntos
Anaplasmose/diagnóstico , Proteínas da Membrana Bacteriana Externa/imunologia , Doenças dos Bovinos/diagnóstico , Doenças Endêmicas , Ensaio de Imunoadsorção Enzimática/veterinária , Reação em Cadeia da Polimerase/veterinária , Anaplasmose/epidemiologia , Animais , Anticorpos Antibacterianos/sangue , Proteínas da Membrana Bacteriana Externa/genética , Bovinos , Doenças dos Bovinos/epidemiologia , Proteínas Recombinantes/imunologia , Sensibilidade e Especificidade , Análise de Sequência de DNARESUMO
OBJECTIVE: To determine the effectiveness of antimicrobial treatment for otitis media with effusion ("secretory" otitis media) in children. DATA SOURCE: We report the reexamination of a previously published study by Mandel et al that evaluated the efficacy of a 2-week course of antimicrobials (amoxicillin trihydrate) with and without a 4-week course of an oral decongestant-antihistamine combination in a double-blind, placebo-controlled, randomized trial involving 518 infants and children with otitis media with effusion. DATA SYNTHESIS: At 4 weeks, amoxicillin efficacy as determined by a tympanometric criterion (P = .121) or by a measure of improvement in hearing (P = .311) was insignificant. Only by otoscopic judgment, which is shown to contain a systematic bias as used in this clinical trial, could an argument be made for a marginal efficacy of amoxicillin at the 4-week end point. Logistic regression analyses of the combined effects of treatment and prognostic factors showed no significant differences between placebo- and antibiotic-treated groups for unilateral effusions and for bilateral effusions. When subjects with unilateral and bilateral effusions were combined, the estimated efficacy of antibiotic treatment was 12.3% by otoscopy (P = .014) and 4.8% by tympanometry (P = .171). We also demonstrate the sensitivity of outcome to diagnostic measures used and provide statistical evidence questioning the validity of otoscopic observations in this study. Six weeks after the termination of amoxicillin therapy, the recurrence of effusion was two to six times higher in the amoxicillin-treated children than in those treated with placebo (P = .001), and resolution of effusion was not significantly different among antibiotic and placebo groups (13.6% and 11.3%, respectively; P = .477). CONCLUSIONS: Amoxicillin with and without decongestant-antihistamine combination is not effective for the treatment of persistent asymptomatic middle-ear effusions in infants and children.
Assuntos
Amoxicilina/uso terapêutico , Otite Média com Derrame/tratamento farmacológico , Resultado do Tratamento , Amoxicilina/administração & dosagem , Amoxicilina/efeitos adversos , Viés , Broncodilatadores/administração & dosagem , Criança , Pré-Escolar , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Antagonistas dos Receptores Histamínicos H1/administração & dosagem , Humanos , Lactente , Masculino , Otite Média com Derrame/diagnóstico , Prognóstico , Análise de RegressãoRESUMO
The peer review process serves a vital role in the publication of biomedical information. When properly functioning, review should focus exclusively on questions of scientific validity and should avoid becoming enmeshed in questions such as "authorization" and "data ownership." We present a case in which the dissenting views of a coinvestigator were suppressed because the principal investigator and grantee institution informed a medical journal that the coinvestigator was not "authorized" to use the data generated by a publicly funded grant and because the editor of a scholarly journal refused to review the dissenting manuscript and to submit that dissent to external reviewers for peer review. The current peer review system, as shown by this case, is unable to embrace dissent within the peer review process and to use dissent to serve scientific truth and the public interest.
KIE: The authors present a case involving the University of Pittsburgh School of Medicine in which the dissenting views of one of the authors, Cantekin, a coinvestigator for a National Institutes of Health funded trial, were surpressed from publication. The principle investigator and the grantee institution claimed that the coinvestigator was not authorized to use data from the publicly funded grant, and the editor of a scholarly journal refused to review the dissenting manuscript or submit it for external peer review. At the time this article was submitted, the case had attracted the attention of the media and of the U.S. Congress. It raises the issues of ownership of data from publicly financed research and of the failure of the current peer review process to deal with dissent in scientific publication.
Assuntos
Pesquisa Biomédica , Dissidências e Disputas , Políticas Editoriais , Processos Grupais , Disseminação de Informação , Revisão por Pares/normas , Saúde Pública , Editoração , Má Conduta Científica , Governo Federal , National Institutes of Health (U.S.) , Otite Média , Philadelphia , Apoio à Pesquisa como Assunto , Estados UnidosRESUMO
Disease is a major constraint in small ruminant production systems in lesser-developed countries throughout the world. Animal health projects have been an integral part of the Small Ruminant Collaborative Research Support Program (SR-CRSP) from its inception. At the onset, these projects were oriented toward herd health care and veterinary extension activities. Later, all the projects developed a sharper focus in that they were directed to more basic studies of infectious disease. Diseases currently being investigated include caseous lymphadenitis, contagious caprine pleuropneumonia, caprine arthritis-encephalitis, ovine pulmonary carcinoma, ovine progressive pneumonia and neonatal mortality of alpaca. Continued, sharply focused studies are projected for the future to take advantage of recombinant technology in the development of multivalent vaccines.