David A. Kindig

Changes in the Location of Death after Passage of Medicare's Prospective Payment System

We reviewed age-specific national mortality data for the years 1981 through 1985 to evaluate changes in the location of death among the nations elderly after implementation of Medicares prospective payment system (PPS). Although it was unchanged in 1981 and 1982, the percentage of deaths occurring in the nations nursing homes increased from 18.9 percent in 1982 to 21.5 percent in 1985. The increases in nursing home deaths were greatest between 1983 and 1984, when 33 states showed larger-than-expected increases when compared with a base period before implementation of PPS. These changes were accompanied by a decline in the percentage of deaths that occurred in hospitals. These changes in the location of death were most pronounced in the Midwest, South, and West; they were very small in the Northeast and in states not affected by the PPS. Furthermore, the states with high population enrollments in health maintenance organizations and with large declines in the mean hospital length of stay in 1984 showed the greatest shifts in the location of death. We conclude that Medicares PPS resulted in the increased transfer of terminally ill patients from hospitals to nursing homes. Further study is required to determine whether such transfer is medically appropriate.

Understanding population health terminology.

Population health is a relatively new term, with no agreement about whether it refers to a concept of health or a field of study of health determinants. There is debate, sometimes heated, about whether population health and public health are identical or different. Discussions of population health involve many terms, such as outcomes, disparities, determinants, and risk factors, which may be used imprecisely, particularly across different disciplines, such as medicine, epidemiology, economics, and sociology. Nonetheless, thinking and communicating clearly about population health concepts are essential for public and private policymakers to improve the populations health and reduce disparities. This article defines and discusses many of the terms and concepts characterizing this emerging field.

Skill mix changes: substitution or service development?

An extensive review of published studies where doctors were replaced by other health professions demonstrates considerable scope for alterations in skill mix. However, the studies reported are often dated and have design deficiencies. In health services world-wide there is a policy focus which emphasises the substitution of nurses in particular for doctors. However, this substitution may not be real and increased roles for non-physician personnel may result in service development/enhancement rather than labour substitution. Further study of skill mix changes and whether non-physician personnel are being used as substitutes or complements for doctors is required urgently.

Message design strategies to raise public awareness of social determinants of health and population health disparities.

CONTEXT Raising public awareness of the importance of social determinants of health (SDH) and health disparities presents formidable communication challenges. METHODS This article reviews three message strategies that could be used to raise awareness of SDH and health disparities: message framing, narratives, and visual imagery. FINDINGS Although few studies have directly tested message strategies for raising awareness of SDH and health disparities, the accumulated evidence from other domains suggests that population health advocates should frame messages to acknowledge a role for individual decisions about behavior but emphasize SDH. These messages might use narratives to provide examples of individuals facing structural barriers (unsafe working conditions, neighborhood safety concerns, lack of civic opportunities) in efforts to avoid poverty, unemployment, racial discrimination, and other social determinants. Evocative visual images that invite generalizations, suggest causal interpretations, highlight contrasts, and create analogies could accompany these narratives. These narratives and images should not distract attention from SDH and population health disparities, activate negative stereotypes, or provoke counterproductive emotional responses directed at the source of the message. CONCLUSIONS The field of communication science offers valuable insights into ways that population health advocates and researchers might develop better messages to shape public opinion and debate about the social conditions that shape the health and well-being of populations. The time has arrived to begin thinking systematically about issues in communicating about SDH and health disparities. This article offers a broad framework for these efforts and concludes with an agenda for future research to refine message strategies to raise awareness of SDH and health disparities.

Variation in Chinese population health related quality of life: results from a EuroQol study in Beijing, China.

The purpose of this study is to measure Chinese population health related quality of life (HRQoL) using European quality of life (EQ-5D) instrument, to examine the validity of EQ-5D in measuring Chinese population HRQoL, to explore the relationships between EQ-5D and other health determinants, and to display the similarities and differences of HRQoL between the Chinese population and the populations of other countries. The data used in this study includes 2994 respondents whose age are 12 years and older, which is from the 2000 Beijing Household Health Survey. Univariate and bivariate analyses have been used to examine the level of HRQoL and the relationships between HRQoL and other variables. Multi-variate analyses have been used to explore the relationships between the EQ-5D Visual Analogue Scale (VAS) and the EQ-5D five dimension indicators. There are four principal findings from this study. First, the EQ-5D instrument is a valid measure for Chinese HRQoL, but with a significant ceiling effect. Second, Pain/Discomfort and Anxiety/Depression are the major Chinese HRQoL problems and the extents of these problems differ in subgroup populations. Third, typically mean scores are lower for older age group; this is observed at lower ages in the Chinese population than in populations from developed countries. Fourth, Chinese HRQoL has strong association relationship with population socio-economic status (SES), which might imply that issues brought on by the rapid economic transition have both positive and negative impacts on Chinese HRQoL.

A population health framework for setting national and state health goals.

WITH THE APPOINTMENT OF THE US DEPARTment of Health and Human Services Advisory Committee on National Health Promotion and Disease Prevention for 2020, the process for setting national health goals in 2009 for the coming decade is under way. The Healthy People 2010 goals and objectives have served as the framework for establishing outcomes for virtually every public health planning process in the United States from National Institutes of Health grants to federal health programs and to state and local health plans. Although an initial process produced a Draft Model with 4 guiding principles and a proposal for a smaller number of objectives for Healthy People 2020, a specific framework has not yet been decided and will be established after a series of public hearings. This Commentary proposes a population health guiding framework for national and state planning processes, including both broad overall goals as well as a prioritized set of policies and interventions aligned with the multiple determinants of health. The ultimate purpose of population health policy is to improve the health of individuals and populations by investments in the determinants of health through policies and interventions that influence these determinants. Without careful attention to the outcomes, attention to determinants and policies could proceed without reference to the ultimate goals and become ends instead of means to an end. A shortcoming of this step of broader goal setting is that it is often framed in general terms without quantification, so it is not likely that the impact of making progress on some objectives can be assessed. Healthy People 2010 devoted significant attention to the 467 objectives in 28 focus areas, but the 2 broad goals of “increasing quality and years of healthy life” and “eliminating disparities” did not have specified quantitative targets. Although the “Healthy People in Healthy Communities” model in Healthy People 2010 contains health determinant categories, the focus areas are presented alphabetically rather than by determinant. The FIGURE is a model that could be a starting point for a framework more precisely aligned to a population health perspective. The right side represents a way of conceptualizing broad population health outcomes. Previous health improvement frameworks have identified both increasing the overall population mean, as well as reducing and eliminating disparities within the population. Within disparities, multiple domains could be policy targets such as race/ ethnicity, socioeconomic status, sex, and geographic location. In addition, such outcomes should include both length of life (mortality) and health-related quality of life. Although it is possible to combine all 4 quadrants into a single summary measure, considering them separately is important because different patterns of determinants will probably produce different changes in each of them. Each quadrant in the Figure is arbitrarily sized equally, and similarly the domain bars within the disparity quadrants are depicted as equal. It is probably not the case that each quadrant or domain should receive equal weight. This is not an empirical issuebut ratheroneof social valuation fordifferentnations, states, or other population groups to decide. The point of presenting them this way is to encourage such consideration as a component of goal setting, which has been done occasionally. For example, the World Health Report 2000 weighted the mean and disparity equally based on a survey of about 1000 respondents. Similarly in a State Health Report Card for Wisconsin, equal weighting was primarily used, although the method used for summarizing disparities across domains resulted in slight variation from equality. The Figure’s left-hand side represents the determinants of the population health outcomes represented on the Figure’s left side. Based on the Evans-Stoddart model, these determinants are divided into 5 categories. For example, medical care includes prevention, treatment, and management of disease. Examples of individual behaviors are smoking, exercise, and eating habits. The social environment includes socioeconomic factors, most often measured by income, educational level, and occupation, while the physical environment consists of air and water quality as well as the built environment, ie, the constructed structures such as buildings, roads, parks, and other physical infrastructure that make up communities. Genetics refers to inher-

Virus-like particles in established murine cell lines: electron-microscopic observations.

Virus-like particles identical in morphology to the RNA tumor vi ruses have been observed by electron microscopy in six lines of murine L cells and one line of murine liver cells. Control cultures of embryonic mouse cells and 3T3 cells do not contain the particles, and no biologic activity has as yet been associated with them.

The Value Of The Nonprofit Hospital Tax Exemption Was

The federal government encourages public support for charitable activities by allowing people to deduct donations to tax-exempt organizations on their income tax returns. Tax-exempt hospitals are major beneficiaries of this policy because it encourages donations to the hospitals while shielding them from federal and state tax liability. In exchange, these hospitals must engage in community benefit activities, such as providing care to indigent patients and participating in Medicaid. The congressional Joint Committee on Taxation estimated the value of the nonprofit hospital tax exemption at

24.6 Billion In 2011

12.6 billion in 2002--a number that included forgone taxes, public contributions, and the value of tax-exempt bond financing. In this article we estimate that the size of the exemption reached

Beyond the Institute of Medicine Health Literacy Report: Are the Recommendations Being Taken Seriously?

24.6 billion in 2011. The Affordable Care Act (ACA) brings a new focus on community benefit activities by requiring tax-exempt hospitals to engage in communitywide planning efforts to improve community health. The magnitude of the tax exemption, coupled with ACA reforms, underscores the publics interest not only in community benefit spending generally but also in the extent to which nonprofit hospitals allocate funds for community benefit expenditures that improve the overall health of their communities.