The use of expensive health technologies in the era of managed care: the remarkable case of neonatal intensive care

The use of neonatal intensive care (NIC) continued to rise rapidly in the 1990s despite the concerns of observers about its cost effectiveness and its successes being mostly in facilities with high volume and capabilities. The objective of this study is to test the effects of insurance type, competition among hospitals, and market pressure from managed care plans on the supply and cost of NIC. The analysis uses logistic and linear models with techniques to avoid bias from (a) market area definitions based on actual patient flows and (b) self-selection of hospitals by patients with unmeasured risk of needing NIC. The data source contains all births in short-term hospitals in New Jersey during 1990 and 1994. Both the number of days and charges for NIC are reported. Key findings are that the decision of a hospital to offer NIC was associated with teaching status, the proportion of infants in the market area with documented high risk, and the market concentration of major competitors. The market share of managed care plans and the concentration of enrollment were not associated with either NIC being offered or with the standardized charges. Whether a particular patient was given to a NIC depended on patient risk factors and whether a NIC unit was present, but not on payer group. The results are consistent with the hypothesis that young insured parents (with the advice of their obstetricians) prefer hospitals with NIC and also are relatively profitable enrollees for health plans. In conclusion: using the results here and in other research, public and private policy makers may consider several ways to strengthen the incentives for health plans to contract for cost-effective birth-related services. The results also raise questions for a number of regulatory and payment policies and call for better public data on costs and outcomes for NIC.     

Issue Attitudes and Survey Continuity across Interview Mode in the 2000 NES

Nathan J. Kelly Department of Political Science, University at Buffalo, The State University of New York, Buffalo, NY 14260-4120 e-mail: nkelly{at}buffalo.edu H. Whitt Kilburn Department of Political Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-3265 e-mail: wkilburn{at}email.unc.edu Can researchers draw consistent inferences about the U.S. public'sissue attitudes when studying survey results from both the in-personand telephone interview modes of the 2000 National ElectionStudies (NES) survey? We address this question through an analysiscontrasting the distribution of issue attitudes across modesin the dual sample design of the 2000 NES. We find clear differencesacross mode even when applying a method devised by the NES toimprove comparability by recoding issue attitude scales fromthe in-person mode. We present an alternative method of recodingthese scales, which substantially improves comparability betweenmodes. Through an analysis of the covariance structure of theissues and simple models of vote choice, we discuss the implicationsof the results for the study of issue attitudes in the 2000NES.     

Democratic Survival, Peace, and War in the International System

Post-World War II Western foreign policies are often based on the claim that the spread of democracy will result in global peace. Our understanding of how this propagation can bring about peace is limited, and we have little reason to believe that the causal arrow points only in one direction. We tackle these issues by modeling the linkages between states' regime types, interstate conflict, and the strength of the democratic community relative to the autocratic community. Analysis of our model suggests initial increases in the strength of the democratic community increase the level of conflict in a system. Beyond a threshold of democratic strength, however, conflict wanes as the democratic community waxes. Our model also suggests that the survival rate of democracies increases as the material strength of the democratic community increases and decreases as systemic conflict rises. Empirical analyses offer support for the survival propositions.     

Gunshot fatalities in children and adolescents in New York City

We reviewed the case records of all fatalities due to gunshot wounds in children and adolescents under 19 years of age in New York City from 1996 to 2000. The epidemiological profile, circumstances, toxicology results, location, and injuries were examined. There were 263 deaths: 242 homicides, 17 suicides, and 4 accidents. Among the homicides, 96% involved Black or Hispanic and 68% involved 17 and 18-year-old decedents. There were 11 times as many male as female homicides. The detection of ethanol and/or illicit drugs was 56% in the homicide and 53% in the suicide groups. Suicide notes were found in 18% of suicides, and an additional 35% verbally expressed a plan to commit suicide. Most suicides (77%) were in the home and half of the homicides occurred on the street.