Contract–Management Capacity in Municipal and County Governments

Under pressure to do more with less, governments across the country have moved from direct service provision to providing services by contract. Proponents argue that contracting can reduce costs and improve flexibility and customer satisfaction. Critics point to a growing number of failed contracts, arguing there are numerous pitfalls associated with contracting. Missing from these debates is a discussion of how governments' managerial capacity can improve contract performance. In this article, we identify specific capacities that governments can use to harness the promise of contracting while avoiding its pitfalls. We present analyses of data on municipal and county government contracting activities that show how governments invest in contract– management capacity in response to several internal and external threats to effective contract performance. Because government investment in contract–management capacity is uneven—that is, some governments invest in less capacity even when circumstances would call for more—our analyses may help to explain why some contract arrangements are more successful than others.     

Understanding Women in Scotland

This article explores obstacles to understanding the history and contemporary experiences of women in Scotland, and to the development of feminist research in Scotland. It is argued that explanations which invoke Scottish male chauvinism and misogyny alone are insufficient, and that the marginalization of women in Scotland is produced both by male domination within Scotland, and by English cultural and political hegemony within the UK. The article comments on the relationship of the concept of ‘Britishness’ to that of ‘Scottishness’ (and other identities within the UK) and illustrates how the frequent confusion of ‘British’ with ‘English’ serves to obscure Scottish experience. It is also argued that the place of Scotland within the British state has led to the creation of an institutional framework that disadvantages women, and a system of government that excludes women. This implies that feminist debates on the state in Britain require a specific focus on the form of the British state, and in the context of constitutional change in particular this is important for the development of future strategies. It is argued that the double marginalization of women in Scotland is not just a problem in relation to the development of feminist research, but is also a political problem in that it contributes to a degree of alienation from feminism in England. The article concludes by arguing for the necessity of recognition of difference, but also for dialogue, as the basis for feminist alliances in different parts of the UK.     

Special report on patient care. HCFA finally issues patient-dumping regulations

EMTALA has always been an especially worrisome law for providers because its requirements are both sweeping and vague, with potentially drastic penalties for violations. The new regulations remove only some of the law's vagueness. As with previous EMTALA amendments, all United States hospitals, as well as emergency department physicians and other doctors who see patients in the emergency department, should carefully review their internal policies regarding patient ++ transfers in light of the new regulations. For example, hospitals must have an internal policy for following up on suspicious transfers, as failure to detect an inappropriate transfer can now potentially result in a Medicare decertification action. Also, hospitals with specialized services (e.g., burn units or shock-trauma units) should review their policies on receiving transfer patients in light of the greater specificity of the new regulations. Finally, because of the confusing new requirements regarding ambulance services, all hospitals should review their relationships with and policies regarding, ambulance services and ambulance diversion.     

A study of various morphologic variables and troponin I in pericardial fluid as possible discriminators of sudden cardiac death

Pathologists frequently examine victims of sudden cardiac death. In some cases, a firm diagnosis of cardiac-related death can be made based on conclusive gross and histologic findings. In many other cases, we find evidence supportive of, but not diagnostic of, cardiac death (e.g., atherosclerotic coronary artery disease, cardiomegaly, myocardial scarring). A final cohort consists of cases of sudden death with minimal to mild cardiac disease, no other significant pathology, and negative toxicologic studies. This prospective study compared 38 cardiac-related deaths with 52 control cases with respect to concentrations of pericardial cardiac troponin I (cTnI), heart weight, evidence of old and/or recent myocardial injury, and presence of significant coronary artery disease. The influence of documented chest trauma and/or perimortem cardiopulmonary resuscitation (CPR) on levels of cTnI was also analyzed. Even though median cTnI levels were significantly higher in cardiac deaths than in controls (p = .003), cTnI was not found to be a significant predictor of cardiac deaths, as determined by discriminant analysis (p = .52). Heart weight >500 g, evidence of old and recent myocardial injury, and significant coronary artery disease were seen statistically more often in cardiac deaths than in controls (p < or = .005 in each case), and median age was significantly higher in cardiac deaths than in controls (p = .001). Based on a stepwise logistic regression model, significant coronary artery disease, old and recent myocardial injury, and heart weight >500 g were found to contribute significantly to the prediction of cardiac death. Finally, neither chest injury nor CPR significantly affected concentrations of cTnI in pericardial fluid. These data confirm that the presence of acute and remote myocardial injury, significant coronary artery disease, and cardiomegaly (heart weight >500 g) strongly supports the diagnosis of a cardiac-related death. In contrast to a recently published report, we do not find that elevated concentrations of cTnI in pericardial fluid are strong indicators of cardiac-related deaths using our methodology.     

The Comparability of Male Violent Substance Abusers in Violence or Substance Abuse Treatment

The abuse of alcohol is strongly associated with violent behavior in general and domestic violence in particular. The present study examined the compara-bility of dual-problem (i.e., substance abuse and conjugal violence) men in substance abuse and violence treatment milieus. Thirty males in substance abuse treatment and 33 men in violence treatment were identified as being dual-problematic and were administered the Addiction Severity Index (ASI) to assess psychosocial and substance abuse status, the Conflict Tactics Scale (CTS) for the frequency and type of abusive behavior, the Symptoms Checklist-90 (SCL-90) for psychological distress, and the 16 Personality Factor (16PF) for personality attributes. When dual-problem men from each milieu were compared on these measures, men in the substance abuse-milieu reported not only significantly more severe substance abuse problems, but also more frequent partner sexual abuse. Few other differences emerged. Thus, while current referral procedures may be appropriate in identifying and directing more severe substance abuse problems to the appropriate treatment setting, violent men with difficulties comparable to those seen in violence treatment may also be found in substance abuse treatment. These findings emphasize the need for: (1) routine objective screening for family violence and substance abuse in these two treatment milieus; (2) informed and up-to-date staff in both settings who are sufficiently prepared for the therapeutic challenges such men may present, and (3) more study of how treatment for dual-problem men may be coordinated by the violence and substance abuse treatment communities to optimize their outcome.