Three Years in a Mad-House: The Story of my Life at the Asylum, my Escape, and the Strange Adventures which Followed

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An analysis of the revenue policy -making process of the Texas Legislature

The purpose of this dissertation was to develop a conceptual framework which can be used to account for policy decisions made by the House Ways and Means Committee (HW&MC) of the Texas House of Representatives. This analysis will examine the actions of the committee over a ten-year period with the goal of explaining and predicting the success of failure of certain efforts to raise revenue.^ The basis framework for modelling the revenue decision-making process includes three major components--the decision alternatives, the external factors and two competing contingency theories. The decision alternatives encompass the particular options available to increase tax revenue. The options were classified as non-innovative or innovative. The non-innovative options included the sales, franchise, property and severance taxes. The innovative options were principally the personal and corporate income taxes.^ The external factors included political and economic constraints that affected the actions of the HW&MC. Several key political constraints on committee decision-making were addressed--including public attitudes, interest groups, political party strength and tradition and precedents. The economic constraints that affected revenue decisions included court mandates, federal mandates and the fiscal condition of the nation and the state.^ The third component of the revenue decision-making framework included two alternative contingency theories. The first alternative theory postulated that the committee structure, including the individual member roles and the overall committee style, resulted in distinctive revenue decisions. This theory will be favored if evidence points to the committee acting autonomously with less concern for the policies of the Speaker of the House. The Speaker assignment theory, postulated that the assignment of committee members shaped or changed the course of committee decision-making. This theory will be favored if there was evidence that the committee was strictly a vehicle for the Speaker to institute his preferred tax policies.^ The ultimate goal of this analysis is to develop an explanation for legislative decision-making about tax policy. This explanation will be based on the linkages across various tax options, political and economic constraints, member roles and committee style and the patterns of committee assignment. ^

Everyone is; should healthcare? Outsourcing: Issues in strategic planning, organizational culture, and organizational ethics

Expenditures for personal health services in the United States have doubled over the last decade. They continue to outpace the growth rate of the gross national product. Costs for medical care have steadily increased at an annual rate well above the rate of inflation and have gradually outstripped payers' ability to meet their premiums. This limitation of resources justifies the ongoing healthcare reform strategies to maximize utilization and minimize costs. The majority of the cost-containment effort has focused on hospitals, as they account for about 40 percent of total health expenditures. Although good patient outcomes have long been identified as healthcare's central concern, continuing cost pressures from both regulatory reforms and the restructuring of healthcare financing have recently made improving fiscal performance an essential goal for healthcare organizations. ^ The search for financial performance, quality improvement, and fiscal accountability has led to outsourcing, which is the hiring of a third party to perform a task previously and traditionally done in-house. The incomparable nature and overwhelming dissimilarities between health and other commodities raise numerous administrative, organizational, policy and ethical issues for administrators who contemplate outsourcing. This evaluation of the outsourcing phenomenon, how it has developed and is currently practiced in healthcare, will explore the reasons that healthcare organizations gravitate toward outsourcing as a strategic management tool to cut costs in an environment of continuing escalating spending. ^ This dissertation has four major findings. First, it suggests that U.S. hospitals in FY2000 spent an estimated $61 billion in outsourcing. Second, it finds that the proportion of healthcare outsourcing highly correlates with several types of hospital controlling authorities and specialties. Third, it argues that healthcare outsourcing has implications in strategic organizational issues, professionalism, and organizational ethics that warrant further public policy discussions before expanding its limited use beyond hospital “hotel functions” and back office business processes. Finally, it devises an outsourcing suitability scale that organizations can utilize to ensure the most strategic option for outsourcing and concludes with some public policy implications and recommendations for its limited use. ^

Family health history discussion in patient-provider encounters

Ascertaining the family health history (FHH) may provide insight into genetic and environmental susceptibilities specific to a variety of chronic diseases, including type II diabetes mellitus. However, discussion of FHH during patient-provider encounters has been limited and uncharacterized. A longitudinal, observational study was conducted in order to compare the content of FHH topics in a convenience sample of 37 patients, 13 new and 24 established. Each patient had an average of three follow-up encounters involving 6 staff physicians at the Audie L. Murphy Memorial Veterans Hospital (VHA) in San Antonio, TX from 2003 to 2005. A total of 131 encounters were analyzed in this study. The average age of the selected population was 68 years and included 35 males and two females. Transcriptions of encounters were obtained, coded and analyzed, in NVIVO 8. Of the 131 total encounters transcribed among the 37 patients, only 24 encounters (18.3%) included discussion of FHH. Additionally, the relationship between FHH discussion and discussion of self-care management (SCM) topics were assessed. In this study, providers were more likely to initiate discussion on family health history among new patients in the first encounter (ORnew = 8.55, 95% CI: 1.49–52.90). The discussion of FHH occurred sporadically in established patients throughout the longitudinal study with no apparent pattern. Provider-initiated FHH discussion most frequently had satisfactory level(s) of discussion while patient-initiated FHH discussion most frequently had minimal level(s) of discussion. FHH discussion most oftentimes involved topics of cancer and cardiovascular disease among primary-degree familial relationships. Overall, family health histories are largely, an underutilized tool in personalized preventive care.^

Nitrogen dioxide exposures among a selected group of residents of substandard housing in Houston, Texas

Nitrogen dioxide (NO$\sb2)$ levels in sixteen substandard houses located in Houston, Texas were examined. The classification of the houses as substandard was based on an assessment of structural integrity which would affect air exchange rates. In these homes, unvented gas space heaters were operated as the primary source of heat.^ The Ogawa passive sampling device was used to measure NO$\sb2$ concentrations over 24 to 48-hour periods during generally cold weather. A sampler was placed in the kitchen and bedroom of each house. The female head of household was asked to wear a monitor during area monitoring to assess her personal exposure. Outdoor levels of NO$\sb2$ were also measured.^ Mean (standard deviation) levels of kitchen, bedroom and personal exposures were 280 (125) ppb, 256 (155) ppb and 164 (102) ppb, respectively. Additional short-term ($<$24 hours) samples were measured in three houses. The mean level of NO$\sb2$ measured outdoors was 51 ppb over the course of the study.^ The measurements obtained with the Ogawa sampler were compared to those levels obtained using a reference method (chemiluminescence). Outdoor levels measured with the diffusion samplers were 48% higher.^ These results suggest that wintertime NO$\sb2$ levels within substandard houses using gas appliances for heating and cooking are extremely elevated. Further work is needed to investigate the prevalence of possible health effects associated with these exposures. ^

Association between sugar-sweetened beverages and both gestational weight gain and gestational diabetes

This cross-sectional study aimed at evaluating the association between sugar sweetened beverage (SSB) consumption and both excessive gestational weight gain (EGWG) and gestational diabetes mellitus (GDM). The study was conducted in the postpartum units of Memorial Hermann Hospital, Lyndon Baines Johnson General Hospital, the University of Texas Medical Branch at Galveston General Hospital, and the University of Texas at Brownsville Hospital. Between June 2009 and September 2010, women between the ages of 18 and 49 years with singleton pregnancies who delivered an infant born at 37 weeks of gestation or later were approached. Descriptive, univariate and multivariate analysis were employed in our study using the Statistical Analysis System (SAS) software version 9.1 (SAS Institute Inc. Cary, North Carolina). Our investigation did not find statistically significant associations between SSBs and EGWG. Our study reported no evidence of an association between SSBs and GDM except for sports drinks. However, the estimate of this association was deemed very imprecise. In conclusion, our study did not find strong provide strong support for the hypothesis that high consumption of SSBs increases the risk of EGWG or GDM. ^