ECONOMIC ANALYSIS OF THE DEMAND FOR PRESCRIPTION MEDICINE IN THE UNITED STATES

The purpose of this study was to understand the role of principle economic, sociodemographic and health status factors in determining the likelihood and volume of prescription drug use. Econometric demand regression models were developed for this purpose. Ten explanatory variables were examined: family income, coinsurance rate, age, sex, race, household head education level, size of family, health status, number of medical visits, and type of provider seen during medical visits. The economic factors (family income and coinsurance) were given special emphasis in this study.^ The National Medical Care Utilization and Expenditure Survey (NMCUES) was the data source. The sample represented the civilian, noninstitutionalized residents of the United States in 1980. The sample method used in the survey was a stratified four-stage, area probability design. The sample was comprised of 6,600 households (17,123 individuals). The weighted sample provided the population estimates used in the analysis. Five repeated interviews were conducted with each household. The household survey provided detailed information on the United States health status, pattern of health care utilization, charges for services received, and methods of payments for 1980.^ The study provided evidence that economic factors influenced the use of prescription drugs, but the use was not highly responsive to family income and coinsurance for the levels examined. The elasticities for family income ranged from -.0002 to -.013 and coinsurance ranged from -.174 to -.108. Income has a greater influence on the likelihood of prescription drug use, and coinsurance rates had an impact on the amount spent on prescription drugs. The coinsurance effect was not examined for the likelihood of drug use due to limitations in the measurement of coinsurance. Health status appeared to overwhelm any effects which may be attributed to family income or coinsurance. The likelihood of prescription drug use was highly dependent on visits to medical providers. The volume of prescription drug use was highly dependent on the health status, age, and whether or not the individual saw a general practitioner. ^

PRETERM BIRTH AND OCCUPATIONAL PHYSICAL ACTIVITY: A CASE-CONTROL STUDY OF THE RELATIONSHIP BETWEEN LENGTH OF GESTATION AND THE PHYSICAL DEMAND OF U.S. ARMY MILITARY OCCUPATIONAL SPECIALTIES (UNITED STATES)

A case-control study has been conducted examining the relationship between preterm birth and occupational physical activity among U.S. Army enlisted gravidas from 1981 to 1984. The study includes 604 cases (37 or less weeks gestation) and 6,070 controls (greater than 37 weeks gestation) treated at U.S. Army medical treatment facilities worldwide. Occupational physical activity was measured using existing physical demand ratings of military occupational specialties.^ A statistically significant trend of preterm birth with increasing physical demand level was found (p = 0.0056). The relative risk point estimates for the two highest physical demand categories were statistically significant, RR's = 1.69 (p = 0.02) and 1.75 (p = 0.01), respectively. Six of eleven additional variables were also statistically significant predictors of preterm birth: age (less than 20), race (non-white), marital status (single, never married), paygrade (E1 - E3), length of military service (less than 2 years), and aptitude score (less than 100).^ Multivariate analyses using the logistic model resulted in three statistically significant risk factors for preterm birth: occupational physical demand; lower paygrade; and non-white race. Controlling for race and paygrade, the two highest physical demand categories were again statistically significant with relative risk point estimates of 1.56 and 1.70, respectively. The population attributable risk for military occupational physical demand was 26%, adjusted for paygrade and race; 17.5% of the preterm births were attributable to the two highest physical demand categories. ^

PROJECTION OF HEALTH DEMAND IN TERMS OF HOSPITAL ADMISSIONS FOR SELECTED DIAGNOSES IN HEALTH SYSTEMS AGENCY SERVICE AREAS

The National Health Planning and Resources Development Act of 1974 (Public Law 93-641) requires that health systems agencies (HSAs) plan for their health service areas by the use of existing data to the maximum extent practicable. Health planning is based on the identificaton of health needs; however, HSAs are, at present, identifying health needs in their service areas in some approximate terms. This lack of specificity has greatly reduced the effectiveness of health planning. The intent of this study is, therefore, to explore the feasibility of predicting community levels of hospitalized morbidity by diagnosis by the use of existing data so as to allow health planners to plan for the services associated with specific diagnoses.^ The specific objectives of this study are (a) to obtain by means of multiple regression analysis a prediction equation for hospital admission by diagnosis, i.e., select the variables that are related to demand for hospital admissions; (b) to examine how pertinent the variables selected are; and (c) to see if each equation obtained predicts well for health service areas.^ The existing data on hospital admissions by diagnosis are those collected from the National Hospital Discharge Surveys, and are available in a form aggregated to the nine census divisions. When the equations established with such data are applied to local health service areas for prediction, the application is subject to the criticism of the theory of ecological fallacy. Since HSAs have to rely on the availability of existing data, it is imperative to examine whether or not the theory of ecological fallacy holds true in this case.^ The results of the study show that the equations established are highly significant and the independent variables in the equations explain the variation in the demand for hospital admission well. The predictability of these equations is good when they are applied to areas at the same ecological level but become poor, predominantly due to ecological fallacy, when they are applied to health service areas.^ It is concluded that HSAs can not predict hospital admissions by diagnosis without primary data collection as discouraged by Public Law 93-641. ^

AN ECONOMIC ANALYSIS OF THE DEMAND FOR CARE IN A FREE-STANDING EMERGENCY CENTER

Free-standing emergency centers (FECs) represent a new approach to the delivery of health care which are competing for patients with more conventional forms of ambulatory care in many parts of the U.S. Currently, little is known about these centers and their patient populations. The purpose of this study, therefore, was to describe the patients who visited two commonly-owned FECs, and determine the reasons for their visits. An economic model of the demand for FEC care was developed to test its ability to predict the economic and sociodemographic factors of use. Demand analysis of other forms of ambulatory services, such as a regular source of care (RSOC), was also conducted to examine the issues of substitution and complementarity.^ A systematic random sample was chosen from all private patients who used the clinics between July 1 and December 31, 1981. Data were obtained by means of a telephone interview and from clinic records. Five hundred fifty-one patients participated in the study.^ The typical FEC patient was a 26 year old white male with a minimum of a high school education, and a family income exceeding $25,000 a year. He had lived in the area for at least twenty years, and was a professional or a clerical worker. The patients made an average of 1.26 visits to the FECs in 1981. The majority of the visits involved a medical complaint; injuries and preventive care were the next most common reasons for visits.^ The analytic results revealed that time played a relatively important role in the demand for FEC care. As waiting time at the patients' regular source of care increased, the demand for FEC care increased, indicating that the clinic serves as a substitute for the patients' usual means of care. Age and education were inversely related to the demand for FEC care, while those with a RSOC frequented the clinics less than those lacking such a source.^ The patients used the familiar forms of ambulatory care, such as a private physician or an emergency room in a more typical fashion. These visits were directly related to the age and education of the patients, existence of a regular source of care, and disability days, which is a measure of health status. ^

Nitrification rates in the NW Mediterranean Sea

During spring, ammonium oxidation and nitrite oxidation rates were measured in the NW basin of the Mediterranean Sea, from mesotrophic sites (Ligurian Sea and Gulf of Lions) to oligotrophic sites (Balearic Islands). Nitrification rates (average values for 37 measurements) ranged from 72 to 144 nmol of N oxidised/l/d, except in the Rhône River plume area where the rates increased to 264-504 nmol/l/d because of the riverine inputs of nitrogen. Maximal rates were located around the peak of nitrite within the nitracline at about 40 to 60 m and just above the phosphacline. At 1 station, relatively high values of nitrification (50 to 130 nmol/l/d) were also measured deep in the water column (240 m). Day-to-day variations were measured demonstrating the response within a few hours to hydrological stress (wind-induced mixing of the water column) and showing the role of hydrological characteristics on the distribution of nitrification rates. Because of the homogenous temperature (13°C) in the Mediterranean Sea, the spatial (geographical and vertical) fluctuations of nitrifying rates were linked to the presence of substrate due to mineralisation processes and/or Rhône River inputs. We estimate the contribution of nitrate produced by nitrification to the N demand of phytoplankton to range from 16% at mesotrophic to 61% at oligotrophic stations.

Abundance of bacteria, cyanobacteria and nanoflagellates at sime series station DYNAPROC

The variability in microbial communities (abundance and biomass), bacterial production and ectoaminopeptidase activity, particulate and dissolved organic carbon (POC, DOC), and particulate and dissolved lipids was examined in spring 1995 in the northwestern Mediterranean, where a transition from the end of a bloom to pre-oligotrophic conditions was observed. Four time series of 36 h each and 4 h sampling intervals were performed at 5 m and at the chlorophyll maximum (30 m) between 11 and 31 May. Simultaneous measurements of pigments, abundance of hetero- and autotrophic flagellates, bacteria and POC enabled the estimation of living POC (defined as autotrophic-C plus heterotrophic-C biomass), and thus the detrital organic carbon. During the first 2 time series (11 to 15 May), the bacterial-C biomass was higher than the autotrophic-C biomass at 5 m (ratio 1.4 and 1.7), whereas the opposite trend was observed in the chlorophyll peak (ratio 0.7 for the first cycle). However, at the end of May, autotrophic-C biomass was equivalent to bacterial-C biomass at both depths studied. The detrital pool remained a more or less constant fraction of the POC (52, 53 and 47% on 11-12 May, 14-15 May and 30-31 May) at the chlorophyll peak, whereas it decreased significantly with time (62 to 53%) at 5 m. Relationships between bacterial activities and evolution of available resources were not systematically evidenced from our 36 h diel cycle data. Nevertheless, at the monthly scale, comparison of bacterial carbon demand (BCD) to potential carbon resources (detrital POC and DOC) showed that bacteria fed differently on the various pools. From ectoaminopeptidase turnover rates and detrital POC, the potential hydrolysis rate of detritus was calculated. Depending on the choice of conversion factors for bacterial production and estimates of hydrolysis turnover rates, it was shown that bacterial hydrolysis of detritus could be one of the DOC accumulation sources. We observed that the percentage of BCD supplied by detrital POC hydrolysis increased in the surface and decreased in the chlorophyll peak. An index of lipid degradation in POC, the lipolysis index, increased during the month at 5 m, also indicating a higher hydrolysis of POC. The opposite trend was observed in the chlorophyll maximum layer. The selective decrease in dissolved lipids in DOC in the chlorophyll maximum layer, particularly free fatty acids, also suggests that bacteria utilized increased fractions of carbon sources from the DOC. We concluded that partitioning between DOC and detritus as resources for bacteria can change during the rapid transition period from mesotrophy to oligotrophy in the northwestern Mediterranean.