This paper presents the first national estimates of the effects of the SCHIP expansions on insurance coverage. Using CPS data on insurance coverage during the years 1996 through 2000, we estimate two-stage least squares regressions of insurance coverage. We find that SCHIP had a small, but statistically significant positive effect on insurance coverage. Our regression results imply that between 4% and 10% of children meeting income eligibility standards for the new program gained public insurance. While low, these estimates indicate that states were more successful in enrolling children in SCHIP than they were with prior Medicaid expansions focused on children just above the poverty line. Crowd-out of private health insurance was estimated to be in line with estimates for the Medicaid expansions of the early 1990s, between 18% and 50%.

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OBJECTIVES: This report describes trends in the rates of lower-extremity amputation and revascularization procedures and vascular disease risk factors. METHODS: We analyzed trends in National Hospital Discharge Survey data for 1979 through 1996 and in National Health Interview Study data for 1983 through 1994. RESULTS: Despite a decline between 1983/84 and 1991/92, by 1995/96 the rate of major amputation had increased 10.6% since 1979/80. The earlier 12-year decline was positively correlated with reductions in the prevalence of smoking (r = 0.88, P < .0001), hypertension (r = 0.65, P = .02), and heart disease (r = 0.73, P = .007), but not diabetes (r = -0.33, P = .29). During the 1980s, amputation and angioplasty rates were inversely correlated (r = -0.75, P = .001), but the decline in amputation rates occurred before the increase in angioplasty. The major amputation rate, which has increased since 1993, was 24.95 per 100,000 people in 1996. CONCLUSIONS: Major amputation rates fell in the years following the diffusion of distal bypass surgery but before the widespread use of peripheral angioplasty. Because disease prevalence and primary amputation rates are unknown, it is difficult to estimate the contribution of recent improvements in vascular surgery to limb preservation.

PURPOSE Although potentially costly, enhancing primary care depression management on an ongoing basis results in substantial long-term treatment effectiveness. The purpose of this article is to compare the cost-effectiveness of this approach with that of usual care. METHODSThe study was conducted in 12 community primary care practices randomized to enhanced or usual care after stratifi cation by baseline practice patterns. Practices assigned to enhanced care encouraged depressed patients to engage in active treatment, using practice nurses to provide regularly scheduled care management during the course of 24 months. We analyze outcomes for 211 adults (73.4% of potential eligible patients) beginning a new treatment episode for major depression determined by previsit screening. Outcomes included blinded estimates of days free of depression impairment as well as health care costs for 2 years.RESULTS Enhanced care signifi cantly increased the number of days free of depression impairment for 2 years when compared with usual care (647.6 days vs 588.2 days, P <.01). The incremental cost-effectiveness ratio for enhanced care ranged from $9,592 to $14,306 per quality-adjusted life-year (QALY). The number of incremental days free of depression impairment increased between the fi rst year and the second year (23.0 vs 36.4, respectively, P <.001) while incremental health plan costs decreased signifi cantly ($568 vs -$12, P <.001).CONCLUSIONS Enhancing primary care depression management on an ongoing basis should be considered for adoption by policy and health plan leaders. Most primary care depression programs designed to improve acute depression management last 6 months or less. Because brief programs have little to no sustained effect 1 year after termination, [21][22][23][24] we tested a model that enhances primary care depression management on an ongoing basis. By supplementing acute management 25 with systematic monitoring for 24 months, this model incorporates chronic disease management principles 26,27 and results in clinically signifi cant improvements in both symptoms and functioning at 2 years. 28 Given the clinical effectiveness at modest cost, we hypothesized that enhancing primary care depression management on an ongoing basis would be cost-effective when compared with usual care. Although it is premature to draw defi nitive conclusions when comparing the relative costs of brief and ongoing models of care, evidence of the cost-effectiveness of ongoing models provides important new information about the value of extending the brief programs currently being disseminated. METHODSExperimental Design and Sample Our methods, described in detail elsewhere, 25 are summarized here. After approval by the Human Research Advisory Committee of the University of Arkansas for Medical Sciences and the Colorado Multi-Institutional Review Board, the research team conducted the study in 12 community primary care practices across the United States, none of which employed onsite mental health professionals to treat depr...

This article examines hospital reorganization and restructuring activities following merger for two study periods: 1983-1988 and 1989-1996. In both periods, hospitals rated strengthening hospital financial position as the most important reason for merger. There were also similarities in reorganizing actions, especially reductions in service duplication, consolidation of departments and programs, reductions in medical and support FTEs, and reductions in administrative staffing. Hospital mergers during 1989-1996, however, focused increasingly on reducing nursing FTEs and less on converting acquired hospitals to new service lines.