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Recently, some researchers have argued that high state rates of Centers for Medicare and Medicaid Services (CMS) Online Survey, Certification and Reporting (OSCAR) nursing facility deficiencies indicate stringent enforcement, leaving the impression of better-quality care soon to follow; others maintain that the rank ordering of states' quality of nursing facility care remains fairly constant, resting on deep-seated state characteristics that change slowly, so that short-term improvement in poor-quality care is unlikely. The authors examine change in the process and outcome quality of states' Medicare nursing facility long-term care programs across 1999 to 2005, using linear and two-stage least squares regression. They find that (1) nationally, process quality generally falls across this period while outcome quality generally increases; (2) neither a prominent enforcement stringency index nor state culture, a relatively stable state characteristic, exerts much influence on state process and outcome quality scores over time, but (3) the relative costs and benefits for CMS compliance appear to contribute to explaining change in states' quality of resident outcomes over time; and (4) states' process quality is much less stable than outcome quality, and outcome indices distinct from OSCAR deficiency data provide more reliable and possibly more valid measures of care quality.

Background: Video-assisted thoracoscopic surgery (VATS) for pulmonary resection was first described 18 years ago; however, it has yet to gain widespread acceptance in community hospitals in the United States. The majority of surgeons who routinely perform VATS resections work in academic or government institutions. There is little data reporting outcomes of VATS pulmonary resections by community-based surgeons. This article reports the outcomes of a hybrid technique for VATS pulmonary resection in a single-surgeon, community-based practice., Methods: A retrospective study was performed on all VATS pulmonary resections performed from January 2000 to March 2008 by a community-based, solo-practice surgeon using a hybrid VATS technique, which utilizes dual access through a thoracoscopy port and a utility incision., Results: A total of 1170 VATS pulmonary resections were performed over the study period, which is the largest single-surgeon series on VATS pulmonary resection to our knowledge. Among them, 746 cases were for malignant disease. Mean operative time was 52 minutes (median 48 minutes). Mean length of stay was 7 days (median 4 days). Mean length of ICU stay was 1.4 days, with 83% of patients having no days spent in the ICU. Mean length of chest tube duration was 4.5 days. The morbidity rate was 21.1 %, with neuropraxia as the most frequent complication. Perioperative mortality was 4.3% and overall mortality was 16.4%, with a mean follow-up of 425 days., Conclusions: This series shows that our hybrid VATS approach to pulmonary resection is safe and feasible at community hospital-based practices.

Background: Although video-assisted thoracoscopic surgery (VATS) for pulmonary resection was first described more than 15 years ago, it has yet to gain grass-roots acceptance. The majority of surgeons who routinely perform VATS resections work in academic or government institutions. The perceived complexity of the technique, inadequate instrumentation and resources, and concern regarding the potential compromise of surgical and oncologic principles may present a greater barrier to adoption by community-based surgeons. This article illustrates some of the technical aspects of a hybrid technique that enables a single surgeon to perform VATS pulmonary resection on a routine basis in a community-based practice., Methods: From January 2005 to March 2008, 492 VATS pulmonary resections were performed by a community-based, solo-practice surgeon using a hybrid VATS technique. The highlight of this technique is utilization of a thoracoscopy port and a utility incision. The advantages of this dual access are ease in instrumentation, visualization, lighting, and retraction. In addition, this technique allows immediate access under direct vision for urgent control of bleeding, which can be difficult using a conventional thoracoscopic approach., Results: Mean operative time was 52 (median, 48) minutes. Mean length of stay was 7 (median, 4) days. Mean length of ICU stay was 1.7 days, with 85% of patients having no days spent in the ICU. Mean length of chest tube duration was 4 days. Perioperative mortality was 3.5% and overall mortality was 9.8%, with a mean follow-up of 239 days. These results compare favorably with the conventional VATS approach., Conclusions: This series shows that our hybrid VATS approach to pulmonary resection is safe and feasible at community hospital-based practices.

States employ home and community-based services (HCBS) increasingly in Medicaid support of long-term care and rely less on nursing facilities. We examine how states' nursing facilities and HCBS programs compare and whether states' long-term care responses match their ideological inclination toward, material capacity for supporting, and their citizens' need for these public social programs. We use cross-sectional panel data on structural, process, and outcome quality for nursing facilities and HCBS congregate residential programs. We rank states, correlate these measures, and use regression to link inclination, capacity, and need to quality. We find that states' nursing facility and HCBS program quality are not closely related and that state HCBS congregate residential program quality is independent of inclination, capacity, and need. This latter result underscores a need for uniform HCBS standards and better data on quality.

We address two issues in this exploratory study. First, to what degree do variables prominent in explaining cross-state variation in the generosity of other public assistance programs also help to explain the resources states devote to nursing facility long-term care for the elderly, a service supported largely by states' Medicaid programs? Second, to what degree do the resources that states commit to this purpose influence the quality of state nursing facility processes and, in turn, translate into state nursing facility residents' quality-of-life outcomes? We find unusual features to the pattern of factors explaining state resource levels. We also find surprises in relations among the three aspects of quality, but overall, raising resource adequacy improves nursing facility process quality, which, in turn, bolsters nursing facility residents' quality-of-life outcomes. We close with suggestions for further improvement.

Elderly Americans commit suicide at higher rates than other age groups. We contend that macro- and micro-social variables contribute distinct aspects to explanations of this tragic loss: the former focus on circumstances that affect overall rates, the latter reveal why certain individuals succumb to suicide. Our analysis focuses on the macro-social end of a causal sequence including variables at both levels. We describe how elderly suicide rates vary among states, show that macrosocial indicators of social integration contribute to cross-state variation in elderly suicide rates, and explain how selected aspects of state-level public policy contribute to reducing elderly suicide rates.

The past 20 yr have seen an explosion in advances for the management of Type I diabetes mellitus. Not only new delivery systems, such as the continuous subcutaneous insulin pump, but also better and more stable types of insulin with predictable pharmacokinetics and pharmacodynamics have been developed. An artificial pancreas is now on the horizon. This progress has had a significant impact on modern perioperative care of the diabetic patient.