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1.  Uninsured and unstably insured: the importance of continuous insurance coverage. 
Health Services Research  2000;35(1 Pt 2):187-206.
OBJECTIVE: To examine the importance of continuous health insurance for access to care by comparing the access and cost experiences of insured adults with a recent time uninsured to the experiences of currently uninsured adults and experiences of adults with no time uninsured within a reference time period (continuously insured). DATA SOURCES: Adults ages 18-64. Data draw from three different survey databases: the Robert Wood Johnson Foundation 1996-1997 Community Tracking Survey, the Kaiser/Commonwealth 1997 National Survey of Health Insurance, and the 1995-1997 Kaiser/Commonwealth State Low Income Surveys. STUDY DESIGN: The study groups individuals into three insurance categories based on respondents' reports of insurance coverage within a reference time period: continuously insured; insured when surveyed but with recent time uninsured; and currently uninsured. In the two Kaiser/Commonwealth surveys the recently uninsured group included any insured respondent with a time uninsured in the past two years. In the Community Tracking Survey, the recently uninsured group included any insured respondent with a time uninsured in the past year. Measures of access include foregoing health care when needed, usual source of care, use of health care services, difficulties paying for medical care, and satisfaction with care. DATA COLLECTION: All three surveys were conducted primarily by telephone. The Community Tracking Survey drew from 60 community sites, with an additional random national sample. The Kaiser/Commonwealth National Survey was a random national sample; the Kaiser/Commonwealth State Low Income Surveys included adults ages 18-64 with incomes at or below 250 percent of poverty in seven states: Minnesota, Oregon, Tennessee, Florida, Texas, New York, and California. PRINCIPAL FINDINGS: Compared to the continuously insured, those insured but with a recent time uninsured were at high risk of going without needed care and of having problems paying medical bills. This group was two to three times as likely as those with continuous coverage to report access problems. Rates of access and cost problems reported by insured adults with a recent time uninsured neared levels reported by those who were uninsured at the time of the survey. These two groups also rated care received more negatively than did adults with continuous insurance coverage. In general, the access gap between persons insured and uninsured widened as a result of distinguishing insured adults with a recent time uninsured from insured adults with no time uninsured. CONCLUSION: Studies that focus on current insurance status alone will underestimate the extent to which having a time uninsured during the year contributes to access difficulties and undermines quality of care, and will underestimate the proportion of the population at risk because they are uninsured. Policy reforms are needed to maintain continuous insurance coverage and avoid spells uninsured. Currently uninsured and unstably insured adults are both at high risk.
PMCID: PMC1089095  PMID: 10778809
2.  New Technology Review Process: The Laparoscopic Adjustable Gastric Band 
The Permanente Journal  2011;15(4):54-60.
The Interregional New Technologies Committee (INTC) is one evaluation route for new medical technologies or technologies with expanded indications within Kaiser Permanente (KP). The primary focus of the INTC is to consider all available published evidence on a particular technology, surgical technique, or implantable device for a specific clinical indication and provide a recommendation on the sufficiency of the evidence for determining net medical benefit to Permanente Medical Group leaders and Kaiser Foundation Health Plan management throughout KP Regions. This iterative process provides an objective, evidence-based assessment to inform decision making by physicians and support the most appropriate care for KP members. This overview illustrates the INTC process and how it supports clinical decision making using implantation of laparoscopic adjustable gastric bands (LAGBs) as an example. In February 2011, the US Food and Drug Administration (FDA) approved lowering the acceptable body mass index for the Lap-Band from 35 to 30 kg/m2 for patients with at least one comorbid condition. It is difficult to find published studies on medical technologies that have been recently approved by the FDA. The manufacturer often submits clinical data to the FDA, but details are frequently not publicly available at the time of approval. The LAGB example demonstrates the complex issues addressed by the INTC, particularly when there is some evidence of short-term improvement in outcomes with a medical device but little if any confirmation of long-term safety or effectiveness.
PMCID: PMC3267562  PMID: 22319417
3.  Project LEAN--lessons learned from a national social marketing campaign. 
Public Health Reports  1993;108(1):45-53.
The Henry J. Kaiser Family Foundation initiated a social marketing campaign in 1987 to reduce the nation's risk for heart disease and some cancers. Consensus on recommendations for dietary change have stimulated the development of a variety of social marketing campaigns to promote behavior change. Project LEAN (Low-Fat Eating for America Now) is a national campaign whose goal is to reduce dietary fat consumption to 30 percent of total calories through public service advertising, publicity, and point-of-purchase programs in restaurants, supermarkets, and school and worksite cafeterias. The public service advertising reached 50 percent of the television viewing audience and the print publicity, more than 35 million readers. The toll-free hotline received more than 300,000 calls. Thirty-four organizations joined the foundation in partnership and raised $350,000 for collaborative activities. Thirteen States implemented local campaigns. Lessons have been learned about the use of the media, market segmentation, effective spokespersons, and successful partnerships. These lessons will be valuable to others planning social marketing campaigns on nutrition and other preventive behaviors.
PMCID: PMC1403329  PMID: 8434097
4.  Intestinal Protozoan Infections: Prevalence in the San Francisco Bay Area 
Western Journal of Medicine  1981;135(3):188-190.
A sample of 415 members of the Kaiser Foundation Health Plan (KFHP) were tested for intestinal protozoa. This parasite survey group was found to be comparable in age distribution, sex and ethnic background with the membership at large. Gastrointestinal complaints were no more numerous in this group than in a large series of KFHP members taking multiphasic examinations. Because KFPH membership included, at the time of the survey, approximately 27 percent of all residents of the San Francisco Bay Area, the membership may be considered approximately representative of the entire area. Fourteen percent of persons were found to be infected with one or more intestinal protozoan parasites, while 5.5 percent harbored potentially pathogenic sorts. Entamoeba histolytica was found in 0.7 percent of those surveyed, Giardia lamblia in 1.7 percent and Dientamoeba fragilis in 3.1 percent.
PMCID: PMC1273112  PMID: 7340117
5.  Lessons From the Frozen North 
Western Journal of Medicine  1989;151(2):217-219.
Presented in part as the Kaiser Foundation Distinguished Lecture at the annual meeting of the Western Association of Physicians, February 7, 1989.
PMCID: PMC1026936  PMID: 2773481
6.  A Conversation About Health Care Reform 
Western Journal of Medicine  1994;161(1):83-86.
Professor Victor R. Fuchs is the Henry J. Kaiser Jr Professor at Stanford (California) University, where he applies economic analysis to social problems of national concern, with special emphasis on health and medical care. He holds joint appointments in the Economics Department and the School of Medicine's Department of Health Research and Policy. Professor Fuchs is a Distinguished Fellow of the American Economic Association and a member of the American Philosophical Society, the American Academy of Arts and Sciences, and the Institute of Medicine of the National Academy of Sciences. He was the first economist to receive the Distinguished Investigator Award of the Association for Health Services Research and has also received the Baxter Foundation Health Services Research Prize. Professor Fuchs is president-elect of the American Economic Association. His latest book, The Future of Health Policy, was published by Harvard University Press in 1993.
The following edited conversation between Professor Fuchs and Linda Hawes Clever, MD, Editor of the journal, took place on April 8, 1994.
PMCID: PMC1011385  PMID: 7941523
7.  Relationship between socioeconomic status, health status, and lifestyle practices of American Indians: evidence from a Plains reservation population. 
Public Health Reports  1994;109(3):405-413.
This paper presents information on the prevalence of a variety of health behaviors and health conditions on an American Indian reservation in the Plains region of the western United States. In addition, data from two non-Indian comparison groups were used to examine the extent to which differences in health status and health behaviors between Indians and non-Indians could be explained by differences in socioeconomic status. The American Indian data were from a survey conducted in 1988 during an evaluation of a local community-based health promotion program, part of the Kaiser Family Foundation's Community Health Promotion Grants Program. The comparison groups were 12 communities in California surveyed in evaluating the Community Health Promotion Grants Program and three Plains States participating in the Behavioral Risk Factor Surveillance Survey. The results show that the higher prevalences of risk-taking behavior among Indians and their poorer self-reported health status remained after adjustment for socioeconomic status. Also, among Indians, higher levels of income and education were not associated with improved self-reported health status and lower prevalence of tobacco use, as was the case with the comparison groups. The higher prevalences of risk-taking behaviors and ill health among American Indians residing on one reservation, even among those with higher socioeconomic status, suggests a need for the investigation of other social and environmental influences.
PMCID: PMC1403505  PMID: 8190864
8.  A community-based approach to preventing alcohol use among adolescents on an American Indian reservation. 
Public Health Reports  1995;110(4):439-447.
This paper examines the effectiveness of a 5-year community-based health promotion program to reduce the rate of substance use, particularly alcohol, by adolescents on a Plains State American Indian reservation. The program was part of the Kaiser Family Foundation Community Health Promotion Grants Program. Since a reservation control group was not available, adolescents serving as control groups for other Community Health Promotion Grants Program communities, including a small sample of rural American Indians, were used as a basis for comparison. School-based surveys of 9th and 12th graders were carried out on the reservation and in five relevant California control communities--two suburban, three rural--in 1988, 1990, and 1992. The results showed that the use of both alcohol and marijuana declined substantially among American Indian adolescents living on the reservation. Binge drinking (five or more drinks on an occasion) declined from 46 percent to 30 percent, and marijuana use (in the past month) declined from 46 percent to 29 percent over the 4-year period. However, there were similar, if smaller, declines in alcohol use in the comparison groups. Since there was no evidence of a relative increase in exposure to alcohol and drug programs on the reservation, the authors are cautious in attributing the significant and heartening declines in substance use among adolescents on the reservation to the community-based program.
PMCID: PMC1382153  PMID: 7638331
9.  Health Benefits Offer Rates: Is There a Nonresponse Bias? 
Health Services Research  2005;40(2):401-412.
To determine whether a nonresponse bias exists in the offer rate for health benefits in firms with fewer than 50 workers and to present a simple adjustment to correct for observed bias.
Data Sources
The 2003 Employer Health Benefits Survey (EHBS) conducted by the Kaiser Family Foundation and Health Research and Educational Trust, and a follow-up survey of nonrespondents to the 2003 EHBS.
Study Design
We conducted a follow-up survey to the 2003 EHBS to collect health benefits offering data from firms with fewer than 50 workers. We used McNemar's test to verify that the follow-up survey provided results comparable to the EHBS, and t-tests were used to determine nonresponse bias. We applied a simple weighting adjustment to the EHBS.
Data Collection
The data for both the EHBS and the follow-up survey were collected by the same survey research firm. The EHBS interviews the person most knowledgeable about the firm's health benefits, while the follow-up survey interviews the first person who answers the telephone whether they are the most knowledgeable or not.
Principal Findings
Firms with 3–9 workers were more likely to exhibit a bias than were firms with 10–24 workers and 25–49 workers. Although the calculated bias for each size category was not significant, there is sufficient evidence to warrant caution when reporting offer rates.
Survey nonresponse in the EHBS produces an upward bias on estimates for the offer rates of small firms. Although not significant, this upward bias is because of nonresponse by small firms that do not offer health benefits. Our research is limited in that we only control for differences in the size of the firm.
PMCID: PMC1361148  PMID: 15762899
Bias; nonresponse analysis; health benefits offer rate
10.  The Kaiser Family Foundation Community Health Promotion Grants Program: findings from an outcome evaluation. 
Health Services Research  2000;35(3):561-589.
OBJECTIVES: To present results from an outcome evaluation of the Henry J. Kaiser Family Foundation's Community Health Promotion Grants Program (CHPGP) in the West, which represented a major community-based initiative designed to promote improved health by changing community norms, environmental conditions, and individual behavior in 11 western communities. METHODS: The evaluation design: 14 randomly assigned intervention and control communities, 4 intervention communities selected on special merit, and 4 matched controls. Data for the outcome evaluation were obtained from surveys, administered every two years at three points in time, of community leaders and representative adults and adolescents, and from specially designed surveys of grocery stores. Outcomes for each of the 11 intervention communities were compared with outcomes in control communities. RESULTS: With the exception of two intervention communities-a largely Hispanic community and a Native American reservation-we found little evidence of positive changes in the outcomes targeted by the 11 intervention communities. The programs that demonstrated positive outcomes targeted dietary behavior and adolescent substance abuse. CONCLUSIONS: Improvement of health through community-based interventions remains a critical public health challenge. The CHPGP, like other prominent community-based initiatives, generally failed to produce measurable changes in the targeted health outcomes. Efforts should focus on developing theories and methods that can improve the design and evaluation of community-based interventions.
PMCID: PMC1089138  PMID: 10966086
11.  Estimates of preventive versus nonpreventive medical care demand in an HMO. 
Health Services Research  1979;14(1):33-43.
Multiple regression analysis is used to investigate whether medical services in a large HMO are distributed primarily on the basis of need and predisposing factors (such as health status, age and sex) or according to enabling characteristics (such as coinsurance and income) of the population. Equations are formulated to estimate the likelihood and volume of preventive visit demand, nonpreventive visit demand and hospital admissions for a sample of 3,892 individuals enrolled in the Kaiser Foundation Health Plan of Portland, Oregon. The results indicate that predisposing and need factors are the main determinants of nonpreventive visits and hospital utilization, while enabling characteristics are important determinants (along with age and education) of preventive utilization. There are marked differences in the impact of explanatory factors on utilization by dependents (children) versus nondependents (adults).
PMCID: PMC1072099  PMID: 468551
12.  The California Cost and Coverage Model: Analyses of the Financial Impacts of Benefit Mandates for the California Legislature 
Health Services Research  2006;41(3 Pt 2):1027-1044.
To produce cost estimates of proposed health insurance benefit mandates for the California legislature.
Data Sources
The 2001 California Health Interview Survey, 2002 Kaiser Family Foundation/Health Research and Education Trust California Employer Health Benefits Survey, Milliman Health Cost Guidelines, and ad hoc surveys of large health plans were used.
Study Design
We developed an actuarial model to estimate short-term (1 year) changes in utilization and total health care expenditures, including insurance premiums and out-of-pocket expenditures, if insurance mandates were enacted. This model includes baseline estimates of current coverage and total current expenditures for each proposed mandate.
Principal Findings
Analysis of seven legislative proposals indicated 1-year increases in total health care expenditures among the insured population in California ranging from 0.006 to 0.200 percent. Even when proposed mandates were expected to reach a large target group, either utilization or cost was sufficiently low to keep total cost increases minimal.
Our ability to develop a California-specific model to estimate the impacts of proposed mandates in a timely fashion provided California legislators during the 2004 legislative session with more-detailed coverage and cost information than is generally available to legislative bodies.
PMCID: PMC1713222  PMID: 16704670
Insurance mandates; health care expenditures; utilization and cost impacts; evidence-based policy analysis
13.  Increasing Health Insurance Costs and the Decline in Insurance Coverage 
Health Services Research  2005;40(4):1021-1039.
To determine the impact of rising health insurance premiums on coverage rates.
Data Sources & Study Setting
Our analysis is based on two cohorts of nonelderly Americans residing in 64 large metropolitan statistical areas (MSAs) surveyed in the Current Population Survey in 1989–1991 and 1998–2000. Measures of premiums are based on data from the Health Insurance Association of America and the Kaiser Family Foundation/Health Research and Educational Trust Survey of Employer-Sponsored Health Benefits.
Study Design
Probit regression and instrumental variable techniques are used to estimate the association between rising local health insurance costs and the falling propensity for individuals to have any health insurance coverage, controlling for a rich array of economic, demographic, and policy covariates.
Principal Findings
More than half of the decline in coverage rates experienced over the 1990s is attributable to the increase in health insurance premiums (2.0 percentage points of the 3.1 percentage point decline). Medicaid expansions led to a 1 percentage point increase in coverage. Changes in economic and demographic factors had little net effect. The number of people uninsured could increase by 1.9–6.3 million in the decade ending 2010 if real, per capita medical costs increase at a rate of 1–3 percentage points, holding all else constant.
Initiatives aimed at reducing the number of uninsured must confront the growing pressure on coverage rates generated by rising costs.
PMCID: PMC1361195  PMID: 16033490
Health care costs; health insurance coverage; health care spending growth; uninsured; insurance premiums
14.  New Technology for Multiphasic Health Testing 
This paper comments on the early technology used in multiphasic health testing and reviews the more significant advances in biomedical instrumentation, computer technology, programming techniques and medical protocols which have taken place over the past few years. Multiphasic health testing in itself is still a new systems technology-first applied within the Kaiser-Permanente Foundation in the 50's and 60's, given a spurt during the late 60's and early 70's when industry decided it was a product ready to market, then languishing due to lack of physician acceptance and lack of third party reimbursement, and recently given new impetus through the growing popularity of Fitness programs and the increased emphasis on environmental health monitoring. The theme has shifted away from early disease detection and toward health monitoring, and most technological advances have supported this shift.
PMCID: PMC2578309
15.  Physician Awareness of Drug Cost: A Systematic Review 
PLoS Medicine  2007;4(9):e283.
Pharmaceutical costs are the fastest-growing health-care expense in most developed countries. Higher drug costs have been shown to negatively impact patient outcomes. Studies suggest that doctors have a poor understanding of pharmaceutical costs, but the data are variable and there is no consistent pattern in awareness. We designed this systematic review to investigate doctors' knowledge of the relative and absolute costs of medications and to determine the factors that influence awareness.
Methods and Findings
Our search strategy included The Cochrane Library, EconoLit, EMBASE, and MEDLINE as well as reference lists and contact with authors who had published two or more articles on the topic or who had published within 10 y of the commencement of our review. Studies were included if: either doctors, trainees (interns or residents), or medical students were surveyed; there were more than ten survey respondents; cost of pharmaceuticals was estimated; results were expressed quantitatively; there was a clear description of how authors defined “accurate estimates”; and there was a description of how the true cost was determined. Two authors reviewed each article for eligibility and extracted data independently. Cost accuracy outcomes were summarized, but data were not combined in meta-analysis because of extensive heterogeneity. Qualitative data related to physicians and drug costs were also extracted. The final analysis included 24 articles. Cost accuracy was low; 31% of estimates were within 20% or 25% of the true cost, and fewer than 50% were accurate by any definition of cost accuracy. Methodological weaknesses were common, and studies of low methodological quality showed better cost awareness. The most important factor influencing the pattern and accuracy of estimation was the true cost of therapy. High-cost drugs were estimated more accurately than inexpensive ones (74% versus 31%, Chi-square p < 0.001). Doctors consistently overestimated the cost of inexpensive products and underestimated the cost of expensive ones (binomial test, 89/101, p < 0.001). When asked, doctors indicated that they want cost information and feel it would improve their prescribing but that it is not accessible.
Doctors' ignorance of costs, combined with their tendency to underestimate the price of expensive drugs and overestimate the price of inexpensive ones, demonstrate a lack of appreciation of the large difference in cost between inexpensive and expensive drugs. This discrepancy in turn could have profound implications for overall drug expenditures. Much more focus is required in the education of physicians about costs and the access to cost information. Future research should focus on the accessibility and reliability of medical cost information and whether the provision of this information is used by doctors and makes a difference to physician prescribing. Additionally, future work should strive for higher methodological standards to avoid the biases we found in the current literature, including attention to the method of assessing accuracy that allows larger absolute estimation ranges for expensive drugs.
From a review of data from 24 studies, Michael Allan and colleagues conclude that doctors often underestimate the price of expensive drugs and overestimate the price of those that are inexpensive.
Editors' Summary
Many medicines are extremely expensive, and the cost of buying them is a major (and increasing) proportion of the total cost of health care. Governments and health-care organizations try to find ways of keeping down costs without reducing the effectiveness of the health care they provide, but their efforts to control what is spent on medicines have not been very successful. There are often two or more equally effective drugs available for treating the same condition, and it would obviously help keep costs down if, when a doctor prescribes a medicine, he or she chose the cheapest of the effective drugs available. This choice could result in savings for whoever is paying for the drugs, be it the government, the patient, or a medical insurance organization.
Why Was This Study Done?
Doctors who prescribe drugs cannot be expected to know the exact cost of each drug on the market, but it would he helpful if they had some impression of the cost of a treatment and how the various alternatives compare in price. However, systems deciding how drugs are priced are often very complex. (This is particularly the case in the US.) The researchers wanted to find out how aware doctors are regarding drug costs and the difference between the alternatives. They also wanted to know what factors affected their awareness.
What Did the Researchers Do and Find?
They decided to do a systematic review of all the research already conducted that addressed this issue so that the evidence from all of them could be considered together. In order to do such a review they had to specify precise requirements for the type of study that they would include and then comprehensively search the medical literature for such studies. They found 24 studies that met their requirements. From these studies, they concluded that doctors were usually not accurate when asked to estimate the cost of drugs; doctors came up with estimates that were within 25% of the true cost less than one-third of the time. In particular doctors tended to underestimate the cost of expensive drugs and overestimate the cost of the cheaper alternatives. A further analysis of the studies showed that many doctors said they would appreciate more accurate information on costs to help them choose which drugs to prescribe but that such information was not readily available.
What Do These Findings Mean?
The researchers concluded that their systematic review demonstrates a lack of appreciation by prescribing doctors of the large difference in cost between inexpensive and expensive drugs, and that this finding has serious implications for overall spending on drugs. They call for more education and information to be provided to doctors on the cost of medicines together with better processes to help doctors in making such decisions.
Additional Information.
Please access these Web sites via the online version of this summary at
A brief guide to systematic reviews has been published by the BMJ (British Medical Journal)
The Web site of the Cochrane Collaboration is a more detailed source of information on systematic reviews; in particular there is a newcomers' guide and information for health-care consumers
The Kaiser Family Foundation, a nonprofit, private operating foundation focusing on the major health care issues in the US, has a section on prescription drugs and their costs
PMCID: PMC1989748  PMID: 17896856
16.  Facilitating Physician Access to Medical Reference Information 
The Permanente Journal  2005;9(4):27-32.
Context: Computer-based medical reference information is augmenting—and in some cases, replacing—many traditional sources. For Kaiser Permanente (KP) physicians, this change presents both advantages and obstacles to finding medical reference information.
Objective: To improve understanding of physician information-seeking behavior and the barriers that limit use of both print-based and computer-based medical reference resources.
Design: During 2002 and 2003, two quality-improvement surveys were distributed to full-time KP physicians. Survey instruments sent by conventional mail and by e-mail were based on results of telephone interviews and focus groups, and were designed to be concise and easy to use. Participant response rates exceeded 83%.
Outcomes Measures: The surveys examined physician use of online medical reference information, medical libraries and services, self-directed learning resources, and continuing medical education (CME).
Results: Of the physicians who responded to the survey, 89% used online resources frequently to enhance care, to inform clinical decisions, to update knowledge, to educate patients, or for a combination of these purposes. Compared with responses from older physicians, responses from younger physicians showed a greater proclivity for using nearly all types of online information. Most physicians obtained CME credits primarily through in-person education programs; few physicians used self-directed electronic learning tools. Obstacles to effective access to information included lack of time, overly complex access methods, and lack of awareness about available resources.
Conclusions: A considerable gap exists between physicians' need for information and the resources currently available for delivering this information. Although we observed a clear shift from using printed medical references to using computer-based resources, many barriers prevent their effective use. Clinicians need easy-to-use, seamless systems of medical reference information that are accessible remotely anytime.
PMCID: PMC3396103  PMID: 22811642
17.  Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data 
BMJ : British Medical Journal  2003;327(7426):1257.
Objective To compare the utilisation of hospital beds in the NHS in England, Kaiser Permanente in California, and the Medicare programme in the United States and California.
Design Analysis of routinely available data from 2000 and 2001 on inpatient admissions, lengths of stay, and bed days in populations aged over 65 for 11 leading causes of use of acute beds.
Setting Comparison of NHS data with data from Kaiser Permanente in California and the Medicare programme in California and the United States; interviews with Kaiser Permanente staff and visits to Kaiser facilities.
Results Bed day use in the NHS for the 11 leading causes is three and a half times that of Kaiser's standardised rate, almost twice that of the Medicare California's standardised rate, and more than 50% higher than the standardised rate in Medicare in the United States. Kaiser achieves these results through a combination of low admission rates and relatively short stays. The lower use of bed days in Medicare in California compared with Medicare in the United States suggests there is a “California effect” as well as a “Kaiser effect” in hospital utilisation.
Conclusion The NHS can learn from Kaiser's integrated approach, the focus on chronic diseases and their effective management, the emphasis placed on self care, the role of intermediate care, and the leadership provided by doctors in developing and supporting this model of care.
PMCID: PMC286244  PMID: 14644968
18.  Interlibrary loan in primary access libraries: challenging the traditional view 
Introduction: Primary access libraries serve as the foundation of the National Network of Libraries of Medicine (NN/LM) interlibrary loan (ILL) hierarchy, yet few published reports directly address the important role these libraries play in the ILL system. This may reflect the traditional view that small, primary access libraries are largely users of ILL, rather than important contributors to the effectiveness and efficiency of the national ILL system.
Objective: This study was undertaken to test several commonly held beliefs regarding ILL system use by primary access libraries.
Hypotheses: Three hypotheses were developed. H1: Colorado and Wyoming primary access libraries comply with the recommended ILL guideline of adhering to a hierarchical structure, emphasizing local borrowing. H2: The closures of two Colorado Council of Medical Librarians (CCML) primary access libraries in 1996 resulted in twenty-three Colorado primary access libraries' borrowing more from their state resource library in 1997. H3: The number of subscriptions held by Colorado and Wyoming primary access libraries is positively correlated with the number of items they loan and negatively correlated with the number of items they borrow.
Methods: The hypotheses were tested using the 1992 and 1997 DOCLINE and OCLC data of fifty-four health sciences libraries, including fifty primary access libraries, two state resource libraries, and two general academic libraries in Colorado and Wyoming. The ILL data were obtained electronically and analyzed using Microsoft Word 98, Microsoft Excel 98, and JMP 3.2.2.
Results: CCML primary access libraries comply with the recommended guideline to emphasize local borrowing by supplying each other with the majority of their ILLs, instead of overburdening libraries located at higher levels in the ILL hierarchy (H1). The closures of two CCML primary access libraries appear to have affected the entire ILL system, resulting in a greater volume of ILL activity for the state resource library and other DOCLINE libraries higher up in the ILL hierarchy and highlighting the contribution made by CCML primary access libraries (H2). CCML primary access libraries borrow and lend in amounts that are proportional to their collection size, rather than overtaxing libraries at higher levels in the ILL hierarchy with large numbers of requests (H3).
Limitations: The main limitations of this study were the small sample size and the use of data collected for another purpose, the CCML ILL survey.
Conclusions: The findings suggest that there is little evidence to support several commonly held beliefs regarding ILL system use by primary access libraries. In addition to validating the important contributions made by primary access libraries to the national ILL system, baseline data that can be used to benchmark current practice performance are provided.
PMCID: PMC35251  PMID: 11055297
19.  Study on construction of cDNA library of the treated changliver cell and quality analysis 
The study aims to construct cDNA library of Changliver cell by SMART (switching mechanism at 5′ end of RNA transcript) technique and analyze its quality. cDNA of Changliver cell was made with RT-PCR and LD-PCR (long-distance PCR), the cDNA library was constructed with SMART cDNA library construction kit. Through testing, the high quality cDNA library containing whole long cDNA of Changliver cell had been constructed. The titer of the amplified cDNA library was 4.5 × 1010 pfu/ml and the average exogenous inserts of the recombinants is 1.5 kb. These results showed that the Changliver cell cDNA library had an excellent quality and lay foundation for screening whole long cDNA of related genes.
PMCID: PMC3454184  PMID: 23105481
cDNA library; SMART; Changliver cell; LD-PCR; immunoscreening
20.  Regionalization of services within a multihospital health maintenance organization. 
Health Services Research  1980;15(3):231-247.
Among the many factors that may explain lower costs for enrollees in Health Maintenance Organizations (HMOs) is the possibility that the HMO provides inpatient services more efficiently. While direct cost comparisons are in appropriate, it is reasonable to examine whether the Kaiser program in the San Francisco Bay Area regionalizes services among its ten hospitals. The presence of each of 43 facilities/services reported is examined in a regression model that includes type of hospital, size, a size-type interaction, and the distance to the nearest competing facility. When the generally smaller size of the Kaiser hospitals was controlled for, Kaiser hospitals had fewer technologically based services and concentrated these services in larger hospitals. Kaiser had more outpatient-oriented services. Among non-Kaiser hospitals, some specialized facilities were competitively distributed.
PMCID: PMC1072166  PMID: 7204063
21.  The NEOUCOM Cooperative Cataloging Service: development and review of the first four years. 
The Basic Medical Sciences Library of the Northeastern Ohio Universities College of Medicine (NEOUCOM) provided a Cooperative Cataloging Service to fourteen of its affiliated hospitals' libraries since March 1978, using the OCLC system. Analysis of the first four years of service showed that the hospital libraries spent almost $30,000 to catalog more than 18,000 titles. Personnel expenses and other costs eclipsed the savings from a 31.3% duplication rate. Centralized bibliographic control control and the principal by-product of the service, a uniform, machine-related data base, provided the foundation for an on-line integrated library system to serve the consortium. The hospital libraries contributed 44% of the unique titles in this data base, which emphasis the need to share resources and continue cooperation.
PMCID: PMC227140  PMID: 6860826
22.  Health information outreach: the land-grant mission 
Service to the state is one of the core principles of the land-grant mission. This concept of service is also fundamental to a significant number of outreach activities in academic health sciences libraries, particularly those libraries affiliated with the public land-grant universities. The Dana Medical Library at the University of Vermont has a lengthy tradition of outreach to health care providers and health care consumers of the State of Vermont. Building on the foundation of the land-grant institution—which grew out of federal legislation introduced in the mid nineteenth century by Justin Morrill, Vermont's congressional representative—the Dana Medical Library has based its outreach activities on its dedication of service to the state in the promotion of healthy citizens through information dissemination in support of health care delivery. Reengineering library services designed to meet the specific information needs of its diverse clientele, partnering with disparate health care organizations, and relying on fees for service to expand its outreach activities, the Dana Medical Library has redefined the concept of health information outreach for the new millennium.
PMCID: PMC35257  PMID: 11055303
23.  Library management in the tight budget seventies. Problems, challenges, and opportunities. 
This paper examines changes in the management of university, special, and medical libraries brought about by the budget curtailments that followed the more affluent funding period of the mid-1960s. Based on a study conducted for the National Science Foundation by the Indiana University Graduate Library School, this paper deals with misconceptions that have arisen in the relationship between publishers and librarians, and differentiates between the priority perceptions of academic and of special librarians in the allocation of progressively scarcer resources. It concludes that libraries must make strong efforts to reduce the growing erosion of materials acquisitions budgets because of growing labor costs as a percentage of all library expenditures; that they must make a working reality of the resource-sharing mechanisms established through consortia and networks; and that they must use advanced evaluative techniques in the determination of which services and programs to implement, expand, and retain, and which to curtail and abandon.
PMCID: PMC199291  PMID: 831887
24.  Coral life history and symbiosis: Functional genomic resources for two reef building Caribbean corals, Acropora palmata and Montastraea faveolata 
BMC Genomics  2008;9:97.
Scleractinian corals are the foundation of reef ecosystems in tropical marine environments. Their great success is due to interactions with endosymbiotic dinoflagellates (Symbiodinium spp.), with which they are obligately symbiotic. To develop a foundation for studying coral biology and coral symbiosis, we have constructed a set of cDNA libraries and generated and annotated ESTs from two species of corals, Acropora palmata and Montastraea faveolata.
We generated 14,588 (Ap) and 3,854 (Mf) high quality ESTs from five life history/symbiosis stages (spawned eggs, early-stage planula larvae, late-stage planula larvae either infected with symbionts or uninfected, and adult coral). The ESTs assembled into a set of primarily stage-specific clusters, producing 4,980 (Ap), and 1,732 (Mf) unigenes. The egg stage library, relative to the other developmental stages, was enriched in genes functioning in cell division and proliferation, transcription, signal transduction, and regulation of protein function. Fifteen unigenes were identified as candidate symbiosis-related genes as they were expressed in all libraries constructed from the symbiotic stages and were absent from all of the non symbiotic stages. These include several DNA interacting proteins, and one highly expressed unigene (containing 17 cDNAs) with no significant protein-coding region. A significant number of unigenes (25) encode potential pattern recognition receptors (lectins, scavenger receptors, and others), as well as genes that may function in signaling pathways involved in innate immune responses (toll-like signaling, NFkB p105, and MAP kinases). Comparison between the A. palmata and an A. millepora EST dataset identified ferritin as a highly expressed gene in both datasets that appears to be undergoing adaptive evolution. Five unigenes appear to be restricted to the Scleractinia, as they had no homology to any sequences in the nr databases nor to the non-scleractinian cnidarians Nematostella vectensis and Hydra magnipapillata.
Partial sequencing of 5 cDNA libraries each for A. palmata and M. faveolata has produced a rich set of candidate genes (4,980 genes from A. palmata, and 1,732 genes from M. faveolata) that we can use as a starting point for examining the life history and symbiosis of these two species, as well as to further expand the dataset of cnidarian genes for comparative genomics and evolutionary studies.
PMCID: PMC2291459  PMID: 18298846
25.  A health/patient education database for family practice. 
Using pilot project funding from the W. K. Kellogg Foundation, the American Academy of Family Physicians Foundation (AAFP/F) developed a program by which health/patient education print materials were reviewed. Favorably reviewed materials were entered into a database accessible through the AAFP/F's Huffington Library. The review service and resulting database were designed to help the busy clinician identify scientifically accurate, reliable materials for use in patient education. The review process developed for the project is described, as is the database and its use by family physicians. Research findings from the pilot project are discussed, some of which assisted in planning the self-supporting second phase of the program.
PMCID: PMC225580  PMID: 1958908

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