Screening for patients with alcohol problems: severity of patients identified by the CAGE.

Primary care physicians are well situated to identify patients with substance abuse problems and motivate them to seek appropriate assistance, but active programs are the exception. A study in a community setting was undertaken to assess the CAGE (the first letters of key words in a series of four questions about drinking: cut down; annoyed; guilty; and eye-opener), instrument in the routine screening for alcohol problems in both new and established patients. The screening process identified subjects for a pilot evaluation of a motivational interview designed to encourage problem-solving behavior. This article focuses on the screening results and the use of the CAGE instrument. During June and July of 1990, 687 patients of two primary care physicians belonging to a large group practice were asked to complete a health questionnaire that included the CAGE. Those who responded affirmatively to at least two of the four CAGE questions were requested to participate in follow-up assessment of problems associated with alcohol and health. The type and severity of alcohol problems experienced by patients who scored positive on the CAGE are described. Prevalence of a positive score on the CAGE was 8.6 percent with males, smokers, and blue collar and unemployed persons being more likely to score positive. The positive predictive value was .68. Primarily, persons with moderate alcohol problems were identified. Results show that the CAGE instrument is a useful screening device for identifying those with mild to moderate substance abuse problems, increasing the opportunity for intervention prior to serious medical complications. The instrument is easily administered, and has demonstrated relatively high levels of sensitivity and specificity. When combined with assessment and motivational interviews, the CAGE shows promise in the secondary prevention of substance abuse and related health problems.     

The Farm Crisis and Mental Health: A Longitudinal Study of the 1980s1

Abstract This paper examines rural/urban differences and trends in mental health during the farm crisis of the 1980s in a large panel sample from a midwestern state. A community research perspective, which attributes differences to life styles, culture, and community context, is contrasted with an economic stress perspective, which focuses on individual differences in economic circumstances as determinants of rural-urban differences in mental health. Survey samples from 1981, 1986, and 1989 are used to examine differences among seven categories of community type. Multiple regression analysis of the trend and panel data provide support for both the individual economic distress and community context models.     

Will taxpayers ever like taxes?: Responses to the U.S. Tax Reform Act of 1986

Major policy changes like the 1986 Tax Reform Act (TRA) in the United States provide natural experiments to study attitudinal and behavior responses to law. Surprisingly, public evaluations of the TRA became increasingly negative after passage, while general support for the tax system became more positive in response to the changes. To explain this puzzle, we propose a dynamic model of taxpayer attitudes that is consistent with the observed loose linkage between logically-connected concepts. We briefly review the political context, objectives and impacts of the 1986 Tax Reform Act, and present several studies testing the impact of self-interest, prior beliefs, and social discussion on changes in attitudes and behavior.Results suggest that the complexity of taxes and difficulty in knowing objective impacts weakens the role of self-interest in attitudinal changes, thereby strengthening the role of prior beliefs and discussion. Evaluations of tax laws are most responsive to more politically-oriented influences.     

Informal Work in Nonmetropolitan Pennsylvania1

Abstract It is well recognized that the informal economy—unregulated economic activities that generate real or in-kind income—features prominently in the day-to-day lives of many in the developing world. Researchers have begun to explore the informal economy in developed countries but this work has focussed primarily on urban areas to the neglect of rural areas. In this paper the nature and correlates of informal work in nonmetropolitan Pennsylvania are described through an analysis of survey data on 505 families. Results indicate that participation in informal activities is widespread, is not more typical of the poor, does not contribute greatly to family income on average but does help many poor families weather difficult economic times, is both economically and noneconomically motivated, and, net of other sociodemographic variables, is positively related to rurality of residence and formal labor supply.     

Estimation of noncentrality parameters

We propose some estimators of noncentrality parameters which improve upon usual unbiased estimators under quadratic loss. The distributions we consider are the noncentral chi-square and the noncentral F. However, we give more general results for the family of elliptically contoured distributions and propose a robust dominating estimator.     

Effects of Medicaid managed care policies on mental health service use among a national probability sample of children in the child welfare system

Children in the child welfare system are dependent upon Medicaid to finance services for their considerable mental health needs. This study examines the effects of Medicaid policies on mental health service use among a national probability sample of children in the child welfare system. Data for this study came from the National Survey of Child and Adolescent Well-Being, the Caring for Children in Child Welfare study, and the Area Resource File. Weighted multivariate logistic regression analyses were conducted to estimate effects of policy variables on children's use of mental health services, controlling for child-level covariates and county-level health resources. Children in counties with behavioral carve-outs under Medicaid managed care had lower odds of inpatient mental health service use. Medicaid managed care enrollment and variations in type of provider reimbursement did not affect use of mental health services. Older age, greater need for mental health services, and higher levels of caregiver education were associated with increased odds of service use. Restrictions on use of inpatient mental healthcare caused by behavioral carve-outs may disproportionately affect children in the child welfare system who have high rates of such use. Careful adoption of carve-outs is necessary to assure appropriate care for these children.     

Low dose risk estimation via simultaneous statistical inferences

Summary.  The paper develops and studies simultaneous confidence bounds that are useful for making low dose inferences in quantitative risk analysis. Application is intended for risk assessment studies where human, animal or ecological data are used to set safe low dose levels of a toxic agent, but where study information is limited to high dose levels of the agent. Methods are derived for estimating simultaneous, one-sided, upper confidence limits on risk for end points measured on a continuous scale. From the simultaneous confidence bounds, lower confidence limits on the dose that is associated with a particular risk (often referred to as a bench-mark dose ) are calculated. An important feature of the simultaneous construction is that any inferences that are based on inverting the simultaneous confidence bounds apply automatically to inverse bounds on the bench-mark dose.