The rate of hospitalizations due to ambulatory care-sensitive conditions (ACSCs) has been widely accepted as an indicator of access and quality of primary care. This study aimed to examine the trends and geographic variation of ACSC hospitalizations in US veterans health-care system, to identify factors associated with ACSC hospitalizations and to develop a quality indicator that can monitor access and effectiveness of primary care at hospital level. Using fiscal years 1997-2007 data, we found total ACSC hospitalizations per 1000 ACSC patients decreased by 58%; ACSC hospitalizations as percentage of total hospitalizations decreased 9%. However, significant geographic variations of ACSC hospitalizations remained and we found that adjustment of case-mix or confounding factors was essential in making meaningful comparisons among hospitals in a health-care system. Further, this study also reveals that low-income veterans still had higher ACSC hospitalization rates and patient travel time less than 30 minutes to the nearest VA providers was associated with fewer ACSC hospitalizations, which possess important policy implications.
Bone marrow aspirate particle smears, biopsy imprints, and biopsy sections were compared to determine the accuracy of the three samples in assessing for overall cellularity, differential cell count, megakaryocyte density, iron stores, and tumor infiltration. Aspirate particle smears and biopsy imprints were stained by Wright-Giemsa method. Aspirate particle smears were also stained with Prussian-blue. Biopsy sections were 1 1/2-2 micron thick and were prepared from non-decalcified plastic embedded samples and stained with combined Prussian-blue-hematoxylin-eosin, and Giemsa. One hundred-eight sets of specimens from 99 patients were examined. In 20 cases, chi-square analysis showed a comparable degree of cellularity (p less than 0.001) and megakaryocyte density (p less than 0.001) among the three preparations. Differential count comparison by regression analysis indicated that mean percentages of neutrophilic cells in the proliferation compartment were comparable in the three groups (p less than 0.01). A better correlation was obtained among the three groups in the percent neutrophilic cells in the maturation-storage compartment, normoblasts, eosinophils, and plasma cells (p less than 0.001). Lymphocytes in the aspirate smears correlated with the biopsy imprints (p less than 0.01) but not with the biopsy sections (p greater than 0.05). Monocytes did not correlate in any of the groups (p greater than 0.05). In 47 cases, chi-square analysis of iron stores in the aspirate particle smears correlated well with those in the biopsy sections (p less than 0.001). Fifty-two marrows that were done for staging nonhematological malignancies revealed malignant cells in 21 cases, biopsy sections were positive in all, biopsy imprints were positive in 19 (90%), and aspirate particle smears were positive in 7 (33%). Thirty-six marrows done for staging non-Hodgkin's lymphoma showed malignant cells in 13 cases. Twelve (92%) biopsy sections, three (23%) biopsy imprints, and nine (69%) aspirate particle smears contained lymphoma cells. In conclusion, a satisfactory evaluation of marrow samples for diagnostic studies can be achieved by examination of biopsy sections along with aspirate particle smears or biopsy imprints. Any of the three marrow preparations alone is not sufficient for accurate diagnosis in all cases. The biopsy imprint is an accurate modality for identifying nonhematological tumor metastasis in the bone marrow.
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