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Table 3 shows the selected parameter estimates from the second-stage estimation. As discussed, the adjusted Wald tests of whether the coefficients of the [lambda]''s were zero were the tests for the endogeneity of having a regular doctor or site. The last column of Table 3 reports the result of the joint tests. The endogeneity of having a regular doctor or site was present for flu shots, blood pressure checkups, and cholesterol level checkups. No selection biases were found in the equations of pap smears or mammograms within the past two years.As described before, the effects of having a regular doctor ([I.sub.d]) and having a regular site ([I.sub.s]) conditional on the choice of a usual source of care are [gamma]1 + ([[alpha].sub.d][[lambda].sub.d] - [[alpha].sub.0][[lambda].sub.0]) and [gamma]2 + ([[alpha].sub.s][[lambda].sub.s] - [[alpha].sub.0][[lambda].sub.0]), respectively. These two effects are show in Table 4. Marginal effects of having a regular doctor and a regular site on the probabilities of receiving preventive services were reported. The [lambda]''s were calculated for each individual based on the predicted probabilities from the first-stage estimation. Because the [lambda]''s vary by individuals, the averages of the [lambda]''s were used in calculating the marginal effects.

The sample composition of the 15,501 individuals is shown in Table 1. Predisposing variables were age, gender, race, ethnicity, education, marital status, region of residence, and MSA (Metropolitan Statistical Area) status. For need variables, individuals'' general health status was used. Family poverty level and insurance status were included as enabling factors. Having insurance was defined as having coverage for physician and hospital services. Insurance status was grouped into: no insurance for 12 months, insured for 1-11 months, insured for 12 months by different types of plans, and insured for 12 months by the same plan. The probabilities of having no usual source of care, having a regular doctor, and having a regular site in the first stage were estimated by a multinomial logit model. In the selection stage, a reduced-form estimation was employed. The probabilities of having no usual source of care, a regular doctor, and a regular site were predicted for each individual. These probabilities were then transformed into the endogeneity correction terms. Whether an individual had children and the total number of conditions the children had were included as two additional exogenous variables appearing only in the selection stage.

[H.sub.1]: Veterans Affairs nursing homes differ in their implementation of QI practices.Determinants of quality improvement implementation have been actively investigated. Zinn and colleagues (1998) have hypothesized that nursing homes adopt QI as a management tool in response to environmental pressures as conceptualized by resource dependence and institutional theory. They found that perceived competition, the Medicare share of hospital discharges in the market, and the Medicare census within the nursing home were associated with QI adoption. These factors, though, are likely to be less important in the VA.Studies from nonnursing home settings have demonstrated that organizational culture, those values, beliefs, and norms of an organization that shape its behavior, is an important determinant of QI implementation (Parker et al. 1999; Shortell et al. 1995). Shortell et al. reported that the implementation of QI practices among hospitals is associated with a group! developmental culture, that is, a culture where innovation, risk-taking, and teamwork are highly valued. This finding makes sense intuitively since in health care delivery organizations, QI represents a substantial departure from traditional quality assurance methods. For a health care organization to implement QI successfully, employees must be willing to take chances and learn new ways of doing their work. Moreover, because QI in health care settings requires communication among employees from different clinical disciplines, a culture that emphasizes teamwork also seems essential. The generalizability of this earlier research to nursing homes, where much care is provided by aides with little formal education and clinical training, is uncertain. We therefore test the hypothesis:

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