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Evaluating partnerships for community health improvement: tracking the footprints.

Private-public partnerships are increasingly seen as an important mechanism for improving community health. Despite their popularity, traditional evaluations of these efforts have produced negative or mixed results. This is often attributed to weak interventions or an insufficient period of time to observe an impact. This study examines two additional possibilities--the need for a well-articulated shared vision and the governance and management capabilities of the partnership itself. We conducted a midstream process evaluation of twenty-five community partnerships associated with the Community Care Network (CCN) Demonstration Program. We examined how the roles of a common shared vision, strong governance, and effective management influence a partnership's ability to achieve its objectives. The findings, based on both qualitative and quantitative analyses, underscore the importance of membership organizations' perceived benefits and costs of participation and management capabilities to the partnership's progress toward a vision. Based on the qualitative data, six key governance and management characteristics are identified that separate the top performing partnerships from the lowest performing ones. We explore the implications of this research for future evaluations of public-private community health partnerships.

Community Health Planning↗

High-tech software sleuthing. New computer tools give government tighter handle on hard-to-track healthcare fraud.

After developing new data-mining techniques, the government no longer needs to rely on outdated methods when investigating allegations of hard-to-track healthcare fraud. Today, federal officials, such as U.S. Deputy Attorney General Eric Holder Jr. (left), have an enhanced ability to collect and analyze massive amounts of financial and medical information necessary to successfully prosecute perpetrators of crimes that drain the Medicare program.

Aged↗

Change practice patterns without ruffling feathers.

When physicians act as change agents among their peers, they encounter many of the same resistances that quality improvement professionals face. Practice guidelines are one of several keys to influencing doctors to bring their utilization rates in line with their peers. Good data are another must-have tool for achieving physician buy-in on changing care practices. Most doctors pay attention to peer influence and pressure when it comes to changing their familiar care practices. Physicians report that sometimes the motivation to change springs from the desire to stave off external controls by payers and the government.

Algorithms↗

Social deprivation, income inequality, social cohesion and dental caries in Brazilian school children.

This ecological study investigated the associations between social deprivation, income inequality and social cohesion and dental caries levels in school children of the Distrito Federal, Brazil. Three sources of data were used: (1) area-based data from a 1997 social survey carried out on 13,000 families, (2) 1995 census data collected for the Government of the Distrito Federal (GDF), and (3) dental caries data from a 1997 oral health survey on 7296 6-12-year-old school children. Results of simple linear regression showed that percent with less than eight years of education (P = 0.03) and percent who did not have a maid (P = 0.009), were negatively statistically significantly associated with the percent of children free of caries. None of the deprivation measures were statistically significantly associated with mean DMF-T scores (P > 0.05). GINI coefficient, an indicator of social inequalities, was negatively statistically significantly associated with both measures of dental caries experience, percent of caries free (P = 0.003) and mean DMF-T scores (P = 0.01). Per thousand number of homicides or attempted homicides, an indicator of social cohesion was of marginal statistical significance associated with caries experience. Results of multiple linear regression analyses showed that only the Gini coefficient remained statistically significantly associated with both dental clinical measures used, after adjusting for potential confounding. In conclusion, relative rather than absolute levels of income were stronger determinants of the onset of caries in this study.

Brazil↗

Genetics in cancer care: confronting a Pandora's Box of dilemmas.

PURPOSE/OBJECTIVES: To provide an overview of sociopolitical, bioethical, and psychological issues emerging from the application of genetic technologies in cancer care in the United States and to provoke oncology nurses to consider the impact that advances in genetics may have on their practice. DATA SOURCES: Published professional articles, tests, and proceedings as well as government and lay publications. DATA SYNTHESIS: This article reviews underlying sociopolitical issues and forecasts bioethical dilemmas and psychological responses likely to emerge from expanding genetic screening and treatment options in oncology. The sociopolitical issues revolve around individual rights, the role of government, and the influence of religious dogma and public perception. The bioethical dilemmas fall within a framework of five scenarios, and a range of psychological responses are described. CONCLUSIONS: Significant changes will occur in cancer care as a result of advances in genetic technology. These changes will be accompanied by a new set of dilemmas in clinical practice and by as yet undescribed psychological responses. In addition to building a knowledge base relevant to these new technologies, oncology nurses must anticipate the new dilemmas and be prepared to manage the emotional responses of their patients. NURSING IMPLICATIONS: Nurse are in a strategic position to make significant contributions to the genetics data base by designing and conducting research to describe the ethical dilemmas and patient/family responses engendered as genetic science is integrated into cancer care.

Bioethics↗

Medicare wants more encounter data.

Two years ago, the federal government began requiring managed health plans to submit encounter data for their Medicare members. This data requirement has been expanded for 1998. Encounter data are intended to replace the claims-based information that Medicare loses when beneficiaries switch from fee-for-service providers to managed care plans. Encounter data are needed for a variety of purposes.

Data Collection↗

Medicare program; reissuance of the wage index in the 1981 schedule of limits on hospital per diem inpatient general routine operating costs--HCFA. Proposed notice.

We are reissuing for public comment the change in the types of data that were used to calculate the wage index that was contained in the schedules of limits on hospital per diem inpatient general routine operating costs reimbursable under Medicare that were applicable to cost reporting periods beginning on or after July 1, 1981 and for cost reporting periods ending after September 30, 1981. The cost limits for cost reporting periods beginning on or after October 1, 1982 are governed by the notice published in the Federal Register on September 30, 1982 (47 FR 43296) and August 30, 1983 (48 FR 39426) and are not affected by this reissuance. The wage index was originally issued as part of the schedule of limits published on June 30, 1981 (46 FR 33637) and September 30, 1981 (46 FR 48010) and is being reissued as the result of the April 29, 1983 decision of the United States District Court for the District of Columbia in the case of District of Columbia Hospital Association, et al. v Heckler, et al. (No. 82-2520 DDC). The District Court held that the 1981 schedule of hospital cost limits was invalid for failure to comply with the Administrative Procedure Act insofar as the schedule incorporated or was formulated by using a wage index that was calculated by excluding Federal government hospital wage data.

Centers for Medicare and Medicaid Services, U.S.↗

[Making census data accessible to local users in the public and private sectors].

The authors outline ways in which government statistical offices can make census data available to local public- and private-sector users. Several computer programs, including REDATAM-Plus and Geographical Information Systems, are discussed. "The successful implementation of the use of the census data at the local level will require that...national agencies facilitate the institutionalization of technology transfer by providing, among other things, technical support, training at a distance, data and cartography standards, and solutions to data protection issues." The geographical focus is on Latin America and the Caribbean. (SUMMARY IN ENG)

Americas↗

The cost of childhood asthma to Australian families.

There have been no estimates of the actual cost of asthma care to Australian families. Previous estimates have been of the total cost to the community and have relied upon data collected by government departments and agencies. It was the aim of this investigation to estimate the cost of childhood asthma from the parents perspective in Australian families. A total of 238 asthmatic children aged 8-12 years were identified through prevalence studies of asthma in Sydney and Belmont, N.S.W. Children were selected if they had wheezed in the previous 12 months, had used asthma medicines or had airway hyperresponsiveness when tested. The study sample had a wide range of asthma severity. Data were collected retrospectively and prospectively. Parents completed a questionnaire which asked about health insurance and special asthma equipment costs in the previous 12 months. Every 2 weeks for a total of 3 months between February and June parents completed further questionnaires which assessed costs incurred because of their child's asthma, together with time spent obtaining treatment. Items included doctor consultations and tests, alternative practitioner consultations and tests, medications and alternative therapies purchased, hospital and ambulance use, and the cost of childcare as a consequence of asthma. We collected two or more months of prospective data from a total of 193 children. The mean annual cost of asthma to the family was A$212.48 per asthmatic child and 13.4 hr were spent obtaining treatment. For the group of children who had not visited a doctor in the previous year, the mean annual cost was A$85.60 and 13.1 hr were spent obtaining treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Asthma↗

Cost of malaria control in China: Henan's consolidation programme from community and government perspectives.

OBJECTIVE: To assist with strategic planning for the eradication of malaria in Henan Province, China, which reached the consolidation phase of malaria control in 1992, when only 318 malaria cases were reported. METHODS: We conducted a prospective two-year study of the costs for Henan's malaria control programme. We used a cost model that could also be applied to other malaria programmes in mainland China, and analysed the cost of the three components of Henan's malaria programme: suspected malaria case management, vector surveillance, and population blood surveys. Primary cost data were collected from the government, and data on suspected malaria patients were collected in two malaria counties (population 2 093 100). We enlisted the help of 260 village doctors in six townships or former communes (population 247 762), and studied all 12 325 reported cases of suspected malaria in their catchment areas in 1994 and 1995. FINDINGS: The average annual government investment in malaria control was estimated to be US$ 111 516 (case-management 59%; active blood surveys 25%; vector surveillance 12%; and contingencies and special projects 4%). The average cost (direct and indirect) for patients seeking treatment for suspected malaria was US$ 3.48, equivalent to 10 days' income for rural residents. Each suspected malaria case cost the government an average of US$ 0.78. CONCLUSION: Further cuts in government funding will increase future costs when epidemic malaria returns; investment in malaria control should therefore continue at least at current levels of US$ 0.03 per person at risk.

Animals↗

Shigellosis remains an important problem in children less than 5 years of age in Thailand.

This is a review of existing data on the burden of shigellosis in Thailand to determine trends, vulnerable groups, predominant species and serotypes, and antimicrobial resistance patterns. Diarrhoea and dysentery morbidity and mortality data from 1991 to 1999 was collected from the routine surveillance system and demographic data from the government census. International and local literature published between 1988 and 2000 was systematically reviewed. Based on the routine surveillance system, the annual incidence of bacillary dysentery decreased from 1.3 to 0.2/10,000 persons per year. The remaining burden is highest in children <5 years of age at 2.7/10,000 persons per year. In comparison, a prospective study utilizing active surveillance found an incidence in children <5 years of age that was more than 100-fold higher at 640/10,000 persons per year. Despite the decrease in morbidity and mortality based on routinely collected data, shigellosis remains an important problem in children <5 years of age in Thailand.

Child Health Services↗

A computer program suitable for analysis of choice of categories in biomedical data recognition problems.

The optimum choice of categories in problems of medical data recognition is governed by the choice of categories, the selection of appropriate features, and by the choice of a loss function. Under these circumstances it is often difficult to find out the suitable classification scheme. The computer program described here serves for the design of the optimum recognition procedure. The Bayes rule is used as decision rule. A criterion for the comparison of different choice of categories is given. The program can be performed after estimation of the underlying prior probabilities and the conditional densities obtained from a training set, and before testing the decision rule with real data.

Classification↗

Prevalence of diabetes mellitus and population attributable fractions for coronary heart disease and stroke mortality in the WHO South-East Asia and Western Pacific regions.

The aims of this study were to obtain the most recent representative data for the prevalence of diabetes in adult populations in the World Health Organisation's South-East Asia and Western Pacific regions and to quantify the contribution of diabetes to the burden of mortality from cardiovascular diseases in these regions. Previous reports indicate that there are 83 million individuals with diabetes in the Asia-Pacific region, but since many of the country-specific estimates were not from nationally representative studies, this figure may not accurately reflect the current burden of diabetes. Information on the prevalence of diabetes was obtained by searching Medline and government health websites. Data were available from 12 countries representing 78% of the total population of the Asia-Pacific region. Six of 10 countries with complete data reported a prevalence of diabetes exceeding those estimates currently cited by the World Health Organization; three of which have also already exceeded the World Health Organization projections for 2030. In the 12 countries in the region with nationally representative data, the prevalence of diabetes ranged from 2.6% to 15.1%. Hazard ratios from the Asia Pacific Cohort Studies Collaboration were used to calculate population attributable fractions for diabetes for fatal cardiovascular diseases in the region. Population attributable fractions ranged from 2% to 12% for coronary heart disease, 1% to 6% for haemorrhagic stroke, and 2% to 11% for ischaemic stroke. Accurate estimates of the prevalence of diabetes are of great importance and standard methods are needed for periodic surveillance across the Asia-Pacific region and elsewhere.

Adolescent↗

The impact of Federal Alcohol and Drug Abuse block grants on state and local government substance abuse program expenditures: the role of federal oversight.

Are the federal Alcohol and Drug Abuse (ADA) block grant funds substituting for or supplementing state and local government spending on substance abuse? Using panel data on state and local government substance abuse programs, this study explores the fiscal effects of the ADA block grant money and the increased enforcement (after 1989) of federal restrictions on state spending of ADA block grants. The findings here reveal that for the current period, the federal ADA grant has no statistically significant effect on state and local government substance abuse spending both before and after 1989, and the increased enforcement of federal restrictions on the ADA grants after 1989 does not change this result. An additional finding is that lagged ADA grants have had a large effect on substance abuse spending both before and after 1989--a feature of the program not considered in previous studies.

Financing, Government↗

A comparison of mail, telephone, and home interview strategies for household health surveys.

The method of data collection in household health surveys can be a major determinant of cost and data quality. A survey strategy can comprise mail, telephone, or home interview methods, individually or in combination to follow up non-respondents. The purpose of this study in Montreal was to compare cost and data quality of various strategies. Strategies which began with mail or telephone contact, followed by the two other methods, provided response rates as high as a home interview strategy (all between 80 and 90 per cent), for one-half the cost of home interviews when used as the sole method. The telephone response rate was higher than the mail response rate. Comparing different follow-up approaches to strategies beginning with mail or telephone, it proved less costly, and equally effective, to use home interviewing as a last resort for persistent non-respondents. Validity of response (comparing individual responses with records of a government health insurance data bank) and willingness to answer sensitive questions were greatest in mail strategy.

Canada↗

Firearm-related death and injury among children and adolescents.

As the articles in this journal issue show, gun violence affects children and youth in many ways: psychologically, emotionally, financially, and legally. But first and foremost, gun violence affects children's physical safety. Therefore, this issue opens with an overview of the physical toll that firearms exact upon children and youth, reviewing the incidence of firearm-related injury and death among Americans under age 20. This article analyzes trends and current status in firearm death and injury, based on nationwide data collected by the federal government. Several key findings emerge from the data: Firearm death rates among children and youth in the United States have declined dramatically since 1993, but remain high compared with historical rates in this country and rates in other developed nations. A majority of these deaths are homicides. Certain groups of children and youth, especially adolescents, boys, minority youth, and those residing outside the Northeast, are particularly at risk for firearm death. The problem is most acute among black teenage males. Firearm injuries are much more likely to result in death than are other injuries for which children and youth visit emergency departments--a reflection of the extreme lethality of firearms. Given these findings, the authors call for a concerted effort to reduce youth firearm deaths to levels comparable to those of other industrialized nations, using a wide variety of approaches that span the public health, criminal justice, and educational spheres. They also recommend improved data systems to track firearm injury and death, so that researchers can better analyze these incidents and evaluate intervention strategies.

Accidents↗

Grieving and death rituals of Latinos.

PURPOSE/OBJECTIVES: To describe the grieving behaviors and selected death beliefs and rituals for two Latino groups: island Puerto Ricans and Mexican immigrants. DATA SOURCES: Published articles, book chapters, books, government documents, and clinical experience. DATA SYNTHESIS: Limited scientific research exists on the grieving process and beliefs about death of Latinos. Death is seen as an extension of life in some Latino cultures, a belief that seems to assist positively in the grieving process. Rituals and ceremonies to honor the dead still are practiced in many Latino cultures and are rooted partly in their cultural heritage. CONCLUSIONS: Nurses caring for Latinos with cancer can provide better care with an understanding of grieving behaviors observed early in the disease process and at the time of imminent death. IMPLICATIONS FOR NURSING PRACTICE: Culturally competent care can be given when beliefs and values about death are understood. Allowing Latino clients to grieve and honor the dead in a culturally appropriate way will enhance the nurse/client/family relationship.

Cultural Characteristics↗

Rating threat mitigators: faith in experts, governments, and individuals themselves to create a safer world.

This research explores public judgments about the threat-reducing potential of experts, individual behavior, and government spending. The data are responses of a national sample of 1225 to mail surveys that include measures of several dimensions of public judgments about violent crime, automobile accidents, hazardous chemical waste, air pollution, water pollution, global warming, AIDS, heart disease, and cancer. Beliefs about who can best mitigate threats are specific to classes of threats. In general, there is little faith that experts can do much about violent crime and automobile accidents, moderate faith in their ability to address problems of global warming, and greater expectations for expert solutions to the remaining threats. People judge individual behavior as effective in reducing the threats of violent crime, AIDS, heart disease, and automobile accidents but less so for the remaining threats. Faith in more government spending is highest for AIDS and the other two health items, lowest for the trio of violent crime, automobile accidents, and global warming, and moderate for the remaining threats. For most threats, people are not distributed at the extremes in judging mitigators. Strong attitudinal and demographic cleavages are also lacking, although some interesting relationships occur. This relative lack of sharp cleavages and the generally moderate opinion indicate ample opportunity for public education and risk communication.

Adult↗