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PubMed1978

Duration of hospitalization for bacteremic infections at Boston City Hospital during 12 selected years between 1935 and 1972.

In survivors of both community-acquired (CA) and hospital-acquired (HA) bacteremic infections at Boston City Hospital during 12 selected years between 1935 and 1972, the mean hospital stay fluctuated widely from one selected year to the next, but it was generally shorter and early discharges were more frequent in the years when effective antibacterial agents were used. The greatest reduction in hospital stay occurred by 1941. The size of the fluctuations and reductions also varied with the causative organism. The average duration of hospitalization of all survivors of HA bacteremic infections after the first positive blood culture was 10.5 days longer than the total hospitalization of survivors of CA infections. The reduced length of hospital stay after 1935 is attributed to the successful use of effective antibacterial drugs, and the greater effect in CA than in HA cases is attributed to more frequent infections in the latter with organisms resistant to those drugs.

Boston↗
PubMed2002

Traffic injury data, policy, and public health: lessons from Boston Chinatown.

We note that long-standing land use and transportation policy are critical factors in creating traffic conditions and will have to play a role in reducing injuries. We present the historical progression of events that created current traffic conditions in Boston Chinatown and an analysis of traffic-related injuries at the community level for the years 1996-1998. Injuries were found to be as likely on weekends as on weekdays and frequently occurred late at night. Nighttime occupant injuries were found to be more likely on Friday, Saturday, and Sunday nights (relative risk = 2.26; confidence interval = 1.35-3.78, P =.0014). Injuries varied significantly by location for occupant (P = <.001) and for pedestrian injuries (P =.039). There were no peaks of injuries at traditionally defined commuter hours, which have been the standard time for assessing "worst case" traffic impacts by developers and government agencies. There was, however, a strong association between injuries and vehicle volume at 9 intersections with simple configurations for AM and PM commuter hours (R(2) = 0.589, P =.010), resulting in a calculated increase of 3-5 injuries per year for each increase of 1,000 vehicles. There was no such association at 10 intersections with complex configurations (R(2) = 0.104, P =.397). The 24-hour weekend patterns of vehicle volumes showed that traffic abated only between 3 and 7 AM, and the patterns appeared qualitatively to mirror the 24-hour pattern of injuries, suggesting that they were also indicative of injury risk. We suggest that there is a need for both long-term changes in policy and more immediate interventions. We also conclude that researchers should be cautious about assuming that traffic patterns conform to naive expectations such as rush hour peaks.

Accidents, Traffic↗
PubMedDate not supplied

Duration of hospitalization for acute bacterial meningitis at Boston City Hospital during 12 selected years, 1935-1972.

An analysis is presented of the duration of hospitalization of the patients with acute bacterial (purulent) meningitis which occurred at Boston City Hospital during 12 selected years between 1935 and 1972. Considerable differences in the length of stay in the hospital were noted depending on the bacterial etiology, whether the infection was present on admission or acquired within the hospital, and, of course, whether the patient survived or died. Most of the deaths occurred within the first few days after admission or after the diagnosis was first established, but even among fatal cases, the survival time differed depending on the etiology and site of acquisition of the infection. During the years after effective antibiotics became available the hospital stay of patients who survived after admission for meningococcal, influenzal, or pneumococcal meningitis was shorter than before. The same has not been true for meningitis caused by other gram-positive cocci, gram-negative rods, or mixed infections, probably reflecting the relative ineffectiveness of antimicrobial therapy in such patients.

Acute Disease↗
PubMed1992

Participatory management at Boston's Beth Israel Hospital.

In the mid-1980s, the senior management of Boston's Beth Israel Hospital became concerned that continuous cost-cutting efforts could lower the quality of the hospital's services and the morale of its staff. This led them to investigate organizational approaches to "participatory management" to determine whether any of these might be of value to the hospital. They decided that an approach developed in the 1930s called the "Scanlon Plan" would be compatible with the workplace culture of Beth Israel, could help the hospital meet the ongoing problems of change, and could help the staff at all levels develop a sense that they owned the problems of quality, productivity, and efficiency, which would motivate them to address these problems constructively in the face of necessary budget constraints. This plan has two mechanisms to foster employees' positive participation: (1) a process to ensure that all members of the organization have the opportunity to improve productivity, primarily through an open suggestion system and a responsive committee structure, and (2) a means of providing equitable rewards for all members of the organization as productivity and quality improve. This essay describes in some detail the plan and why it was selected, explains how it was adapted, prepared for, and finally implemented in 1989, and reports its success, lessons learned, and future plans as of early 1992. The authors believe Beth Israel's experience with the Scanlon Plan is noteworthy as an example of a leading teaching hospital's taking a quality improvement program seriously and making it work.

Attitude of Health Personnel↗
PubMed1999

Debt management and financial planning support for primary care students and residents at Boston University School of Medicine.

Boston University Medical Center created the Office of Residency Planning and Practice Management as part of The Robert Wood Johnson Foundation's Generalist Physician Initiative. Since 1995, the office has improved the medical center's ability to promote and support the generalist career decisions of its students and residents by removing indebtedness as a disincentive. After a brief review of the relationship between indebtedness and specialty selection, the authors delineate the nature and volume of debt-management assistance provided by the office to students and residents through individual counseling sessions, workshops, and other means between April 1995 and March 1998. A case study shows the progression of these services throughout residency training. The medical center also coordinates its debt-management assistance with counseling from physician-oriented financial planning groups. In conclusion, the authors discuss several characteristics of a successful debt-management program for residents.

Boston↗
PubMedDate not supplied

Primary care for persons with disabilities. The Boston, Massachusetts model program.

Boston's Community Medical Group (BCMG) was among the first primary care group practices to provide community-based continuous primary care to people with major disabling conditions, the first to rely on nurse-practitioners as primary care-givers, and one of the first to provide care on a prepaid capitated basis. With more than one thousand person-years' experience, BCMG has demonstrated that it is ethically and operationally feasible (1) to provide prepaid managed care to people with major disabling conditions; (2) to share financial risk for that care with providers; (3) to reinforce principles of independent living and consumer autonomy; (4) to assure high-quality clinical outcomes at reasonable costs.

Boston↗
PubMed1994

Utilization of formal and informal home care by AIDS patients in Boston: a comparison of intravenous drug users and homosexual males.

The assumption that intravenous (i.v.) drug users have weaker informal support networks than homosexual men has led to opposing policy recommendations: one emphasizes outreach and more formal (paid) home care for i.v. drug users, whereas the other maintains that formal home care programs are less effective for this risk group due to the lack of informal (unpaid) caregivers to coordinate efforts. Data from interviews with a sample of 231 persons with AIDS in the Boston area were used to compare the use of formal and informal home care between the two largest risk groups, homosexual men and i.v. drug users. Multivariate regression analysis was also employed to adjust estimates and to determine the significance of population characteristics in explaining utilization differences. IV drug users received about twice as much formal and informal home care as homosexual men. Controlling for functional status, income and assets, insurance and potential caregiver supply, i.v. drug users obtained significantly fewer formal home care services, but more informal care. Overall, i.v. drug users received a greater number of adjusted home care hours. These findings cast doubt upon the previous assumptions of the literature and suggest that members of both risk groups are appropriate candidates for formal home care services.

Acquired Immunodeficiency Syndrome↗
PubMed1996

The influence of health-related quality of life and social characteristics on hospital use by patients with AIDS in the Boston Health Study.

OBJECTIVES: The authors examine whether health-related quality of life (HRQL) and social factors were independent predictors of future hospital use for persons with acquired immunodeficiency syndrome (AIDS). METHODS: A panel of 305 patients with AIDS treated at three provider settings in the Boston, Massachusetts area were enrolled during 1990 and 1991. Data were collected at baseline study enrollment and again 4 months later. Patient interviews, hospital bills, and medical charts were used to measure hospital use (admissions and days during the 4 months after enrollment), sociodemographic characteristics (age, gender, race, education, insurance, homelessness, alcohol use, and AIDS risk factors), disease burden (patient severity and a three-level opportunistic diseases and complications score), HRQL (patient-reported symptoms, activities of daily living, neuropsychological status, and global health assessment), system of care, and use of prophylactic drugs. Logistic regression was used to estimate the odds of admission. Total days of hospital care by patients with at least one admission were analyzed using multiple linear regression. Clinical models of hospital use were developed first from the variables measuring disease burden and system of care. Models estimating the associations between hospital use and all other predictor variables measured at baseline then were estimated using stepwise techniques, controlling for variables in the core model. RESULTS: Patients were more likely than their reference groups to be hospitalized if they had serious opportunistic diseases (adjusted odds ratio [OR] = 2.7), had poorer neuropsychological status (OR = 1.9), were non-white (OR = 2.0), or were homeless (OR = 3.3) (all P < or = 0.05). Activities of daily living were associated moderately (OR = 1.3; P = 0.07). Only system of care and neuropsychological status predicted total hospital days. CONCLUSIONS: The results indicate that future hospital use by persons with AIDS may be influenced by social and other health-related factors in addition to the more clinically related characteristics that are recorded in a medical chart. It therefore may be appropriate to assess these factors when considering options for intervention or when comparing patterns of use among patient groups or settings.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Interest among gay/bisexual men in greater Boston in participating in clinical trials of preventive HIV vaccines.

To estimate interest in HIV preventive vaccine trials, we administered questionnaires to two otherwise demographically similar cohorts of older (mean 40 years) and younger (mean 23 years) gay men in Boston. Questionnaire responses were linked to concurrent behavioral and demographic data. Univariate analyses, performed separately for older and younger cohorts, identified factors that distinguished participants who were "very interested" from those who were "not at all interested". Multivariate logistic regression analyses were used to adjust for confounding. Among all 630 participants, 215 (34%) were "not at all" interested in participating, 306 (49%) were "somewhat" interested, and 102 (16%) were "very" interested. Older men were significantly more likely than younger men to be "very" interested and less likely to be "not at all interested." Among both older and younger men, perceived peer willingness to enroll in vaccine trials predicted interest after adjusting for confounding. Among older men, optimism about success in vaccine development also predicted interest. In the younger cohort, men recruited in community settings (e.g., bars, nightclubs) were more interested in vaccine trial participation than were those recruited by outreach workers and word of mouth on college campuses. Vaccine-induced seroconversion evoked significant concern.

AIDS Vaccines↗
PubMed1998

Costs and outcomes of AIDS care: comparing a health maintenance organization with fee-for-service systems in the Boston Health Study.

OBJECTIVE: A 4-month observational cohort study was performed to compare the performance of one health maintenance organization (HMO) with two fee-for-service (FFS) systems in Boston, Massachusetts in treating 255 patients with AIDS. MAIN OUTCOME MEASURES: Total 4-month costs; cost subcomponents, including inpatient, outpatient, home care, and zidovudine costs; functional status (difficulties with activities of daily living); and satisfaction with care. RESULTS: Compared with FFS patients, HMO patients were better educated, more often white, less often on Medicaid, and more often reported homosexual or bisexual behaviors as HIV risk factors (all factors, p = .001). Both groups had similar duration of AIDS, baseline hemoglobin levels, and leukocyte counts. Total 4-month costs at the HMO were significantly lower than those in the FFS settings ($4799 U.S. versus $8540 U.S.; p = .013), as were outpatient costs ($1131 U.S. versus $1614 U.S.; p = .001), after adjustment for sociodemographic factors, baseline functioning, main HIV risk factor, and other clinical variables. Adjusted physical functioning (p = .32) and patient satisfaction (p = .82). were similar between systems. CONCLUSIONS: The HMO had significantly lower total costs without any observable decrement in functional outcomes or patient satisfaction. The largest component of these cost savings came from reduced spending on inpatient care, but the HMO also spent less on outpatient and home care. Better coordination of care at the HMO may have been responsible for these lower costs.

Acquired Immunodeficiency Syndrome↗
PubMed2002

Treatment of infantile fibrosarcoma with chemotherapy and surgery: results from the Dana-Farber Cancer Institute and Children's Hospital, Boston.

PURPOSE: To retrospectively evaluate the treatment and outcome of patients diagnosed with infantile fibrosarcoma at the Dana-Farber Cancer Institute and Children's Hospital, Boston. PATIENTS AND METHODS: Between 1982 and 1998, a total of 11 infants were diagnosed pathologically with infantile fibrosarcoma. A retrospective chart review was conducted to determine the extent of surgical therapy and chemotherapy required for a favorable clinical outcome. Cytogenetic findings were reviewed and archived tumor specimens were analyzed, when available, for the presence of the TEL/TRKC fusion gene. RESULTS: Three patients had primary surgical resection with negative pathologic margins and have been lost to follow-up. Two patients received chemotherapy only after limited biopsy or subtotal resection and are alive with no evidence of disease 8 and 18 years from diagnosis. Four patients had limited biopsies followed by chemotherapy with delayed resection. One of these four patients had negative margins and received no further chemotherapy. The other three of these patients had positive microscopic margins; two of them received postoperative chemotherapy while the third did not. All four are currently alive with no evidence of disease. Two patients had progressive disease within 7 and 10 months of diagnosis while on chemotherapy after subtotal resections. One of these two patients is dead of disease; the other is alive after palliative radiotherapy. Seven patients had archived or frozen tissue available for molecular analysis. All seven had evidence of TEL gene rearrangement; six exhibited the TEL/TRKC fusion. Six patients had characteristic trisomies previously reported to be associated with infantile fibrosarcoma. CONCLUSIONS: Previously reported series of treatment outcomes in infantile fibrosarcoma have been limited to very few patients due to the rare occurrence of this tumor. In our experience, initial chemotherapy combined with surgery has been successful for most cases. When disease progression occurred, it was within one year of diagnosis. There was no development of distant metastases in the patients with progressive disease. The role of additional chemotherapy for microscopic margins after local control is not clear. We found a high incidence of the TEL/TRKC fusion gene, confirming its utility in diagnosis. We propose a uniform approach to treatment to gather clinical and biologic information about this rare and curable disease.

Boston↗
PubMed1999

Relationship of lead in drinking water to bone lead levels twenty years later in Boston men: the Normative Aging Study.

Tap water in a city like Boston, which has old houses containing lead plumbing, is known to be a significant source of potential lead exposure. Bone lead levels integrate exposure over many years, and in vivo bone lead measurements have recently become possible with the advent of K x-ray fluorescence instruments. Thus we examined the relationship between first morning tap-water lead levels measured in homes in the 1970s and levels of lead in bone measured in the 1990s among middle-aged to elderly men who lived in those homes. We studied 129 participants in the Normative Aging Study who had lead measured in their homes' tap water in 1976 and 1977 by graphite furnace-atomic absorption spectrophotometry. From 1991 to 1995, the same subjects had blood lead levels measured by graphite furnace-atomic absorption spectroscopy and tibia and patella bone lead levels measured by K x-ray fluorescence. We ran multivariate linear regression models predicting bone lead levels that adjusted for factors which had previously been linked with this outcome in the Normative Aging Study (age, pack-years of smoking, and educational level). Among subjects who lived in houses with > or = 50 micrograms lead/liter of first morning tap water representing water that had been standing overnight in the plumbing in 1976 and 1977, those who reported medium or high levels of tap-water ingestion (> or = 1 glass/day) had progressively higher patella lead levels than did those with low levels of ingestion (< 1 glass/day). No such relationship was found among subjects who lived in houses with < 50 micrograms lead/liter of first morning tap water in 1976 and 1977. We conclude that ingestion of lead-contaminated tap water is an important predictor of elevated bone lead levels later in life.

Adult↗
PubMedDate not supplied

Local collaborations: development and implementation of Boston's bioterrorism surveillance system.

The Boston Public Health Commission developed and implemented an active surveillance system for bioterrorism and other infectious disease emergencies. A bioterrorism Surveillance Task Force was formed with representatives from local emergency medicine, infection control, infectious diseases, public health, and emergency medical services. These local agencies worked together to develop a reliable, easy to use electronic surveillance system. Collaboration at the local level and building on existing relationships is a key component of this system. Effective follow-up systems and technology back-up plans are essential. Improved communication networks and increased bioterrorism education for clinicians and the general public have also been achieved.

Bioterrorism↗
PubMed2000

A comparison of organic and conventional fresh produce buyers in the Boston area.

Food safety concerns and the demand for organically grown produce have increased significantly in the United States over the last decade. Key differences in lifestyle characteristics, food safety attitudes and beliefs, perceived food safety risks, and valuation of health risk reductions between organic and conventional food buyers remain largely unknown, however. To better characterize how buyers of organic fresh produce differ from their conventional counterparts, over 700 food shoppers were sampled from ten major retail stores in the Boston area. Survey results show that self-reported organic buyers are more likely than conventional buyers to engage in a variety of health-promoting and environmentally friendly behaviors. Organic buyers are less trusting of federal food safety agencies than are conventional buyers, and perceive greater benefits associated with organically grown produce than do their conventional counterparts. Further, organic buyers have significantly higher risk perceptions than do conventional buyers for food safety hazards associated with conventionally grown produce. Compared to conventional buyers, organic produce buyers also perceive significant risk reductions associated with switching to organically grown produce and are willing to pay a higher price to reduce perceived food safety risks. Few sociodemographic differences between buyer types were observed, possibly due to how organic and conventional food stores were matched. Survey findings highlight the need for greater public education about a range of food safety issues and farming practices to ensure that consumers are making informed decisions in the marketplace.

Attitude↗
PubMed1993

The Boston FICSIT study: the effects of resistance training and nutritional supplementation on physical frailty in the oldest old.

Research indicates that lower extremity muscle weakness in the elderly is consistently related to impaired mobility and fall risk. Reversible components of the muscle weakness of aging include underuse syndromes and undernutrition, both of which are prevalent in nursing home populations. The Boston FICSIT study is a nursing home-based intervention to improve muscle strength through progressive resistance training of the lower extremities and/or multi-nutrient supplementation in chronically institutionalized subjects aged 70-100. Baseline measurements of falls, medical status, psychological variables, functional status, nutritional intake and status, body composition, muscle mass and morphology, muscle function, and gait and balance are taken. The nursing home residents are then randomly assigned to one of four treatment groups for 10 weeks: (1) high intensity progressive resistance training of the hip and knee extensors 3 days per week; (2) multi-nutrient supplementation with a 360-kcal high carbohydrate, low fat liquid supplement every day; (3) a combination of groups (1) and (2); and (4) a control group. Both non-supplemented groups receive a liquid placebo every day, and both non-exercising groups attend three sessions of "leisure activities" every week in order to control for the attentional aspects of the exercise and nutritional interventions. At the end of the 10-week period, all baseline measurements are re-assessed.

Aged↗
PubMed1976

A community health center dental program in Boston, U.S.A.

In 1970, a community-based and federally funded dental program was established in Boston. The multiple objectives of this program included the following: provision of dental treatment; education of schoolchildren in dental health; support for community measures of prevention such as water fluoridation; support of job training programs in dental assisting for community residents; employment of community people; and sensitization and training in community health for dental students and auxiliaries. The program provided a number of dental services at a reasonable benefit-cost ratio of 0.87. Other endeavors included the development of a dental health program with community schools and the involvement of dental students in the delivery of care and in screening for children with dental treatment needs.

Adolescent↗
PubMed1995

Dental caries in homeless adults in Boston.

OBJECTIVES: Information about the oral health status of the homeless is limited. The purpose of this study is to characterize the dental caries status among users of a dental treatment and referral program at homeless shelters in Boston, MA. METHODS: Persons attending the program during a one-year period were assessed for evidence of dental caries experience by a single examiner. DMFT counts were abstracted from patient records. RESULTS: The population examined (n = 73) was 66 percent male with a mean age of 36 years. The racial composition was 51 percent African-American, 34 percent Caucasian, and 14 percent Hispanic. The 70 dentate people examined had a mean DFT of 11.1 (SD = 6.1). The mean percent of DFT that was DT per person was 55.7 percent. Untreated caries was detected in 91.4 percent of those examined. CONCLUSIONS: These findings show evidence of previous dental services utilization by these homeless individuals, but demonstrate a high need for preventive and restorative dental therapy.

Adult↗
PubMed1972

Water pollution: organic compounds in the Charles River, Boston.

The major lipophilic organic compounds present in water collected during November and December 1971 from the Charles River Basin (Boston) are as follows: normal alkanes (C(15) to C(31)), alkyl naphthalenes, alkyl anthracenes or phenanthrenes, pyrene, fluoranthene, dibutyl phthalate, and di(2-ethylhexyl) phthalate. The concentration of the naphthalenes (determined by liquid chromatography) correlates with the effective storm-water runoff content of the river. These data suggest a multiplicity of sources ranging from indigenous biological materials to automobile exhaust condensate.

Alkanes↗