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PubMed1999

[Optimized programming of sustained rate duration in patients with implantable cardioverter-defibrillators and diagnosed atrial fibrillation].

The discrimination of supraventricular versus ventricular tachycardias by an implantable cardioverter-defibrillator (ICD) is still a remaining clinical problem. The false positive detection of supraventricular as ventricular tachycardias causes inadequate electrical therapies of the ICD. To improve the increase of specificity criterias like "Onset" or "Stability" are offered. If these criterias during tachycardia are not fulfilled, the "sustained rate duration" (SRD) is offered as a security criterion. The SRD reasons the delivery of the therapy during tachycardia after a programmable time. Aim of the study was to evaluate, if SRD in patients with known arrhythmia absoluta (AA) in atrial fibrillation and programmed "Onset"/"Stability" increases the sensitivity without loss of specificity in the treatment of hemodynamically tolerated ventricular tachycardias and which programming should be chosen. Our patient collective included 274 patients (pts) with new implanted ICD of the third generation. In 39 (14%) pts AA was known in the medical history. From these 39 (100%) pts, 18 (46%) pts had known tachyarrhythmic episodes (group I) in the area of the ventricular tachycardia-zone > or = 160 beats per minute, whereas in 21 (54%) pts a tachyarrhythmia absoluta (TAA) was unknown (group II). During follow-up of 12 +/- 8 (2-26) months, 151 tachycardias occurred and could be classified as supraventricular tachycardias by stored electrograms. In 9/18 pts of group I, a TAA occurred during follow-up. The initial programmed SRD during first TAA was 62 +/- 39 (35-90) s and was prolonged to 135 +/- 64 (90-180) s. After this prolongation, no inadequate therapy was delivered. In group II, 19/21 (90%) were inadequately treated during TAA. The initial SRD-programming was 45 +/- 28 (0-90) s and was prolonged to 201 +/- 150 (60-480) s during follow-up. After prolongation of the SRD, no more inadequate therapies due to AA were delivered. In pts with new implanted ICD and known TAA, which is hemodynamically tolerated, the SRD should be programmed beside all other available detection parameters for improving the increase of specificity at least 135 s to avoid inadequate therapies of the ICD. In pts with unknown TAA, SRD should be prolonged to 135 s at least the second tachyarrhythmic episode, which is hemodynamically well tolerated.

Adolescent↗
PubMedDate not supplied

Effects of a health promotion program on sustaining health behaviors in older adults.

BACKGROUND: Controversy exists regarding the optimal way to provide health promotion education to the elderly. This prospective randomized study evaluated the effectiveness of individualized assessment and counseling coupled with the receipt of a written health plan on client adherence to health behavior recommendations. METHODS: Two hundred thirty-seven ethnically diverse and predominantly low-income adults 60 and older, participating for the first time in an established statewide public health prevention program delivered in both rural and urban clinics, were recruited and randomly assigned to treatment and control groups. All participants received a standardized assessment that included a health history, nutrition assessment, and limited physical exam from a public health nurse. The treatment group additionally received a written personal health plan and individualized counseling to support implementation of the plan. Both groups were interviewed after one year to determine their adherence to the original recommendations. RESULTS: Seventeen preventive services and health behaviors were evaluated. There were no statistically significant differences between the groups on health care use and previous health behaviors at baseline. Using logistic regression and controlling for socioeconomic and demographic variables, we found that the treatment group that received a personal health plan and counseling completed significantly more preventive referrals and health behavior changes (P < .001). CONCLUSIONS: A client-centered planning process with supportive counseling by public health nurses, combined with health plans provided to clients, can significantly increase the prevention measures taken by older adults.

Aged↗
PubMed2006

Diffusing a research-based physical activity promotion program for seniors into diverse communities: CHAMPS III.

INTRODUCTION: Increasing the physical activity levels of older adults through diffusion of successful research-based programs into community settings is challenging because of differences between research and real-world settings. This project diffused the Community Healthy Activities Model Program for Seniors (CHAMPS) II, an individual-level research-based physical activity promotion program, through three community organizations to reach lower-income and minority (primarily Hispanic or Latino and African American) seniors. METHODS: Through an academic-community partnership, university staff worked with each organization to adapt the program to be appealing and effective, enable their staff and volunteers to provide the program, increase participants' physical activity, and leave sustainable programs in place. Evaluation was based on methods recommended by the Centers for Disease Control and Prevention. RESULTS: The adapted programs, referred to as CHAMPS III, differed from the original program and among organizations. Group-based components and resource guides were included and new features were added; however, individualized components were not offered because of limited resources. A total of 321 people enrolled among three organizations; there was a trend toward increased physical activity at two organizations (an estimated increase of 481 kcal/week [P = .08] and 437 kcal/week [P = .06] expended in physical activity). Evaluation revealed challenges and unexpected community-level benefits. All organizations are continuing efforts to promote physical activity for older adults. CONCLUSION: This project enabled community organizations to implement physical activity promotion programs. The overarching challenge was to retain original program features within each organization's resources yet be sustainable. Although the programs differed from the original research program, they were a catalyst for numerous community-level changes. Our findings can guide similar projects to reach underserved older adults.

Aged↗
PubMed2003

New Moves: a school-based obesity prevention program for adolescent girls.

BACKGROUND: This study tests the feasibility of an innovative school-based program for obesity prevention among adolescent girls. New Moves was implemented as a multicomponent, girls-only, high-school physical education class. METHODS: Six schools were equally randomized into intervention and control conditions. Data were collected at baseline, postintervention, and 8-month follow-up to assess program impact on physical activity, eating patterns, self-perceptions, and body mass index (BMI) among 89 girls in the intervention and 112 girls in the control conditions. Program evaluation also included interviews with school staff, parent surveys, and participant interviews and process evaluation surveys. RESULTS: The feasibility of implementing New Moves was high, as indicated by strong satisfaction among participants, parents, and school staff, and by program sustainability. Participants perceived a positive program impact on their physical activity, eating patterns, and self-image. Girls in the intervention significantly progressed in their stage of behavioral change for physical activity from baseline to follow-up. However, for the majority of outcome variables, differences between intervention and control schools at postintervention and follow-up were not statistically significant. CONCLUSIONS: New Moves was well received and fills a needed niche within school physical education programs. An expanded intervention and evaluation is needed to enhance and assess long-term program effectiveness.

Adolescent↗
PubMed2004

Effects of sustained audit/feedback on self-reported health status of primary care patients.

PURPOSE: Because limited audit/feedback of health status information has yielded mixed results, we evaluated the effects of a sustained program of audit/feedback on patient health and satisfaction. METHODS: We conducted a group-randomized effectiveness trial in which firms within Veterans Administration general internal medicine clinics served as units of randomization, intervention, and analysis. Respondents to a baseline health inventory were regularly mailed the 36-Item Short Form (SF-36) and, as relevant, questionnaires about six chronic conditions (ischemic heart disease, diabetes, chronic obstructive pulmonary disease, depression, alcohol use, and hypertension) and satisfaction with care. Data were reported to primary providers at individual patient visits and in aggregate during a 2-year period. RESULTS: Baseline forms were mailed to 34,050 patients; of the 22,413 respondents, 15,346 completed and returned follow-up surveys. Over the 2-year study, the difference between intervention and control groups (as measured by difference in average slope) was -0.26 (95% confidence interval [CI]: -0.79 to 0.27; P=0.28) for the SF-36 Physical Component Summary score and -0.53 (95% CI: -1.09 to 0.03; P=0.06) for the SF-36 Mental Component Summary score. No significant differences emerged after adjusting for deaths. There were no significant differences in condition-specific measures or satisfaction between groups after adjustment for provider type, panel size, and number of intervention visits, or after analysis of patients who completed all forms. CONCLUSION: An elaborate, sustained audit/feedback program of general and condition-specific measures of health/satisfaction did not improve outcomes. To be effective, such data probably should be incorporated into a comprehensive chronic disease management program.

Aged↗
PubMedDate not supplied

Hospital charges for a community inpatient palliative care program.

Defining financial parameters of palliative care (PC) is important for providing sustainable programming. In our study, we evaluated hospital length of stay (LOS) and charges for the first 164 inpatient PC consultations performed by the Advanced Illness Assistance (AIA) team at Blount Memorial Hospital (BMH). These AIA patients had a median LOS of 11 days (range, 3-114 days), mean total charges per patient of 65,795 dollars, and mean daily charges of 3,809 dollars. Higher mean daily charges (p = 2.74 E-08, chi-square) were associated with patients who received consultation because of nonphysical symptom reasons. Patients were followed in PC consultation (AIA follow-up days) for a median of five days (range, 1-48), and had mean daily charges of 3,117 dollars. These mean daily charges were 414 dollars less than the charges for the five days prior to PC consultation (pre-AIA days) (p = 0.04, t-test). There was a significant decrease in laboratory and imaging charges during AIA follow-up (p = 0.04, t-test). The study included a reference group of patients whose information was obtained retrospectively from the BMH Atlas (MediQual, Marlborough, MA) database. These reference group patients were hospitalized at BMH during the same time, but they were not seen by the AIA team. The reference group was matched by Diagnosis Related Group (DRG), Admission Severity Grade (ASG), and disposition to the AIA patients. The Atlas patients had a shorter median LOS of six days (range, 1-105 days), and significantly greater mean daily charges of 4,105 dollars (p = 0.006, t-test) compared with AIA patients. Mean daily charges decreased for Atlas patients, as their day of discharge approached (p < 0.001). Estimates of potential charge savings were calculated in two ways: 1) by evaluating the effect of decreasing the LOS of Atlas patients with long LOS (more than seven days) to the level of AIA patients with long LOS, and 2) by comparing the actual mean patient charges during AIA follow-up with using the pre-AIA mean daily charges during the AIA follow-up period and correcting for the effect of decreasing charges that occurred as discharge approached. The estimated savings achieved by decreasing long LOS were more than 100,000 dollars per year, and estimated savings achieved using AIA follow-up charges were more than 1,801,930 dollars per year.

Adult↗
PubMed2005

A longitudinal perspective on monitoring outcomes of an innovative program.

OBJECTIVES: The use of outcome assessment to evaluate the performance of programs over many years of operation is becoming an increasingly important aspect of health care management. Over a five-year period of program monitoring, this study examined changes in individual client outcomes three months after discharge from a residential work therapy program for veterans with severe substance use disorders. The study also examined the relationship between these outcomes and changing program features, such as staffing, treatment variables, and follow-up rates. METHODS: Data on admissions characteristics, services delivered during treatment, and status at discharges were collected for 3,390 veterans who were treated in 25 sites in the Department of Veterans Affairs' Compensated Work Therapy/Transitional Residence program. Follow-up data were gathered three months after discharge for 1,771 veterans (52.2 percent). Hierarchical linear modeling was used to examine the association between year of discharge, site-level measures of program staffing and follow-up rate, and individual patient-level treatment variables and outcomes. RESULTS: Over the five-year monitoring period, site staff-to-bed ratios and follow-up rates dropped substantially, and veterans attended more Alcoholics Anonymous and Narcotics Anonymous meetings and had more toxicology screens. Higher staff-to-bed ratios were associated with more positive employment outcomes, and higher follow-up rates were associated with poorer outcomes in substance abuse and lower total income. However, no significant outcome trends were observed in clinical follow-up measures after the analyses adjusted for these factors, suggesting that program effectiveness did not deteriorate during a period of program change. CONCLUSIONS: Long-term evaluations of program process and follow-up status can usefully document sustained program effectiveness over many years. Such efforts should enhance their value by examining and adjusting for the impact of factors such as changing staffing levels and follow-up rates.

Adult↗
PubMed2006

Preventing sexually transmitted infections among adolescents: 'the glass is half full'.

PURPOSE OF REVIEW: Given the disproportionate burden of sexually transmitted infections for adolescents, there is an urgent need to identify effective prevention programs. RECENT FINDINGS: This review documents the efficacy of recent sexually transmitted infection-prevention programs. Overall, the review identified few sexually transmitted infection-prevention trials published since 2000. Moreover, considerable variability in program efficacy was observed across studies. Some studies observed changes in sexually transmitted infection-associated risk behaviors, while only a few identified reductions in biologically confirmed sexually transmitted infections. In general, few programs demonstrated consistency of effects and a significant magnitude of effects across a broad range of outcomes. SUMMARY: New and innovative approaches are needed to amplify sexually transmitted infection intervention effects. Program development and evaluation needs to continue in a coordinated, scientifically rigorous fashion to optimize impact and, as important, to sustain effects over protracted periods. Furthermore, for interventions with demonstrated efficacy, a critical challenge is to translate them into sustainable programs that are widely disseminated. Ultimately, preventing sexually transmitted infections in adolescents does not only depend on the development of effective interventions alone, but on how effectively these interventions can be translated and integrated into self-sustaining components of clinic, school or community programs, particularly in those areas and among adolescent populations most adversely impacted by the epidemic of sexually transmitted infection.

Adolescent↗
PubMed1997

Pesticide use, exposure, and risk: A joint Israeli-Palestinian perspective.

The major predictors of health risk from pesticide exposure are quantity and toxicity of pesticides reaching end-users, field workers, and persons (including children) with casual and indirect exposures to field and food residues, drift, and contaminated groundwater. Past work in Israel and the Palestinian National Authority has documented risks for acute poisoning, daily illness, transient neurotoxic effects, and potential cancer hazards in workers, populations exposed to pesticide drift, and the general population. Risk assessment predicts that reduction in use of agents with high toxicity and pesticide substitution are desired strategies for achieving the largest reductions in risk, but successful implementation and program sustainability depend on maintaining crop yield and increasing farmer earnings. A joint pilot Israeli-Palestinian-NGO program aims to determine whether crop yields and profits can be sustained while reducing pesticide use, promoting integrated pest management, and restricting ecosystem damage. The project involves six components: (1) assessments of health risk and crop yield in relation to pesticide use and exposure; (2) training health-agricultural teams to introduce and evaluate crop growth and managements with reduced pesticide use; (3) tracing and stopping import and trade in banned or restricted pesticides; (4) restricting child labor; (5) promoting information delivery and worker and community right-to-know and right-to-act; and (6) establishing a uniform regional standard for protection of workers and the general public. Preliminary evidence (organochlorines and breast cancer, organophosphates and illness in field workers) indicates that (1) a reduction of use is the foremost determinant of a reduction in health risk; (2) cotton yield can be increased despite a reduction in pesticide use (organophosphates); and (3) a reduction in pesticide use (organophosphates and organochlorines) has to be part of a crop rotation program for food crops timed to seasonal fluctuations in supply, demand, and crop price.

Agricultural Workers' Diseases↗
PubMed2000

Future prospects of voluntary health insurance in Thailand.

Voluntary health insurance schemes in Thailand are still under development and have yet to seriously address the questions of equity and efficiency, while private health insurance is limited to people who can afford the premium. One form of insurance, commonly known as the health insurance card scheme, was first introduced as the Health Card Program in 1983. This program is based on risk sharing of health expenditures, with no cost sharing, in a voluntary health insurance prepayment scheme. With the uncertain performance of the Thai economy, program sustainability and the efficient use of resources are major concerns. The Health Card Program needs enough enrollees to ensure a sufficient pool of risks. This study looks at health card purchase and utilization patterns, using data from Khon Kaen Province, and finds that employment, education levels and the presence of illness are significant factors influencing card purchase. The last factor is related to the problem of adverse selection of the program; families with symptoms of sickness are more likely to buy cards, resulting in greater use of health services. The results also show an improvement in accessibility to health care and a high level of satisfaction among card holders, both key objectives of the program. It is suggested that changes in the health card system could enable it to evolve into a community-based compulsory health insurance scheme for rural areas.

Adolescent↗
PubMed2001

Maintaining quality of care in a comprehensive dual diagnosis treatment program.

This paper describes how a large, multifaceted dual diagnosis treatment program has attempted to preserve its mission through termination of or changes in the nature of resident research projects. Research reports, because of their focus on specific treatment components, often fail to capture the essence of the larger treatment contexts from which they emanate. Although host programs derive benefits from research projects, enhancements are often temporary and difficult to sustain. Programs are thus challenged to respond to resource losses creatively. The author discusses adaptations to losses in the areas of case management, behavioral skills training, an incentive system, money management, and continuity of care.

Case Management↗
PubMed1997

Telemedicine in support of peacekeeping operations overseas: an audit.

BACKGROUND AND OBJECTIVE: Since 1993, the Department of Defense has augmented the medical support for Army units on peacekeeping operations in Macedonia through the medium of telemedicine. This project, known as Operation Primetime 1, was the first satellite-based telemedicine system deployed in support of remote primary-care physician in the U.S. military. Its declared aims are: (1) to improve the standard of care; (2) to reduce evacuations; (3) to support junior physicians in the field; and (4) to improve the military effectiveness of the deployed units. This paper audits the success in attaining those goals for the period January 1994 to April 1995. METHODS: A log was collated from the referring units and questionnaires completed by both referring and consulting physicians. The referring physicians were interviewed on their return from Macedonia, and a more detailed study was undertaken of cases in which a change in outcome was noted. Follow-up interview of consultants was not possible. RESULTS: A total of 53 consults were undertaken on 47 patients. The use of telemedicine affected the decision to evacuate 13 times (13/47), with a net reduction of 9 evacuations. Management of individual cases was changed in 30 of the 47 cases in which telemedicine was used. Physician confidence and military effectiveness were also improved. The level of utilization of the system was largely dependent on a training and sustainment program. Units and General Medical Officers who were trained in the clinical use of telemedicine and the technical sustainment of the equipment used the system; those who were not, did not. Most patients (45/47) were treated satisfactorily with a single consult. Telemedicine under these circumstances seems to be cost effective. The deployed sites chose the referral centers that provided the best service. CONCLUSIONS: Telemedicine is a valuable tool capable of augmenting medical support to deployed military units. A successful deployed telemedicine project requires an integrated support package that includes adequate provision for training and equipment sustainment at both ends of the link. Experience with telemedicine in Operation Primetime indicates the potential for substantial cost savings as well as cost-effective medical care. Further application of telemedicine should be encouraged. Successful deployment of telemedicine projects may hinge on an integrated support package.

Europe↗
PubMed1989

A nontraditional supportive services program: VNA independence plus.

The Visiting Nurse Association (VNA) of Texas received a grant from the Robert Wood Johnson Foundation to develop a financially self-sustaining program of nontraditional, homebased supportive services for the elderly in March 1987. The new, fee-for-service program, VNA Independence Plus, used market research to develop a service package that would meet the needs of area elderly. Services offered include housekeeping, transportation, yard care, and handyman services.

Aged↗
PubMed2000

Failure of a brief educational program to improve interpretation of pulmonary artery occlusion pressure tracings.

OBJECTIVE: To determine whether a brief educational program can reduce variability of interpretation of pulmonary artery occlusion pressure (PAOP) tracings. DESIGN: Prospective, observational study. PARTICIPANTS: Twenty-three intensive care nurses and 18 physicians. INTERVENTIONS: Participants interpreted PAOP tracings before and 1 week after receiving a single, brief educational session and/or written materials ("in-service") designed to reduce interobserver variability of PAOP interpretation. Differences between two reference values before and after in-service (mean population and Chief of Critical Care's readings) were compared for both groups. RESULTS: There were no significant differences in the variabilities in PAOP interpretations before and after in-service in either group. CONCLUSIONS: We conclude that this specific educational program was ineffective in reducing variability of interpretation of PAOP tracings. These data suggest that more comprehensive educational tools and/or sustained programs may be required to improve performance of critical care personnel in PAOP interpretation.

Cardiology↗
PubMed2006

Programming CD8+ T cells for effective immunotherapy.

The differentiation state of CD8+ T cells has emerged as a crucial determinant of their ability to respond to tumor and infection. Signals from T-cell receptors, co-stimulatory molecules and cytokine receptors direct the differentiation process. These signals 'program' sustained and heritable gene expression patterns that govern progressive differentiation and lineage commitment. The epigenetic mechanisms by which T cells are programmed are just beginning to be elucidated. Understanding the mechanisms that control CD8+ T-cell differentiation is important in the development of novel immunotherapy strategies.

Animals↗