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PubMed2000

Financial impact of a home intravenous antibiotic program on a medicare managed care program.

This study quantitates cost savings achieved by a home intravenous antibiotic (HIVA) program in a Medicare managed health care program. In 1998, 66 treatment courses of HIVA therapy were administered for a total of 1542 patient-days of therapy. The calculated cost of HIVA therapy included the actual costs of drugs, supplies, nursing and therapists' salaries, and laboratory studies. Savings were calculated based on the average daily direct variable cost (DDVC) for hospital acute unit or skilled nursing facility (SNF) care associated with the patient's discharge diagnosis-related-group. The number of days on HIVA therapy was assumed to equal the number of days in the hospital acute unit or hospital-based SNF. The average cost per day of HIVA therapy was $122, whereas average DDVC of hospital acute unit care was $798, and the average DDVC of SNF care was $541. In 1 year, the HIVA program saved our health care system $646,000-$834,000, which demonstrates that HIVA programs are powerful tools to reduce costs in Medicare managed health care programs.

Aged↗
PubMedDate not supplied

Objective assessment of dyskinesia in children with cerebral palsy.

The clinical classification of children with cerebral palsy is limited by multiple factors. Distinguishing between spasticity and dyskinesia is critical, because the outcome after standard orthopaedic and neurosurgical interventions is less predictable in children with cerebral palsy who have a significant dyskinetic component. This study applied computer-based analysis of gait to assess objectively the presence of significant dyskinesia in children with cerebral palsy. Three-dimensional gait analysis was performed on 18 normal children, 17 children with principally spastic cerebral palsy, and 23 children with significantly dyskinetic cerebral palsy. Children were assigned to the spastic or dyskinetic groups prospectively, based on clinical analysis by an experienced physician and physical therapist. The children with dyskinesia were found to have a significantly wider, and more variable normalized dynamic base of support, a smaller step profile (step length divided by step width), and a greater and more variable maximal lateral acceleration than the spastic and normal groups (mixed model analysis of variance, p = 0.0001). A predictive model of dyskinesia, (developed by logistic regression analysis), using these gait parameters, exhibited excellent sensitivity, correctly classifying 20 (87%) of 23 children as dyskinetic. This study shows that children with dyskinetic cerebral palsy have distinct gait parameters and that objective assessment of dyskinesia in children with cerebral palsy is possible with computer-based analysis of gait.

Adolescent↗
PubMed1996

Measuring family therapy outcome in a clinical setting: families that do better or do worse in therapy.

This study examined several important family and therapist characteristics as they related to treatment success. A total of 434 families entering family therapy at a sliding-fee clinic in Dallas, Texas were rated (on the Beavers Interactional Competence and Style Scales), and completed several self-report family assessment instruments (Self-Report Family Inventory, FACES III) prior to beginning therapy. The therapists, trainees from various disciplines, had been trained in the Beavers Systems Model. Overall, 75% of the families showed at least some improvement. Those that fared best in therapy were more competent at the outset. While number of therapy sessions was associated with greater gains, there were some families that made great gains in fewer than six sessions. There were important demographic qualities that did not discriminate between greater- vs. lesser-gain families, including income level, ethnicity, therapist gender, and family size. A regression analysis indicated that functional rather than demographic variables were more important in predicting therapy outcome.

Adolescent↗
PubMed1987

The influence of child-preferred activities on autistic children's social behavior.

One of the characteristics of autistic children is severe social avoidance behavior. We assessed whether the type of activity (child-preferred vs. activities that were arbitrarily determined by an adult) engaged in during an interaction was correlated with the amount of social avoidance behaviors these children exhibit. Results revealed a negative correlation between appropriate child-preferred activities and social avoidance behavior. Additional analyses revealed that (a) social avoidance behaviors could be manipulated within a reversal design, and would predictably decrease when the children were prompted to initiate appropriate child-preferred activities; and (b) these procedures could be used to teach children to initiate child-preferred activities in community settings, resulting in reductions in social avoidance responses even after the therapist's prompts were completely removed. These data suggest that the manipulation of task variables may influence the severe social unresponsiveness that is characteristic of autistic children.

Adolescent↗
PubMed1986

Patient, observer and instrument variation in the measurement of strength of shoulder abductor muscles in patients with rheumatoid arthritis using a modified sphygmomanometer.

We describe the use of a modified sphygmomanometer to measure the strength of shoulder abductor muscles. Using a 5 x 5 Greco-Latin square design we compared the measurements of 5 physical therapists taken on 5 patients with rheumatoid arthritis with 2 cuff adaptations. The design variables explained 96.4% of the pressure readings, with patients accounting for 76.6%. There was no significant variation due to order of testing, cuff preparations or observers. The method is simple, portable, inexpensive, comfortable and safe to use. It can also be applied to 26 different muscle groups.

Adult↗
PubMed1979

[The interaction TAT - an auxiliary method in the diagnosis of marital crises].

Out of the need for an auxiliary method, that provides a comprehension representation of matrimonial relationships, the classical TAT procedure was modified to an interactional TAT. The question, whether this modified procedure is suitable as a diagnostic tool, was cause to analyse an extremely selected group of persons. The confirmation of hypotheses deducted from theoretical considerations, permits the statement, that the modified TAT procedure (Interactional-TAT) represents a superior instrument in matrimonial therapy. Its particular merit consists in the variability of tables and the various possibilities of adjustment to the special problem, the therapist is faced with.

Female↗
PubMed2003

Patient depressive symptoms and therapist focus on emotional material: a new look at Project MATCH.

OBJECTIVE: Matching treatment modality to patient attribute generally did not improve outcomes in Project MATCH. Untested was whether actual therapist behaviors, irrespective of treatment modality, interacted with patient attributes to improve outcomes. The present study examined whether patient depressive symptoms interacted with therapist focus on painful emotional material to predict the effectiveness of alcohol treatment. Two competing theoretical approaches to treatment effectiveness were considered in light of the results. METHOD: A self-report measure of pretreatment depressive symptoms was completed by 141 participants from the Providence Clinical Research Unit of Project MATCH. Therapist focus on emotional material was then judged by independent observer ratings of videotaped treatment sessions. The interaction between these patient and therapy variables was tested as a predictor of percentage of days abstinent (PDA) and percentage of heavy drinking days (PHDD) during treatment and over the first year following treatment. RESULTS: The interaction between patient depressive symptoms and therapist emotion focus consistently predicted PDA and PHDD both during treatment and over the first year posttreatment. For patients with clinically elevated depressive symptoms, improved drinking outcomes occurred with a low therapist focus on painful emotional material. Conversely, depressed patients had worse drinking outcomes when the therapist had a high focus on emotional material. Therapist behavior did not affect drinking outcomes for patients with subclinical depressive symptoms. CONCLUSIONS: The interaction between depressive symptoms and therapist focus on emotional material was an important predictor of alcohol treatment effectiveness. The results appear to support a theory in which the reduction of patient arousal is a potential mediator of treatment effectiveness. The consistency and robustness of these findings suggest that matching actual therapist behaviors to patient attributes may improve drinking outcomes more than matching based solely on treatment modality.

Adaptation, Psychological↗
PubMed1994

Swedish physical therapists' beliefs on what makes therapy work.

BACKGROUND AND PURPOSE: The purpose of this study was to find out what practicing physical therapists believe to be the most important factors in successful treatments. SUBJECTS: A national random sample of 187 Swedish physical therapists received the survey instrument by mail. The response rate was 76%. METHODS: On the basis of a pilot interview study and literature review, a survey instrument was constructed consisting of 22 Likert-type items and various demographic variables. RESULTS: The findings indicated that a majority of the respondents believed that the patient's own resources and the patient-therapist relationship rather than the treatment techniques are the most important factors in explaining why physical therapy works. Most physical therapists endorsed a holistic view of treatment (pertaining to the whole person, not just body parts), although significantly more women than men supported this viewpoint. Other background factors had no relationship to the beliefs and attitudes expressed. CONCLUSION AND DISCUSSION: The findings are discussed within the framework of attribution theory, and in the context of viewing physical therapy as an applied biomedical science or a caring profession. In this study, the view of physical therapy as a caring profession prevailed among the majority of the physical therapists.

Adult↗
PubMed1986

[Effect of patient markers and interview procedures on admission to therapy--a catamnestic study of the initial psychotherapeutic interview].

This investigation concerns the individual and institutional factors which play a role in the stratification of therapy and in the selection of patients. To this end, six to eight years after the initial interviews, a catamnestic investigation on one hundred patients was carried out at the Giessen Centre for Psychosomatic Medicine. Identified as variables with a potential for influencing the further career of the patient were individual attributes of the patient and characteristic features of the therapist-patient interaction during the initial interview. A step-by-step multiple correlation analysis was employed to investigate combinations of characteristics in patient and interaction which contribute to the optimal prognosis concerning the variables "admission" and "no admission" to psychotherapy. The combination of predictors is summarized in the case history of a patient in whom suffering has produced a high level of stress, who experiences the disorder as syntonic with his personality, and who possesses a certain ego-strength with regard to self-esteem as well as conceptions of alteration. Such personality traits contribute to the active attempt at finding therapy facilities but simultaneously, in the light of current therapeutic techniques, they are considered desirable qualities in the patient. Thus, there is an interference between the process of decision in the patient and the prognosis-oriented selection of patients within the psychosocial establishment.

Adolescent↗
PubMed1992

The thermodynamics of psychotherapeutic communication.

Given five quantified measures of emotional communication within a psychotherapy session and definitions of work, force and temperature drawn from classical physics, this paper presents calculations of patient and therapist entropy using both the traditional, caloric definition and Shannon's definition, grounded in the work of Boltzmann. Our results depend on the assumption that the patient/therapist system is closed and non-dissipative. We present models for reversible heat absorption and frictional heat dissipation--within the system--which have meaning in emotional communication and psychotherapy. Both calculations of entropy produced a lawful dependence on ln(l+t), where t is time into the session in seconds. The two calculations are essentially the same, verifying in the behavioral domain a law of physics held to be true of material nature. We also verify empirically that the limiting form of the caloric entropy for a purely silent therapist replicates the Shannon entropy for an individual in a monologue. The force field that moves the representations of patient and therapist in 5-dimensional space defines an irreversible process. Thus there are moments of disequilibrium change with respect to the measured variables of emotional communication and at least one moment of disequilibrium between every return to a prior state. This moment may be creative or traumatic. The force field is non-conservative, implying the existence of modalities of heat absorption for patient and therapist which may relate to individual characteristics and reflect human psychological variety. The force field constrains motion to an ellipsoidal shell whose geometry explains the logarithmic growth of Shannon entropy and the finding that the system's absolute temperature grows linearly with respect to time. The finding that the models and methods of physics reveal a degree of lawfulness in the mental/communicative domain as compared to the material speaks strongly for the isomorphic qualities of divergent levels of nature.

Communication↗
PubMed2006

A study of the noninstrumented physical examination of the knee found high observer variability.

OBJECTIVE: This study estimated the inter- and intraobserver reliability of a set of noninstrumented physical examination measures for knee pain in older adults. STUDY DESIGN AND SETTING: Forty-five patients from primary care, and 13 patients from secondary care, were each examined by two out of a team of three physical therapists, and were reexamined by one of these observers 1 month later. The examination items were standardized and included dichotomous, ordinal and continuous variables considered relevant to a primary care context. RESULTS: For individual dichotomous items, median interobserver and intraobserver agreement (kappa) was 0.22 (interquartile range IQR=0.12-0.35) and 0.41 (IQR=0.28-0.56) respectively. For ordinally rated variables, weighted kappa ranged from -0.08 to 0.43 for interobserver agreement, and from 0.00 to 0.79 for intraobserver agreement. The median intraclass correlation coefficient for continuous examination variables was 0.80 (range 0.68-0.89) for interobserver agreement, and 0.84 (range 0.67-0.95) for intraobserver agreement. CONCLUSION: For trained but nonexpert examiners, agreement was generally poor for dichotomous and ordinal examination items; however, kappa-values are liable to be depressed by the low prevalence of clinical signs in this sample. Agreement on continuous variables was notably better.

Aged↗
PubMed1992

Racial/ethnic identity and amount and type of psychiatric treatment.

OBJECTIVE: The purpose of this study was to examine the relationship of racial/ethnic identity to the amount and type of psychiatric treatment received by white, black, Latino, and Asian patients in the Los Angeles County mental health system. METHOD: The patients studied (N = 19,400) consisted of all adult inpatients and outpatients seen in all county mental health facilities between January 1983 and August 1988. Multiple regression analysis was used to test the relationship between race/ethnicity and four measures of treatment received: number of treatment sessions, treatment modality, treatment setting, and therapist's discipline. The covariates included in the analyses were age, sex, socioeconomic status, primary language, diagnosis, and measures of treatment when these were logical predictors and were not acting as dependent variables. RESULTS: Race/ethnicity did not have a consistent significant relationship to the treatment variables studied. However, diagnosis had a consistent and highly significant relationship to all four measures of treatment. A psychotic diagnosis was related to receiving more treatment sessions, greater use of medication, greater use of inpatient treatment, and less treatment by a professional therapist. Socioeconomic status and primary language also had consistent and significant relationships to three of the treatment variables. CONCLUSIONS: In considering modifications to the service delivery system, clinicians must evaluate whether the type of treatment provided to psychotic patients is the treatment of choice in terms of effectiveness and efficiency or whether it involves bias in service delivery. Similarly, the issue of bias in treatment of lower socioeconomic patients must be addressed.

Adolescent↗
PubMed1981

Interaction of therapeutic attitudes with severity of clinical diagnosis.

Investigated whether therapeutic processes, measured by self-reported attitudes of therapists, are differential or generalized; i.e., whether particular types or all types of patients benefit from a given level of a professed technique. Three therapeutic variables (empathic warmth, directiveness, and uncovering), identified by factor analysis, were studied in interaction with two levels of clinical pathology. A total of 161 patients were seen in psychodynamically oriented individual psychotherapy by 22 therapists. Independent ratings of global improvement were made. Results indicated that high scores on empathic warmth and uncovering appear to be more helpful for patients with neurotic and personality trait disorder diagnoses than for patients with borderline and psychotic diagnoses. Low scores on directiveness seemed to be associated with effectiveness in a more general way (across diagnostic groups). For the most part, reference to therapeutic attitudes as helpful or harmful must take into account the particular diagnostic groups that are being treated.

Adolescent↗
PubMed2000

An evaluation of a primary care psychological therapies clinic.

The present study evaluates a primary care psychological therapies clinic providing input one day per week to a GP practice in a rural area of Scotland. Routine data was collected over a 17 month period and a rating scale was used to evaluate treatment outcomes by both GPs and therapist. In addition GP satisfaction with the service was also evaluated. No significant differences were found between counselling and psychology cases on any of the variables examined. Treatment outcome evaluation showed an overall rate of improvement following treatment, with a mean score of 7 on a 1-10 scale, with 10 representing 'much better'. Significant agreement was found between therapist and GP on rating outcome and no significant differences were found between ratings given by psychologist and counsellor. The GPs involved also expressed high levels of satisfaction with the service.

Adolescent↗
PubMed1996

The prophylaxis of depressive episodes in recurrent depression following discontinuation of drug therapy: integrating psychological and biological factors.

Models of long-term treatment in recurrent unipolar illness ideally should integrate both psychological and biological factors. In earlier reports we noted that high treatment specificity (i.e. good-quality maintenance interpersonal psychotherapy) and high delta sleep ratio were each associated with significantly increased wellness intervals in the absence of pharmacotherapy among patients with recurrent unipolar depression. To determine how these specific factors when taken together are related to length of survival time, we examined the concurrent effects of treatment specificity and delta sleep ratio on wellness intervals using survival analysis. We found significant effects of both treatment specificity and delta ratio on survival time. Seventy-three per cent of the patients in the high treatment specificity/high delta ratio group survived the 3-year trial, while 44% of the patients in the low delta ratio but high treatment specificity group survived. None of those rated low on both variables survived. We also found an effect for individual clinicians on treatment specificity and survival time and noted that the prophylactic effect of treatment specificity was maintained even within subsets of therapists grouped by their patients' survival times. Secondary analyses revealed an effect of patient attitudes on treatment specificity and survival time, although, when taken together, treatment specificity was the only variable remaining significantly associated with outcome. We conclude that patients remain well the longest when pre-treatment delta sleep parameters more closely approximate those of non-depressed individuals and when monthly psychotherapy is of higher quality. The key finding is that high specificity is of significant prophylactic benefit even for patients with a biological vulnerability for recurrence. We also conclude that in addition to therapists, patient expectancies contribute to treatment specificity, and high treatment specificity is, in turn, reflected in longer times to recurrence.

Adult↗
PubMed1990

Using parents as therapists to evaluate appropriate behavior of their children: application to a tertiary diagnostic clinic.

We conducted a preliminary analysis of maintaining variables for children with conduct disorders in an outpatient clinic. Eight children of normal intelligence between the ages of 4 and 9 years were evaluated during 90-min sessions. The children's parents conducted the assessments by varying task demands (easy and difficult) and parental attention (attention and no attention) within a multielement design. The assessment focused on appropriate child behavior and was conducted to formulate hypotheses regarding maintaining contingencies. Results demonstrated that the children's appropriate behavior varied across assessment conditions and, for 7 of the 8 children, occurred at a higher rate during one condition than during other conditions. In addition, treatment integrity data demonstrated that parents were able to implement the procedures as intended. The recommended treatments were rated as being both effective and acceptable to parents for up to 6 months following the evaluation. Our results extend previous studies of functional analytic procedures conducted by trained experimenters with severely handicapped children in more controlled settings.

Attention↗
PubMed1995

Patients dropping out of treatment in Italy.

The aim of this study was to explore the extent and the specific features of drop-out for patients having a first contact with an university psychiatric outpatient clinic in Italy over the course of 1 year and to determine which variables were associated with early termination of treatment. Of the 158 patients selected for this study, there was an overall 3-month drop-out rate following the first visit of 63%. Of the 59 patients who had returned once after the initial contact, 28 interrupted subsequently the treatment, although the therapist's plan included further visits. The overall drop-out rate at 3 months was thus 82%. The only 2 variables associated with drop-out rates were the patients' perception of the severity of their disorder and the psychiatric history: continuing patients were more frequently in agreement with the clinician's judgment as compared with those who dropped out and were more likely to have already been in psychiatric treatment.

Attitude to Health↗
PubMed1987

Drug deprivation and reinforcement by diazepam in a dependent population.

Individuals who were using therapeutic doses (approximately 15 mg diazepam or its equivalent daily) of a benzodiazepine persistently and wished to attempt to stop were recruited into a study offering a medically supported outpatient behavioral treatment with a goal of abstinence. All subjects received the same behavioral treatment that emphasized the development of strategies for coping with abstinence and alternatives to benzodiazepines as a coping mechanism. The goal of abstinence was to be achieved within approximately 8 weeks by means of gradual tapering of the daily dose. Some subjects (Group D, n = 23) were randomly assigned to a condition in which their dose was to be tapered on a regime of active diazepam. Others (Group P, n = 19) were switched to placebo at the first treatment session and "tapered" from this pharmacologically inert substitute for diazepam. Supplies of tablets of each preparation were provided by the experimenters, and subjects were specifically requested to use only those tablets. The principal dependent variable was "supplementation", or use of a benzodiazepine other than that specifically authorized by the therapist. Supplementation was detected by measures of plasma benzodiazepine levels as compared to levels predicted if there had been strict compliance with the therapeutic regime. These comparisons were made by two expert judges who were blind to the subjects' experimental assignment. Self-report of supplementation was also obtained. Plasma level determinations indicated a significantly greater frequency of supplementation (84% versus 33% of subjects) for subjects in Group P.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗