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The use of fiscal intermediaries to police Medicare claims has come under the spotlight, mainly because many of those contractors have themselves settled Medicare or Medicaid fraud charges. One answer: the new Medicare Integrity Program, which will beef up federal fraud fighters.
The suicide of a student or staff member is one of the most difficult crisis confronting a high school. This article describes the first year of a school-based postvention program to train and consult with crisis personnel in a structured response to this crisis. Responding to Loss (RTL) is one program offered by Community Action for Youth Survival, a project of the Ronald McDonald Children's Charities. Serving a contiguous three county urban area, this program integrates public health, epidemiological, psychiatric, and prevention paradigms to provide a comprehensive approach to the aftermath of adolescent suicide. RTL provides an interdisciplinary model for comprehensive, school-based postvention programs based on the guidelines developed by the Centers for Disease Control and national and local psychological autopsy data. It highlights the significance of responding to increased rates of suicide in minority youth, suicide witnessed by peers, and suicide victims who have dropped out of school. Organizational issues, such as systematic school entry, development of a computerized school database, proactive training, and collaboration with the offices of medical examiners and coroners, are described. Initial evaluation data from year 1 indicate significant gains in participants' knowledge and skills, as well as a high rate of consumer satisfaction.
There are at present approximately 110 million people with diabetes in the world but this number will reach over 220 million by the year 2010, the majority of them with type 2 diabetes. Thus there is an urgent need for strategies to prevent the emerging global epidemic of type 2 diabetes to be implemented. Tackling diabetes must be part of an integrated program that addresses lifestyle related disorders. The prevention and control of type 2 diabetes and the other major noncommunicable diseases (NCDs) can be cost- and health-effective through an integrated (i.e. horizontal) approach to noncommunicable diseases disease prevention and control. With the re-emergence of devastating communicable diseases including AIDS, the Ebola virus and tuberculosis, the pressure is on international and regional agencies to see that the noncommunicable disease epidemic is addressed. The international diabetes and public health communities need to adopt a more pragmatic view of the epidemic of type 2 diabetes and other noncommunicable diseases. The current situation is a symptom of globalization with respect to its social, cultural, economic and political significance. Type 2 diabetes will not be prevented by traditional medical approaches; what is required are major and dramatic changes in the socio-economic and cultural status of people in developing countries and the disadvantaged, minority groups in developed nations. The international diabetes and public health communities must lobby and mobilize politicians, other international agencies such as UNDP, UNICEF, and the World Bank as well as other international nongovernmental agencies dealing with the noncommunicable diseases to address the socio-economic, behavioural, nutritional and public health issues that have led to the type 2 diabetes and noncommunicable diseases epidemic. A multidisciplinary Task Force representing all parties which can contribute to a reversal of the underlying socio-economic causes of the problem is an urgent priority.
From August 1978 to December 1983, 51 insulin-dependent diabetic patients with end-stage renal disease were selected for treatment by continuous ambulatory peritoneal dialysis. There were 27 male and 24 female patients, with a mean age of 52.3 +/- 13.5 years. Forty-five patients dialyzed themselves by continuous ambulatory peritoneal dialysis and six were treated by continuous cyclic peritoneal dialysis. All patients were treated at home. The cumulative duration of treatment was 65.6 patient-years; 14 patients were dialyzed for at least 24 months. Extrarenal complications were frequent at start of continuous ambulatory peritoneal dialysis, including hypertension in 48 patients, proliferative retinopathy in 50, and cardiovascular complications in 30. Age appeared to be the major risk factor, with success rates at 2 years of 78% in patients under age 50 years and only 50% in patients over age 50. The main cause of death was vascular and the main cause of transfer to other therapeutic modalities was abdominal complications or malnutrition or both. Excellent control of blood pressure, uremia, and blood glucose levels was obtained on a daily program of four exchanges. Improvement in visual status was frequently observed, mainly in the young population. In patients with juvenile diabetes, continuous ambulatory peritoneal dialysis should be part of an integrated program with transplantation, while in the elderly, the method offers a unique opportunity for them to treat themselves at home.
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As healthcare quality assurance programs grow, so too does the need to gather and provide vast amounts of information. To meet this challenge, QA programs have turned to the use of computer systems. As this article makes clear, QA automation involves more than simply the purchase of computer hardware and software. Much time, planning, research, preparation, testing, and education are required to create an effectively automated QA program. The author provides a realistic review of the major stages and elements of the QA automation process, beginning with the search for appropriate software and concluding with the diversification possibilities of a fully integrated program.
OBJECTIVE: To report long-term effectiveness of the Positive Action program. METHODS: Used matched-schools design and school-level achievement and disciplinary data to evaluate program effects on student performance and behavior in elementary schools. RESULTS: Participation in the Positive Action program improved student behavior, school involvement, and academic achievement at all 3 levels of schools, with the results showing a clear dose-response relationship. CONCLUSION: Results provide clear evidence that a coherent, comprehensive, and integrated program can have enduring effects in multiple domains.
Postulating that a program integrating language skills with other aspects of cultural knowledge could assist in developing medical students' ability to work in cross-cultural situations and that partnership with targeted communities was key to developing an effective program, a medical school and two organizations with strong community ties joined forces to develop a Spanish Language and Hispanic Cultural Competence Project. Medical student participants in the program improved their language skills and knowledge of cultural issues, and a partnership with community organizations provided context and resources to supplement more traditional modes of medical education.
To understand the coverage, strategy and cost of hepatitis B (HB) vaccination of China in recent years, a randomized two-stage household sampling survey was carried out at 112 Disease Surveillance Points(DSPs) from 25 provinces, autonomous regions and municipalities of China in 1996. Results showed that the rates of HB vaccination coverage among neonates were 96.9% in the urban DSPs and 50.8% in the rural DSPs in 1993-1994, while in 7-9 year-old students both rates were 85.8% and 31.5% in 1994, respectively. Up to 1994, 97.5% of the urban DSPs and 73.9% of the rural DSPs had a neonates vaccination against HB program integrated with routine EPI. Some of the DSPs had a lower neonates coverage due to insufficient amountad unreasonable distribution of the vaccine (used for adults) and high cost. It seems necessary to evaluate the maternal prescreening program regarding the quality of serological testing to HBVMs. Remarkable achievements have been made in terms of strategy development and planning on HB immunization in China.
OBJECTIVE: To determine whether health care providers are satisfied with an integrated program of mental health care. DESIGN: Surveys using a mailed questionnaire. Surveys were developed for each of the three disciplines; each survey had 30 questions. SETTING: Thirty-six primary care practices in Hamilton, Ont, participating in the Hamilton-Wentworth Health Service Organization's Mental Health Program. PARTICIPANTS: Family physicians, psychiatrists, and mental health counselors providing mental health care in primary care settings. MAIN OUTCOME MEASURE: Satisfaction as shown on 5-point Likert scales. RESULTS: High levels of satisfaction with the model were recorded. Family physicians increased their skills, felt more comfortable with handling mental health problems, and were satisfied with the benefit to their patients. Psychiatrists and counselors were gratified that they were accepted by other members of the primary care team. Areas for improvement included finding space in primary care settings and better scheduling to allow for optimal communication. CONCLUSION: Family physicians, counselors, and psychiatrists expressed great satisfaction with a shared mental health care program based in primary care.
Quality management and quality control of health services have become increasingly important. Central to the concept of quality of care is the consumer's (the patient's) own view of the care provided. UKU (Udvalg for Kliniske Undersøgelser), a task force within the Scandinavian Society for Psychopharmacology, has designed a brief consumer satisfaction rating scale, the UKU-ConSat. The UKU-ConSat rating scale was applied in a randomised comparative two-year study of two community-based treatment programs. The study included 84 patients with schizophrenic disorders according to DSM-IV. The major finding was a significantly increased consumer satisfaction with the new community-based program "Integrated Care" in comparison with best-established practice, called "Rational Rehabilitation." Thus, the new UKU-ConSat rating scale can detect differences, not only for in-patients as has previously been shown, but also between programs in community care settings. By per item analysis it was possible to discriminate between various elements of consumer satisfaction. There were significant correlations between the UKU-ConSat total scores and other clinical outcome domains, viz. symptoms, social function, and patient as well as carer's distress. To conclude, the UKU-ConSat rating scale is suitable for quality management and monitoring of treatment programs in mental health services.
UNLABELLED: Although interdisciplinary pain management programs are both therapeutically effective as well as cost-effective, they are currently being underutilized because of managed care policies. We used this prospective comparison trial, with 1-yr follow-up of chronic pain patients, to demonstrate the short- and long-term efficacy of an interdisciplinary pain management program, and evaluate the impact of managed care's physical therapy "carve out" practices on these treatment outcomes. Consecutive chronic pain patients (n = 201) were evaluated, some of whom had their physical therapy "carved out" from this integrated program. Results revealed that successful completion of interdisciplinary pain management was therapeutically effective. Most importantly, physical therapy "carved out" practices had a negative impact on both the short-term and 1-yr follow-up outcome measures. Thus, interdisciplinary pain management is effective in treating the major health problem of chronic pain. However, insurance carrier policies of contracting treatment "carve outs" significantly compromise the efficacy of this evidence-based, best standard of medical care treatment. This raises important medico-legal and ethical issues. IMPLICATIONS: Interdisciplinary pain management is effective and cost-effective in treating the major health problem of chronic pain. The present study demonstrated its efficacy using a prospective, 1-yr posttreatment evaluation methodology. Moreover, physical therapy "carve out" practices by insurance carriers had a negative impact on the outcomes, raising important medico-legal and ethical issues.
OBJECTIVES: Link traditional agricultural production disciplines to the food sciences and the various disciplines concerned with human nutrition and health in order to find sustainable solutions to malnutrition. DESIGN: Develop a new integrated program area within a university by forging explicit linkages within a wide array of disciplines concerned with food systems and human health. SETTING: The College of Agriculture and Life Sciences, the College of Human Ecology, the Division of Nutrition, and the Cornell International Institute for Food, Agriculture, and Development at Cornell University, Ithaca, New York, USA. INTERVENTIONS: Use food-based, system approaches to meet human nutrition goals. Current focus is on the provision of micronutrients (especially iron, vitamin A and iodine) for people globally. RESULTS: A new program area 'Food Systems for Health' has been developed at Cornell University. The program fosters effective interdisciplinary research, teaching and extension activities directed towards sustainable improvements in human nutrition and health. CONCLUSIONS: The old paradigms of agriculture, human nutrition, and public health must be shifted from current linear approaches to integrated and interactive approaches if effective long-term, food-based solutions to micronutrient malnutrition are to be found.
OBJECTIVE: To evaluate an integrated fellowship in vascular surgery and interventional radiology initiated to train vascular surgeons in endovascular techniques and to train radiology fellows in clinical aspects of vascular diseases. SUMMARY BACKGROUND DATA: The rapid evolution of endovascular techniques for the treatment of vascular diseases requires that vascular surgeons develop proficiency in these techniques and that interventional radiologists develop proficiency in the clinical evaluation and management of patients who are best treated with endovascular techniques. In response to this need the authors initiated an integrated fellowship in vascular surgery and interventional radiology and now report their interim results. METHODS: Since 1999 vascular fellows and radiology fellows performed an identical year-long fellowship in interventional radiology. During the fellowship, vascular surgery and radiology fellows perform both vascular and nonvascular interventional procedures. Both vascular surgery and radiology-based fellows spend one quarter of the year on the vascular service performing endovascular aortic aneurysm repairs and acquiring clinical experience in the vascular surgery inpatient and outpatient services. Vascular surgery fellows then complete an additional year-long fellowship in vascular surgery. To evaluate the type and number of interventional radiology procedures, the authors analyzed records of cases performed by all interventional radiology and vascular surgery fellows from a prospectively maintained database. The attitudes of vascular surgery and interventional radiology faculty and fellows toward the integrated fellowship were surveyed using a formal questionnaire. RESULTS: During the fellowship each fellow performed an average of 1,201 procedures, including 808 vascular procedures (236 diagnostic angiograms, 70 arterial interventions, 59 diagnostic venograms, 475 venous interventions, and 43 hemodialysis graft interventions) and 393 nonvascular procedures. On average fellows performed 20 endovascular aortic aneurysm repairs per year. There was no significant difference between the vascular surgery and radiology fellows in either the spectrum or number of cases performed. Eighty-eight percent (23/26) of the questionnaires were completed and returned. Both interventional radiologists and vascular surgeons strongly supported the integrated fellowship model and favored continuation of the integrated program. Vascular surgery and interventional radiology faculty members wanted additional training in clinical vascular surgery for the radiology-based fellows. With the exception of the radiology fellows there was uniform agreement that vascular surgery fellows benefit from training in nonvascular aspects of interventional radiology. CONCLUSIONS: Integration of vascular surgery and interventional radiology fellowships is feasible and is mutually beneficial to both disciplines. Furthermore, the integrated fellowship provides exceptional training for vascular surgery and interventional radiology fellows in all catheter-based techniques that far exceeds the minimum requirements for credentialing suggested by various professional societies. There is a clear need for cooperation and active involvement on the parts of the American Board of Radiology and the American Board of Surgery and its Vascular Board to create hybrid training programs that meet mutually agreed-on criteria that document sufficient acquisition of both the cognitive and technical skills required to manage patients undergoing endovascular procedures safely and effectively.
In the rush to stay in tune with the rapid pace of change, many organizations are now implementing total quality management (TQM)--often without first examining whether they are ready to take full advantage of what this approach has to offer. Indeed, if TQM is implemented as a quick fix (for example, getting everyone involved in learning tools and techniques, forming continuous improvement teams across departments and disciplines, and then expecting all employees to make significant improvements in the way they serve their customers) when, in fact, there is mistrust, defensive communication, little teamwork across work units, conflicting strategic signals, fragmented organizational structures, and a reward system that ignores performance, virtually any TQM program is likely to fail. Rather than putting more and more pressure on employees to improve--when they cannot because of all these roadblocks--organizations might first consider identifying and then removing their systemic barriers to success with a completely integrated program. Once the necessary foundation for TQM has been established, all employees will be able--and willing--to work together to improve their processes, products, and services for the benefit of their customers.
With the increasing complexity of nursing practice and health care delivery, developing information literacy in students for lifelong learning is a vital element of nursing education. The San Francisco State University School of Nursing has developed, implemented, and evaluated an integrated program of information literacy in its undergraduate curriculum. The curriculum strand includes a variety of instructional strategies woven through all semesters of the nursing program. To evaluate the information literacy program, an exploratory descriptive approach was taken using two different cohorts of students. Baseline testing prior to implementation of the information literacy program and posttesting after implementation of the program revealed selected positive occurrences in students' use of bibliographic databases and journal literature. However, students did not perceive they were more successful in accessing information, and faculty assessment of students' ability to evaluate information did not change from 1992 to 1996. These and other evaluation findings have implications for the development of an information literacy curriculum and its integration with other facets of student learning.
OBJECTIVE: Vocational re-integration of patients with chronic schizophrenia remains even with the help of comprehensive integration programs a very ambitious aim. Therefore, a profound and up-to-date knowledge of vocational outcome predictors is imperative. The objective of the present study was, while minimizing the influence of the instruments used, to generate factors, which predict best the re-integration outcome. METHOD: In a sample of 76 chronic schizophrenia patients ten relevant factors were derived from a factor analysis including 32 variables. In a second step the predictive value of these ten factors centering on vocational outcome were tested by logistic regression analysis. RESULTS: Participants who had a successful outcome showed a good vocational capacity before and during the two-week assessment phase, had no social deficits and no depressive-resignative coping strategies. Schizophrenia symptoms and cognitive deficits, however, were of minor relevance. CONCLUSIONS: The results of our factor-analytic approach confirm earlier findings that vocational functioning observed in a sheltered setting and social competence are the best predictors for successful vocational rehabilitation. Moreover, they serve to substantiate the necessity of developing therapeutic programs that enhance patients' hopefulness and self-confidence.
A computerized system for the quantitative comparison of two-dimensional polyacrylamide gel autoradiographs is being developed that requires relatively limited hardware resources. Two fast, simple, and stable programs--one for background and streak subtraction and one for peak detection--have been developed and tested. Two methods developed by others--one for image smoothing and one for peak matching--also have been tested. A very simple spot-density integration program that works on isolated spots has been written and is being developed further.