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The authors describe a disease management initiative designed to address issues of noncompliance in a diabetic population. The program design was a collaborative effort between a payer and a public health organization representing Hartford Hospital and Hartford Physicians Association. Interventions included a patient self-assessment, phone counseling, and a monetary reward for program participation.
CONTEXT: Rapid expansion of Medicaid managed care has raised concerns about the capacity and willingness of health plans enrolling Medicaid beneficiaries to provide high-quality care. Recently, legislation has facilitated market entry of Medicaid plans, health plans that draw most of their enrollment from the Medicaid population. OBJECTIVE: To characterize and compare the organizational characteristics and programs related to quality of care of commercial and Medicaid health plans that participate in the Medicaid program. DESIGN: Cross-sectional survey conducted September 1997 to April 1998. SETTING: The Medicaid program in 11 states and the District of Columbia. PARTICIPANTS: All 154 health plans in these localities that provided prepaid general medical care to Medicaid beneficiaries during June 1997, of which 130 (84%) responded to the survey. MAIN OUTCOME MEASURES: Health plan reports of structural characteristics, services offered, performance measurement and feedback, disease management programs, information systems capabilities, and provider network composition and relationships. RESULTS: Half of the respondents were Medicaid plans, with 75% or more of enrollees drawn from the Medicaid population. Medicaid plans tended to be smaller and newer than commercial plans that also served the Medicaid population and had more enabling programs targeting the special needs of the Medicaid population, such as inadequate transportation (85% of Medicaid plans vs 62% of commercial plans; P = .003) and illiteracy (66% vs 38%, respectively; P = .002). Overall, 71% of Medicaid plans vs 43% of commercial plans had enabling programs targeted at 6 or more of the 8 special needs we specified (P = .001). While commercial plans had a higher proportion of board-certified primary care physicians (81% vs 73%; P = .01), we found no major differences between Medicaid plans and commercial plans in collection and dissemination of performance measures, designation of specific areas for quality improvement, or use of disease management programs targeted at conditions prevalent in the Medicaid population. Neither commercial nor Medicaid plans reported high success in improving quality of care. CONCLUSIONS: Based on our survey, while Medicaid plans resemble commercial plans serving the Medicaid population in many aspects of quality management, they are more likely to target programs directed to the specific needs of the Medicaid population. Neither commercial nor Medicaid plans have notably strong records in actual quality improvement.
The Basic Shelf Experience is a program designed to assist people living on limited incomes to make better use of their food resources. The purpose of this research was to learn if the Basic Shelf Experience program helps such people to 1. utilize food resources more effectively and 2. cope, through group support, with poverty-associated stressors that influence food security. Both quantitative and qualitative methods were used to evaluate the program objectives. Participants completed a questionnaire at the beginning and end of the six-week program. The questionnaire asked about their food access, food security, and feelings about themselves. Participants returned for a focus group discussion and completed the questionnaire again three months after the program ended. The focus group was designed to elicit information about perceived changes, if any, attributed to the program. Forty-two people completed the questionnaires pre-program and 20 post-program; 17 participated in the three-month follow-up session. While results from quantitative data analysis indicate that program objectives were not met, qualitative data provide evidence that the program did achieve its stated objectives. Our results suggest such programs as the Basic Shelf Experience can assist people living on limited incomes to achieve food security.
OBJECTIVES: Our falls prevention research group has conducted four controlled trials of a home exercise program to prevent falls in older people. The objectives of this meta-analysis of these trials were to estimate the overall effect of the exercise program on the numbers of falls and fall-related injuries and to identify subgroups that would benefit most from the program. DESIGN: We pooled individual-level data from the four trials to investigate the effect of the program in those aged 80 and older, in those with a previous fall, and in men and women. SETTING: Nine cities and towns in New Zealand. PARTICIPANTS: One thousand sixteen community dwelling women and men aged 65 to 97. INTERVENTION: A program of muscle strengthening and balance retraining exercises designed specifically to prevent falls and individually prescribed and delivered at home by trained health professionals. MEASUREMENTS: Main outcomes were number of falls and number of injuries resulting from falls during the trials. RESULTS: The overall effect of the program was to reduce the number of falls and the number of fall-related injuries by 35% (incidence rate ratio (IRR) = 0.65, 95% confidence interval (CI) = 0.57-0.75; and, respectively IRR = 0.65, 95% CI = 0.53-0.81.) In injury prevention, participants aged 80 and older benefited significantly more from the program than those aged 65 to 79. The program was equally effective in reducing fall rates in those with and without a previous fall, but participants reporting a fall in the previous year had a higher fall rate (IRR = 2.34, 95% CI = 1.64-3.34). The program was equally effective in men and women. CONCLUSION: This exercise program was most effective in reducing fall-related injuries in those aged 80 and older and resulted in a higher absolute reduction in injurious falls when offered to those with a history of a previous fall.
We have developed a versatile computer program for optimization of ligand binding experiments (e.g., radioreceptor assay system for hormones, drugs, etc.). This optimization algorithm is based on an overall measure of precision of the parameter estimates (D-optimality). The program DESIGN uses an exact mathematical model of the equilibrium ligand binding system with up to two ligands binding to any number of classes of binding sites. The program produces a minimal list of the optimal ligand concentrations for use in the binding experiment. This potentially reduces the time and cost necessary to perform a binding experiment. The program allows comparison of any proposed experimental design with the D-optimal design or with assay protocols in current use. The level of nonspecific binding is regarded as an unknown parameter of the system, along with the affinity constant (Kd) and binding capacity (Bmax). Selected parameters can be fixed at constant values and thereby excluded from the optimization algorithm. Emphasis may be placed on improving the precision of a single parameter or on improving the precision of all the parameters simultaneously. We present optimal designs for several of the more commonly used assay protocols (saturation binding with a single labeled ligand, competition or displacement curve, one or two classes of binding sites), and evaluate the robustness of these designs to changes in parameter values of the underlying models. We also derive the theoretical D-optimal design for the saturation binding experiment with a homogeneous receptor class.
Programs designed to ensure high quality performance, whatever name they are given, have the same basic elements. They measure compliance with established standards, provide feedback, institute changes as necessary to improve outcomes, and measure again. The first steps include determining which programs need evaluation and identifying the standards. Measurement tools are then developed and the self assessment takes place. After the results are analyzed, the necessary program changes are made, and the cycle is repeated. Failure to determine levels of compliance with government regulations can leave a company vulnerable to sanctions if noncompliance is significant. Self identification of problems before they become apparent outside the department allows the occupational and environmental health nurse to make program and process improvements before the problems become crises. Self assessments are designed to monitor activities, determine program or procedure effectiveness, validate decision making, and investigate unsolicited observations and comments. Self regulation is the hallmark of a mature profession (Phaneuf, 1972), and as such, occupational and environmental health nurses have a professional responsibility to actively engage in formalized self regulation activities.
The purpose of this investigation was to determine the effectiveness of a fitness program designed as an alternative to the standard weight-training and running program and using limited resources and facilities. Forty-three men from the North Carolina Justice Academy, randomly assigned into two groups, completed 12 weeks of physical training. The WT group used a standard weight training and running, whereas the REC group ran and completed a resistive exercise circuit. The REC circuit consisted of nine exercises designed to improve muscular strength and endurance separated by 30 seconds of aerobic exercise. The exercises used chairs, tables, sawhorses, and body weight to provide the resistance. The results indicated that the REC program improved muscular strength and aerobic capacity as well as the WT program. Furthermore, the REC group lost more weight, reduced body fat, and improved their lipid profiles significantly more than the WT group. Thus, the REC program is a viable alternative for the training of public safety officers when only limited resources are available.
Cyclops is a new computer program designed as a graphical front-end that allows easy control and interaction with tasks and programs for 3D reconstruction of biological complexes using cryo-electron microscopy. Cyclops' current plug-ins are designed for automated particle picking and include two new algorithms, automated carbon masking and quaternion based rotation space sampling, which are also presented here. Additional plug-ins are in the pipeline. Cyclops allows straightforward organization and visualization of all data and tasks and allows both interactive and batch-wise processing. Furthermore, it was designed for straightforward implementation in grid architectures. As a front-end to a collection of programs it provides a common interface to these programs, thus enhancing the usability of the suite and the productivity of the user.
In Exp. 1 50 subjects were randomly assigned to one of two videotape conditions. The experimental group watched a TV news program designed to expose some myths about the not-guilty-by-reason-of-insanity plea (NGRI) while controls watched a neutral program. A seven-item test designed to measure knowledge about each myth was administered before and twice after exposure to the videotapes. Analysis showed no significant difference for any exposure. Exps. 2 and 3 showed that reading a brief factual report about NGRI significantly reduced the belief in these myths as compared to beliefs of groups who watched a TV news program.
The independence Bayesian model has been used widely in computer programs designed to support clinical decision-making. A reasoning strategy has been developed to enable these programs to conduct clinically pertinent dialogue and explain their reasoning. It has been implemented in a program for the diagnosis of acute abdominal pain based on the Bayesian model of de Dombal et al. Several features of the dialogue design have been adopted from artificial intelligence research, including shared initiative and critiquing. The program adopts a flexible goal-driven strategy, attempting to confirm the clinician's diagnosis or rule out the likeliest alternative. Symptoms and signs are selected in order of their expected weights of evidence in favour of the hypothesized disease.
An interactive CD-ROM program designed to reduce adolescent substance use was developed and evaluated. The program uses video vignettes to teach refusal skills and socially acceptable responses to substance use situations, specifically offers of marijuana. In a randomized pretest-to-posttest experiment with 74 public school students from six classes in three high schools, significant changes were observed at posttest on (1) the adolescent's personal efficacy to refuse the offer of marijuana, (2) the adolescent's intention to refuse marijuana if offered, and (3) the adolescent's perceptions of the social norms associated with substance use and the importance of respecting another's decision to refuse a drug offer. In addition, adolescents in the treatment condition were able to recall approximately 50% of the portrayed refusal strategies. Findings are discussed with regard to the potential benefits of an interactive multimedia approach for conducting substance use interventions.
There are several problems on the practical use of telemedicine, for example, the difficulties involved in promoting communication between medical facilities, uncooperative clinicians, and the absence of high-speed circuits and high-resolution CRT. From the Japanese point of view, we suggest ways to resolve these problems. We will analyze and propose scenarios for realizing successful communications among medical institutions, medical communication and its characteristics, barriers to the promotion of communications among medical institutions, second-opinion centers, and separate satellites and separate circuits. We also mention the World Wide Web for teleconsultation, provision of assistance to people with data handicaps via a communications satellite, and assistance to programs designed for training telemedicine specialists. Using a communication satellite, we offer programs that explain preventive medicine, support activities for nursing at home, explain the risks of fast food, and support activities for the handicapped and women in a simple manner to computer illiterates.
This article summarizes the results of the Ohio University Sexual Assault Risk Reduction Project, which is a program designed to reduce college women's risk for sexual assault. The program was evaluated at 2 separate universities with 762 women. Participants were randomly assigned either to the program or to the no-treatment comparison group, and they completed measures that assessed sexual victimization, dating behaviors, sexual communication, and rape empathy at the pretest and at the 2-month and 6-month follow-ups. At the 2-month follow-up, there were no differences between the groups on any of the outcome measures. However, those women who were moderately victimized during the 2-month follow-up were significantly less likely to be revictimized during the 6-month follow-up period if they participated in the program.
The study examined the effects of homelessness on access to public entitlements (Medicaid and food stamp programs) in a soup kitchen population. Data were collected between 1997 and 1999 from a sample of 343 adults at two soup kitchen sites in New York City. Five hypotheses, focusing on the effects of housing status (literal homelessness, unstable housing, and domiciled), frequency of drug/heavy alcohol use, drug/alcohol-user treatment history and childcare responsibilities on access to Medicaid and food stamp programs were tested. Multiple logistic regression analysis indicated that both literal homelessness and unstable housing were associated with less access to Medicaid and food stamps. Other significant findings were: current drug/alcohol-user treatment experience was associated with greater access to both Medicaid and food stamps, frequency of drug/heavy alcohol use was associated with less access to Medicaid only, and caring for children was associated with greater access to food stamps only. These findings support the crucial role of housing status in mediating access to entitlements, and the importance of drug/alcohol-user treatment involvement as a cue to seeking entitlements. The need to reduce health disparities through active and sustained outreach programs designed to enhance homeless persons' access to Medicaid and food stamp programs was discussed.
The purpose of this study was to implement and test the effectiveness of an instructional program designed to teach normal children about cerebral palsy. Presentation of the program to 17 first-grade children resulted in a significant increase in the students' knowledge of the disability, compared to that of a control group. Implications of these results for physical and occupational therapists involved in facilitating placement of handicapped children into the least restrictive environment were discussed.
Estimates of percent body surface area (%BSA) burns correlate well with fluid needs, nutritional requirements, and prognosis. Most burn centers rely on the Lund Browder chart and "rule of nines," to calculate the %BSA. Computer-based methods may improve precision and data analysis. We studied two new methods of determining %BSA: a two-dimensional Web-based program (Sage II) and a three-dimensional computer-aided design program (EPRI 3D Burn Vision). Members of our burn team found the Sage II program easy to use and found many of the features useful for patient care. The EPRI program has the advantage of 3D images and different body morphologies but required training to use. Computer-aided methods offer the potential for improved precision and data analysis of %BSA measurements.
This study evaluated the effectiveness of an innovative, classroom-based physical activity prevention program designed to integrate academic curriculum elements along with a physical activity program in providing moderate-to-vigorous intensity physical activity. A convenience sample of three public school classrooms (one first, third, and fifth grade class) was observed implementing the TAKE 10! program while monitored by either CSA accelerometers or digital pedometers. Pedometer step counts and CSA data were recorded for each student and activity. As calculated from CSA data, average MET levels during the activities were 5.72-7.05 (first grade), 5.51-6.77 (third grade), and 4.98-7.19 (fifth grade), and levels were not different between grades (p > 0.05). Average caloric expenditure (Kcal) per 10-minute session was 25.6-27.8 (first grade), 27.6-33.9 (third grade), and 29.7-42.9 (fifth grade). Measured pedometer step counts per session ranged from 644-931 in first grade, 659-1, 376 in third grade, and 1002-1041 in fifth grade. TAKE 10! sessions for all three grades produced exercise levels in the moderate intensity range throughout full duration of the session. Classroom-based physical activity promotion provides a useful strategy to promote meaningful physical activity among school children.
A process evaluation of a school health program designed to improve students' health and educational success is presented. The program included a pediatric nurse practitioner and two nurses placed in three high-risk, urban intervention schools. It is a part of a larger multidimensional pilot intervention project (The Children First Plan). Implemented services and the implementation process are described. Key components for a successful implementation included obtaining buy-in, learning the school culture, defining roles, and keeping a sense of humor. Collaborative efforts among the nursing team, other children-first plan providers, and the school staff improved service delivery. Lack of communication was the primary barrier. In addition, differing philosophies among systems (education, social services, health), problems with referral and feedback, and lack of appropriate providers hampered service delivery. Recommendations for continued program improvement and replication projects are provided.