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PubMed1997

Markets and public programs: insights from Oregon and Tennessee.

Medicaid is the major national program promoting access to care for low-income populations, but the program also is a federal-state partnership. With costs rising and universal access still a remote objective, many states have turned to market-based strategies involving managed care, with the goals of generating savings for the state, improving access for Medicaid beneficiaries, and sometimes expanding coverage to those who were previously uninsured. Yet Medicaid is a complex social insurance system that over time has been used to finance a variety of needs, often using cross-subsidies. In addition, states vary in both the scope of their Medicaid programs and the sophistication of the skills and resources they can bring to bear in shaping them. Understanding how these influence the ability to implement market-based strategies in Medicaid and what the effects of these strategies appear to be is of crucial importance because most states now include some features of this approach in their programs.

Health Care Reform↗
PubMedDate not supplied

Evaluation of needle exchange programs.

Needle exchange programs exist in every major population area in the United States and in many other countries. Some operate legally under emergency health decrees issued by local departments of health, with the stated intention of risk reduction through the removal of used injection equipment from use by injection drug users. It is theorized that this results in a reduced transmission of human immunodeficiency virus, hepatitis, and, possibly, other blood-borne diseases. Needle exchange programs also offer access to drug treatment programs for the participants. It is a difficult but necessary task to evaluate these programs. This article examines examples of evaluations attempted in the past and discusses the challenges of such evaluations. Experimental evaluations, economic program analysis, legal aspects, and risk-benefit assessment along with ethical aspects are considered. An outline of program evaluation is proposed. Needle exchange programs offer an opportunity to encourage risk reduction and to offer counseling and access to health care for individuals at high risk. It is essential that such programs demonstrate their effectiveness. Assumptions of efficacy are insufficient for health care in the twenty-first century.

Humans↗
PubMed2000

A program for the optimization of cyclosporine therapy using population kinetics modeling.

Cyclosporine is one of the most widely used immunosuppressive agents in organ transplantation. Due to large inter- and intra-individual variations, its behavior in the specific patient is still difficult to predict. Dosage optimization is thus mainly performed on a trial-and-error basis. In this paper, we present a new program based on the population kinetics approach, which was designed to help physicians in the difficult task of adjusting patient specific cyclosporine dosing regimens. Dose optimization is carried out by model simulation, using a two-compartment mathematical model of cyclosporine kinetics to predict the drug behavior in the patient. Two of the model parameters are assumed from the literature, the other two are estimated from the patient data through a Bayesian estimation procedure. Previous information needed by the Bayesian algorithm is derived by a population analysis, performed beforehand and based on a nonlinear mixed effect model. A user-friendly graphical interface written in Delphi under Windows makes the program easily accessible to physicians. A preliminary retrospective validation of the program, performed on data from 18 renal transplanted patients, yielded very satisfactory results.

Algorithms↗
PubMed2004

Factors affecting the frequency of value-focused health activities and policies by employers.

OBJECTIVE: We sought to gather employer perspectives about value-focused activities (VFAs), intentions to make decisions based on value, and other factors affecting decisions. METHODS: Health decision-makers (n = 174), both American College of Occupational and Environmental Medicine members and corporate HR/benefits directors, responded to an Internet-based questionnaire. RESULTS: Of a total of 32 listed VFAs, companies reported, on average, performing 5.2 activities currently and considering 2.6. Twenty-five percent of companies reported doing eight or more. The most common VFAs were providing access to flu shots, centers of excellence, and wellness programs. Greater access to detailed outcome data was associated with doing more VFAs, as was greater accountability for absence, disability, and productivity outcomes. CONCLUSIONS: Employers vary widely in the number of VFAs in which they participate. Decision-makers with more information about, and accountability for, value outcomes reported doing more VFAs.

Chi-Square Distribution↗
PubMed2001

The health of women with cerebral palsy.

Over the past 10 years, there has been interest in describing the health and functional status of persons with CP. More recently, information specific to women with CP has become available. From these studies a better appreciation of the affect a lifelong primary disability such as CP has on an individual's life has developed. An understanding of aging with a disability, secondary conditions, associated conditions, comorbidities, and health have promoted a health and wellness agenda for women and men with CP. Women with CP are generally healthy. There appears to be no significant risk for any specific comorbiditv from CP. Women may note a modest change in function over time that may represent issues of aging, but there should be no dramatic loss of function. Any loss of function must be evaluated further for cause, and cannot be attributed to aging alone. Common secondary conditions and health issues include pain and musculoskeletal issues, bladder and bowel problems, poor dental hygiene, and possibly gastroesophageal reflux. Osteoporosis at all ages from limited mobility (secondary osteoporosis) likely is common, but only recently has bone densitometry been used for more routine evaluations; consequently, no data are available in women with CP regarding this. All health issues should be evaluated and appropriate intervention prescribed. There appear to be no significant reproductive health issues for women with CF. Women should engage in all decisions regarding diagnosis and treatment. Women with CP likely participate in some healthy behaviors. However implementing health promotion programs requires some understanding of health behavior theories and models. It may not be enough to modify existing programs for accessibility (e.g., transportation, cost. environment). Engagement in health promotion programs by women with CP must take into account individual perceptions and values, social networks, a sense of personal control, and a readiness to change attitude toward changing lifestyles.

Adult↗
PubMed1997

Using a TTY to contact clinical graduate programs.

This study investigated accessibility of 177 APA-accredited clinical and counseling programs to deaf applicants via TTY phone lines, what happened when we called these numbers, and where these phone lines connected. We were able to obtain TTY phone numbers for 135 schools, of which we could successfully reach 86 schools using a TTY alone. Most of these lines (60%) were connected to campus disabled student services, and none connected directly to the APA-accredited programs or the departments in which they were housed. Comments from university personnel underscore the difficulties facing deaf applicants. We argue that the difficulties deaf applicants encounter when trying to contact programs constitute significant barriers to the application process. We give six specific recommendations for expanding access to programs.

Computer Communication Networks↗
PubMed2005

Management of referred deep brain stimulation failures: a retrospective analysis from 2 movement disorders centers.

BACKGROUND: Since the Food and Drug Administration approved DBS, there has been a surge in the number of centers providing the procedure. There is currently no consensus regarding appropriate screening procedures, necessary training of individuals providing the therapy, the need for an interdisciplinary team, or guidelines for the management of complications. An increasing number of patients come to experienced DBS centers after unsatisfactory results from DBS surgery. An attempt is made herein to evaluate the reasons for DBS failure in a series of such patients and to make recommendations to improve overall DBS outcomes. OBJECTIVE: To improve outcomes of deep brain stimulation (DBS) surgery by analyzing a series of patients who had suboptimal results from DBS. METHODS: Forty-one consecutive patients complaining of suboptimal results from DBS surgery came to the University of Florida Movement Disorders Center, or to Beth Israel Movement Disorders Center, over a 24-month period. All patients had undergone implantation of DBS devices at outside medical centers. Each patient was evaluated by a movement disorders neurologist, and the complete medical record was reviewed. The DBS device for each patient was interrogated for adverse effects and programmed for maximal benefit. Postoperative imaging studies were evaluated whenever possible. RESULTS: The average age of patients was 63.4 years (range, 49-84 years). The indication for surgery (by record review) included 9 patients with essential tremor, 31 with Parkinson disease, and 1 with dystonia. The diagnoses after referral examination included 5 with essential tremor, 26 with Parkinson disease, 3 with Parkinson disease and dementia, 1 with Parkinson disease and essential tremor, 1 with corticobasal degeneration, 1 with dystonia, 2 with multiple system atrophy, 1 with progressive supranuclear palsy, and 1 with myoclonus. Issues related to inadequate preoperative screening: Thirty (73%) of 41 patients saw a movement disorders specialist prior to DBS implantation. Fourteen (34%) patients had neuropsychological testing, 4 (10%) did not have testing, and in 23 cases (56%), it could not be determined whether or not they were tested. Five (12%) of 41 patients had an inadequate medication trial, and 5 patients (12%) had significant cognitive dysfunction prior to their DBS implantation. Surgical and device-related complications: Nineteen (46%) of 41 patients had suboptimally placed electrodes. Seven electrodes (17%) were replaced with improvement. Three patients' devices had failed due to end of battery life, 2 had infections, and 1 had a fractured lead. Programming and medication adjustments: Seven (17%) of 41 patients had no or poor access to programming. Two patients (5%) moved, and 2 physicians (5%) moved, creating issues with access to care. Eight patients (20%) required local follow-up (they flew to remote centers to have the surgery performed). Fifteen patients (37%) were inadequately programmed and improved significantly with reprogramming. Six patients (15%) experienced partial improvement with reprogramming, and 21 patients (51%) failed to improve despite extensive reprogramming. Thirty patients (73%) benefited from medication changes, 4 (10%) had antidepressants added to their regimens, and 1 (2%) had donepezil hydrochloride added. One patient's carbidopa/levodopa (2%) was restarted after complete discontinuation. OUTCOMES: With the various postoperative interventions described, 21 (51%) of 41 patients had good outcomes, 6 (15%) had modest clinical improvement, and 14 (34%) did not improve. CONCLUSIONS: With appropriate intervention, 51% of patients who complained of "failed" DBS procedures ultimately had good outcomes. Thirty-four percent of these patients had persistently poor outcomes despite maximal intervention. This case series provides important insights into reasons for "DBS failure" and proposes strategies to manage patients with DBS more effectively.

Aged↗
PubMed1988

Judgment, 26 October 1988.

The Court held that provisions of a law enacted by the canton Zug restricting access to abortion were invalid because they were in conflict with federal law provisions relating to abortion. The law in question required 1) that abortions could be performed only by specialists in gynecology and obstetrics; 2) that they be approved by a committee of experts; and 3) that authorization for abortions be given only to women who are residents of Zug.

Abortion, Induced↗