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PubMed2006

A population-based model for priority setting across the care continuum and across modalities.

BACKGROUND: The Health-sector Wide (HsW) priority setting model is designed to shift the focus of priority setting away from 'program budgets'--that are typically defined by modality or disease-stage--and towards well-defined target populations with a particular disease/health problem. METHODS: The key features of the HsW model are i) a disease/health problem framework, ii) a sequential approach to covering the entire health sector, iii) comprehensiveness of scope in identifying intervention options and iv) the use of objective evidence. The HsW model redefines the unit of analysis over which priorities are set to include all mutually exclusive and complementary interventions for the prevention and treatment of each disease/health problem under consideration. The HsW model is therefore incompatible with the fragmented approach to priority setting across multiple program budgets that currently characterises allocation in many health systems. The HsW model employs standard cost-utility analyses and decision-rules with the aim of maximising QALYs contingent upon the global budget constraint for the set of diseases/health problems under consideration. It is recognised that the objective function may include non-health arguments that would imply a departure from simple QALY maximisation and that political constraints frequently limit degrees of freedom. In addressing these broader considerations, the HsW model can be modified to maximise value-weighted QALYs contingent upon the global budget constraint and any political constraints bearing upon allocation decisions. RESULTS: The HsW model has been applied in several contexts, recently to osteoarthritis, that has demonstrated both its practical application and its capacity to derive clear evidenced-based policy recommendations. CONCLUSION: Comparisons with other approaches to priority setting, such as Programme Budgeting and Marginal Analysis (PBMA) and modality-based cost-effectiveness comparisons, as typified by Australia's Pharmaceutical Benefits Advisory Committee process for the listing of pharmaceuticals for government funding, demonstrate the value added by the HsW model notably in its greater likelihood of contributing to allocative efficiency.

Journal Article↗
PubMed1993

A longitudinal study of the impact of behavioural change intervention on cleanliness, diarrhoeal morbidity and growth of children in rural Bangladesh.

A community-based intervention was developed through direct participation of the target population in assessment and iterative trials to improve hygiene practices and to reduce childhood diarrhoea in lowland rural Bangladesh. A total of 185 (98%) households with children ages 0-18 months in five contiguous villages were targeted for the interventions. A comparison site was selected for a detailed observational study and for use as a control for the intervention. About 97% of all households with children ages 0-18 months were enrolled for study at the control site. Children in this age group were targeted because at this developmental stage they were most vulnerable to diarrhoeal morbidity and malnutrition (related to unhygienic practices). The intervention was implemented with the assistance of village leaders through a "Clean Life" campaign by local project workers and volunteer mothers who were chosen from the target households. The intervention activities started in January 1986 and lasted for 7 months. Higher adoption rates of the intervention were associated with better cleanliness status, which was related to lower diarrhoea and malnutrition rates in the intervention site. The results of between-site longitudinal analyses showed that after the intervention, the intervention site had substantially higher cleanliness scores, lower diarrhoeal morbidity, and better growth status compared to those of the control site, with differences increasing over time. The findings suggest that this type of community-based intervention can be very beneficial in modifying hygiene behaviours and lowering childhood diarrhoea and malnutrition.

Bangladesh↗
PubMed2005

Bioaugmentation for bioremediation: the challenge of strain selection.

Despite its long-term use in bioremediation, bioaugmentation of contaminated sites with microbial cells continues to be a source of controversy within environmental microbiology. This largely results from its notoriously unreliable performance record. In this article, we argue that the unpredictable nature of the approach comes from the initial strain selection step. Up until now, this has been dictated by the search for catabolically competent microorganisms, with little or no consideration given to other essential features that are required to be functionally active and persistent in target habitats. We describe how technical advances in molecular biology and analytical chemistry, now enable assessments of the functional diversity and spatial distribution of microbial communities to be made in situ. These advances now enable microbial populations, targeted for exploitation, to be differentiated to the cell level, an advance that is bound to improve microbial selection and exploitation. We argue that this information-based approach is already proving to be more effective than the traditional 'black-box' approach of strain selection. The future perspectives and opportunities for improving selection of effective microbial strains for bioaugmentation are also discussed.

Bacteria↗
PubMed2006

Suboptimal pneumococcal pneumonia vaccination rates among patients at risk in a managed care organization in Israel.

OBJECTIVE: Pneumococcal pneumonia is a vaccine-preventable disease that poses a significant threat to immunocompromised patients. Vaccination rates tend to be low despite recommendations for vaccination in several groups of high-risk patients including any person aged 65 years or older. The purpose of this study was to (a) evaluate the vaccination rates among high-risk patients in a managed care setting in Israel and (b) gain a better understanding of the factors associated with suboptimal use of this vaccine. METHODS: Data were extracted from the electronic medical records of the managed care organization for patients with dates of service from January 2000 to December 2004 for whom the vaccine is recommended. Patients were identified via diagnosis codes according to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Vaccination rates were calculated for patients in each disease category. These high-risk patients were contacted to participate in a telephone survey to evaluate the variance in knowledge and awareness levels of the disease between the vaccinated and unvaccinated patients. RESULTS: A total of 672 patients were identified by the ICD-9-CM codes; 140 (20.8%) had been vaccinated and 532 (79.2%) were unvaccinated. Vaccination rates were highest among patients with solid organ transplants (33.3%), followed by nephrotic syndrome (29.4%), bone marrow transplants (10.2%), and human immunodeficiency virus (HIV, 9%), for an overall rate of 20.8%. Of these patients, survey responses were obtained from 364 (54.2%). Respondents who were unvaccinated tended to be less well informed about which patient populations are at risk for the disease and the availability of the vaccine. CONCLUSION: The pneumococcal vaccination rate among immunocompromised patients in this managed care organization was found to be inadequate, at just 20.8% of the target population. Approaches based on direct contact with the patient, such as by a case manager, may be more successful in the future.

Health Education↗
PubMed1998

A tobacco and alcohol use profile of San Francisco's Chinese community.

Relatively little is known about Asian American tobacco and alcohol use patterns. This is particularly true of Chinese living in the United States--either U.S.-born or non-U.S.-born Chinese. This article presents data from a research project studying tobacco and alcohol use patterns in San Francisco's Chinese community. Data were secured both from focus groups and a self-report telephone survey of a random sample of 1,808 Chinese residents in San Francisco. This results indicate that the prevalence of both tobacco and alcohol use is lower for San Francisco's Chinese population than for the general population. Moreover, those persons who report smoking tend to be different from those who report consuming alcohol. The study concludes that specific, culturally relevant tobacco and alcohol prevention programs should be designed to better reach this target population.

Adolescent↗
PubMed1992

Prenatal weight gain advice: an examination of the recent prenatal weight gain recommendations of the Institute of Medicine.

The Institute of Medicine (IOM) recently published new guidelines for maternal weight gain during pregnancy. Using data collected at Moffitt Hospital, University of California at San Francisco, we examined the associations between maternal weight gain outside the recommendations of the IOM and three pregnancy outcomes (small for gestational age [SGA] infants, large for gestational age [LGA] infants, and cesarean delivery). These analyses were repeated using population-specific weight gain ranges derived from a subgroup of women in this cohort with healthy pregnancy outcomes. The purpose of the study was to compare the national guidelines of the IOM with hospital standards. Both the recommendations of the IOM and the hospital ranges were associated with fewer SGA infants, LGA infants, and cesarean deliveries. The overall associations were similar for the population-derived and national ranges. Although the IOM ranges should be examined in other populations and with other birth outcomes, our results validated their recommendations. Maternal weight gain within the IOM recommendations reduced the risk of the outcomes studied; furthermore, these ranges performed as well as those derived from the target population.

Birth Weight↗
PubMed2003

Reporting a health quality improvement project for reducing the disparity in screening mammograms among senior African-American women.

Despite intensive efforts by the established medical community to offer preventive health practices to minority populations, there remains a significant disparity in utilization of many of these services. Between African-American and Caucasian women there exists a significant disparity in the use of screening mammography. Under contract by the Centers for Medicare & Medicaid Services, Quality Improvement Organizations (QIOs) have been charged with reducing disparities in health care among identified minority populations within each state. Quality Insights of Delaware, the QIO for the state, has developed a project that utilizes a collaboration with African-American women and community resources in an effective outreach program to the targeted population.

Black or African American↗
PubMed1982

Regulation of macrophage populations. V. Evaluation of the control of macrophage Ia expression in vitro.

In response to a lymphokine (LK) produced by activated T cells, macrophages can be induced to express Ia in vitro. This appears to be a complex process comprised of a number of discernible events. Peritoneal macrophages elicited by different means, and unstimulated macrophage and monocyte populations, each had a distinct kinetic profile of Ia induction. This response was characterized most noticeably by a latent period before actual Ia expression. The latent period varied from 3 to 7 days, depending on the target population, and was correlated with the state of activation of the macrophage as reflected by 5' nucleotidase activity. In spite of the protracted time course for Ia expression, all macrophage populations could be "triggered" (committed to a subsequent program of Ia expression) by exposure to the LK for as little as 2 hr. To be triggered, however, macrophages first had to go through a period of culture as adherent cells. Both the spontaneous loss and LK-dependent acquisition of Ia correlated with the functional capacity of these macrophages as antigen-presenting cells, indicating that these events are functionally significant.

Animals↗
PubMed1998

[Practical recommendations for general introduction of hepatitis B vaccination].

The Swiss Federal Office of Public Health and the Swiss Advisory Board on Immunisation recommended that universal vaccination against hepatitis B be introduced in January 1998. The target population for immunisation are youngsters between 11 and 15 years of age. This recommendation does not preclude ongoing selective vaccination of individuals in high risk groups, nor the routine immunisation of individuals younger or older than the target age (if needed). Injections should be given in the deltoïd area and needle length is critical to ensure proper resorption of the antigen and adequate immune response. Three doses are recommended at times 0, 1 month and 6 months with no booster dose. The time interval between the second and third dose should not be shorter than 2 months but can be longer than 5 months. Vaccination initiated with one commercial brand can be completed with a different brand. The simultaneous administration of immune globulin with the initiation of vaccination and the measurement of serum antibodies after completion of vaccination are unnecessary.

Adolescent↗
PubMed1977

Antigen mediation of a late-acting suppressor T-cell activity.

Carrier-specific suppressor T cells can suppress antibody secretion by high avidity IgG plaque-forming cells (PFC) within 90 min in vitro. This process can be blocked by the inclusion of soluble carrier in the cell mixture or by the exposure of target cells to anti-carrier antibodies or pronase. Moreover, suppression can be augmented by PFC exposure to the soluble hapten-carrier conjugate. Finally, carrier specificity may be overcome by preincubation of the target population with a hapten-heterologous carrier before addition of heterologous carrier ATC. Thus, it is likely that high avidity suppression depends upon immunogen bound to the surfaces of antibody-secreting cells which serves as a target for suppressor cells or molecules.

Animals↗
PubMed2006

Efficacy of resmethrin aerosols applied from the road for suppressing Culex vectors of West Nile virus.

We determined whether aerosol applications of resmethrin, delivered from the road, suppress the reproductive activity of Culex pipiens pipiens and Cx. restuans mosquitoes in suburban sites located near Boston. Oviposition implies a prior blood-feeding event and hence a potential West Nile virus (WNV) transmission-related event. Droplet size, rate of delivery and meteorological conditions were monitored. The target populations proved to be fully susceptible to the insecticide that was used. The roads in the test sites generally gave adequate opportunity for insecticidal coverage. We found that the aerosol plume may have failed to contact the target mosquitoes and conclude that such insecticidal aerosols, delivered from the road, may not effectively reduce the force of transmission of WNV in our test sites.

Aerosols↗
PubMed1999

Cancer screening among community health center women: eliminating the gaps.

OBJECTIVE: The elimination of health status gaps among minority and low income populations is part of the mission of community health centers (CHCs). Cervical and breast cancer incidence and mortality are related to both minority and socioeconomic status, and CHCs are in a unique position, by virtue of their target population, to effect positive outcomes through screening and early detection. METHODS: Completed in 1995, the survey described in this article included questions from the 1992 NHIS Cancer Supplement, which collected information on the utilization of cancer-screening services, including Pap smear testing, mammography, and clinical breast examination. RESULTS: CHCs are providing access to Pap smear testing, mammography, and clinical breast examination for women who are at an increased risk for morbidity and mortality associated with cancers of the cervix and breast. A higher proportion of CHC women of most racial and ethnic groups and women below poverty level are up to date on cancer screening than comparison groups. In most cases, CHC women meet or exceed the Healthy People 2000 objectives for the nation.

Adolescent↗
PubMed2005

Self-reported health status of the general adult U.S. population as assessed by the EQ-5D and Health Utilities Index.

OBJECTIVE: This study aimed to describe the self-reported health status of the general adult U.S. population using 3 multi-attribute preference-based measures: the EQ-5D, Health Utilities Index Mark 2 (HUI2), and Mark 3 (HUI3). METHODS: We surveyed the general adult U.S. population using a probability sample with oversampling of Hispanics and non-Hispanic blacks. Respondents to this home-visit survey self-completed the EQ-5D and HUI2/3 questionnaires. Overall health index scores of the target population and selected subgroups were estimated and construct validity of these measures was assessed by testing a priori hypotheses. RESULTS: Completed questionnaires were collected from 4048 respondents (response rate: 59.4%). The majority of the respondents were women (52.0%); the mean age of the sample was 45 years, with 14.8% being 65 or older. Index scores (standard errors) for the general adult U.S. population as assessed by the EQ-5D, HUI2, and HUI3 were 0.87 (0.01), 0.86 (0.01), and 0.81 (0.01), respectively. Generally, younger, male and Hispanic or non-Hispanic black adults had higher (better) index scores than older, female and other racial/ethnic adults; index scores were higher with higher educational attainment and household income. The 3 overall preference indices were strongly correlated (Pearson's r: 0.67-0.87), but systematically different, with intraclass correlation coefficients between these indices ranging from 0.59 to 0.77. CONCLUSIONS: This study provides U.S. population norms for self-reported health status on the EQ-5D, HUI2, and HUI3. Although these measures appeared to be valid and demonstrated similarities, health status assessed by these measures is not exactly the same.

Adolescent↗
PubMed2002

Congestive heart failure and QRS duration: establishing prognosis study.

STUDY OBJECTIVES: There is a lack of epidemiologic information about duration of QRS complex in the general heart failure population. We sought to describe age, sex, and clinical subset specific prevalence of QRS prolongation in this population. METHODS: Data were abstracted from the Resource Utilization Among Congestive Heart Failure Study, which identified 29,686 patients with heart failure from a large, mixed-model managed-care organization during 1989 to 1999. A target population of 3,471 had echocardiographic data and ECG data obtained from automated sources during the first year of diagnosis. Systolic dysfunction was defined as heart failure plus a left ventricular ejection fraction < 45%. MEASUREMENTS AND RESULTS: Among the heart failure population, 20.8% of the subjects had a QRS duration > or = 120 ms. A total of 425 men (24.7%) and 296 women (16.9%) had a prolonged QRS duration (p < 0.01). There was a linear relationship between increased QRS duration and decreased ejection fraction (p < 0.01). A prolonged QRS duration of 120 to 149 ms demonstrated increased mortality at 60 months (p = 0.001), when adjusted for age, sex, and race (p = 0.001). Systolic dysfunction was associated with graded increases in mortality across ascending levels of QRS prolongation. CONCLUSIONS: Approximately 20% of a generalized heart failure population can be expected to have a prolonged QRS duration within the first year of diagnosis, suggesting that as many as 20% of patients with heart failure may be candidates for biventricular pacing.

Aged↗
PubMed2004

[Digital cephalometrics].

There are different methods to produce digital head films and all have advantages and disadvantages. With a digital head film and a computer programme for digital cephalometry an analysis can be performed easily. All existing computer programmes for digital cephalometry use reference values to compare with the patient's values. However, the magnification factors of the two data sets, which are compared, must be known and correction to the same magnification must be possible within the programme. Furthermore, the reference values should be age, gender, and population related. Many commercially available programmes do not fulfil these criteria. A well-designed programme for digital cephalometry should have the possibility to calculate age and gender-related reference values based on values of the target population. Furthermore it should have the possibility to analyse several longitudinal head films at the same time and to present the data graphically. A national survey among Dutch orthodontists by the end of 2000 demonstrated that 35% of Dutch orthodontists used digital cephalometry in their office. The most commonly used analysis was the Steiner-Tweed analysis, which was performed by nearly 60% of the orthodontists.

Age Factors↗
PubMed2004

A review of empirical studies on the model of effort-reward imbalance at work: reducing occupational stress by implementing a new theory.

The present study reviews empirical studies of a new occupational stress model of effort-reward imbalance at work to examine its validity as an occupational stress measure and the theory-based intervention approach to occupational stress reduction. The effort-reward imbalance model is valid for demonstrating a stressful work environment that reflects the current labor market and predicts health conditions among a wide range of working populations. The stressful aspects of work measured by the effort-reward imbalance model are different from those shown in the job demand-control model, and the adverse health effects are independent of each other, which suggests that the two models are complementary. The evidence indicates that it is efficient to select psychosomatic symptoms as short-range target outcomes and sick leave as a medium-range target outcome of the theory-based intervention. In addition, it would be preferable to simultaneously measure job satisfaction, morale, motivation, and performance as organizational level outcomes. Although employees engaged in diverse occupations can be target populations, high effectiveness is expected, particularly in service occupations that work shifts. Studies are necessary to determine how long and how intensely interventions are implemented. Target work environments are selected from the perspective of securing or improving employees' sense of fairness and reciprocity by approaching them. Since the theory-based intervention depends largely on organizational changes that are beyond the individual employees' ability, the cooperation of employers is necessary.

Humans↗
PubMed2005

Using qualitative and quantitative formative research to develop tailored nutrition intervention materials for a diverse low-income audience.

More effective nutrition education to reach low-income and ethnic minority populations is needed. As part of a project to develop a tailored nutrition education intervention to meet the needs of low-income Hispanics and non-Hispanics, complementary, mixed methods of formative research were used to determine specific characteristics of the target population. The aim was to ensure that the full array of nutrition messages would be comprehensive enough to effectively tailor to the level of the individual. Barriers to healthy eating were delineated for three main dietary behaviors (number of items delineated in parentheses): lowering fat (11), increasing fruit (8) and increasing vegetables (6). Information was also collected regarding motivators for healthy eating (5), situational barriers to making healthy choices (4), other nutrition-related interests (8) and typical eating habits and food-related choices of the target audience.

Feeding Behavior↗
PubMed2003

Frequency dependent natural selection during character displacement in sticklebacks.

We know little about how natural selection on a species is altered when a closely related species consuming similar resources appears in its environment. In a pond experiment with threespine sticklebacks I tested the prediction that divergent natural selection between competitors is frequency-dependent, changing with the distribution of phenotypes in the environment. Differential growth and survival of phenotypes in a target stickleback population were contrasted between two treatments. In one treatment an offshore zooplankton feeder (the limnetic stickleback species) was added to the same pond as the target. In the other treatment I added the benthic stickleback instead, a species adapted to feeding on invertebrates from sediments and inshore vegetation. The target population was ecologically and morphologically intermediate with phenotypic variance artificially inflated by hybridization. Growth rates of phenotypes within the target population differed between treatments as predicted by character displacement. The impact of adding a second species always fell most heavily on those phenotypes in the target population resembling the added species most closely. However, those individuals in the target population that most resembled the added species did not experience reduced survival. Instead, consistent survival differences between populations suggested the presence of an inshore-offshore gradient in mortality risk. These results provide further support for the hypothesis of character displacement in sympatric sticklebacks. They suggest that displacement along the resource gradient also led to divergence in vulnerability to agents of mortality, probably including predation.

Animals↗