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PubMed2003

The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines.

BACKGROUND: This study tested the effects of two organizational support processes, the provision of financial incentives for superior clinical performance and the availability of a patient (smoker) registry and proactive telephone support system for smoking cessation, on provider adherence to accepted practice guidelines and associated patient outcomes. METHODS: Forty clinics of a large multispecialty medical group practice providing primary care services were randomly allocated to study conditions. Fifteen clinics each were assigned to the experimental conditions "control" (distribution of printed versions of smoking cessation guidelines) and "incentive" (financial incentive pay-out for reaching preset clinical performance targets). Ten clinics were randomized to receive financial incentives combined with access to a centralized patient registry and intervention system ("registry"). Main outcome measures were adherence to smoking cessation clinical practice guidelines and patients' smoking cessation behaviors. RESULTS: Patients' tobacco use status was statistically significant (P < 0.01) more frequently identified in clinics with the opportunity for incentives and access to a registry than in clinics in the control condition. Patients visiting registry clinics accessed counseling programs statistically significantly more often (P < 0.001) than patients receiving care in the control condition. Other endpoints did not statistically significantly differ between the experimental conditions. CONCLUSIONS: The impact of financial incentives and a patient registry/intervention system in improving smoking cessation clinical practices and patient behaviors was mixed. Additional research is needed to identify conditions under which such organizational support processes result in significant health care quality improvement and warrant the investment.

Ambulatory Care Facilities↗
PubMed2002

Treatment of nausea and emesis during cancer chemotherapy. Discrepancies between antiemetic effect and well-being.

The purpose of this study was to describe the relationship between antiemetic effect and well-being in patients receiving four different antiemetic treatment strategies, representing developments in the field during the past 15 years. A total of 162 women with ovarian cancer receiving cisplatin-based chemotherapy and participating in two comparative antiemetic trials were enrolled and studied for up to four cycles. In study I, a combined antiemetic strategy including a nursing intervention program (increased access to support and increased information) and antiemetics based on high-dose metoclopramide and dexamethasone was compared with the standard antiemetic treatment during the 1980s. In study II, ondansetron plus dexamethasone/placebo was evaluated. The assessment methods used were similar for all patients. Questionnaires were used to assess frequency, intensity, and duration of nausea, emesis, anxiety, pain, and well-being at baseline, and for acute (24 hours after chemotherapy) and delayed (up to 2 weeks after chemotherapy) symptoms. The mean intensity of acute nausea during the first cycle was higher in the groups in study I, as compared to the groups in study II. The group receiving a nursing intervention reported better well-being than the other groups. Duration of nausea was an important predictor of well-being, even when nausea intensity was controlled. Apart from nausea intensity, nausea duration and nursing interventions may be important determinants for well-being during chemotherapy.

Drug-Related Side Effects and Adverse Reactions↗
PubMed2003

Dynamic quiz bank: a portable tool set for authoring and managing distributed, Web-based educational programs in radiology.

RATIONALE AND OBJECTIVES: The authors performed this study to evaluate a portable, platform-independent software program that enables users from remote sites to transform raw materials (eg, text, images, video) into Web-ready, interactive tutorials and examinations. MATERIALS AND METHODS: The software program evaluated consists of three modules: a network-based interface developed in the Java programming language, an Oracle 8i relational database with liaison software, and shell scripts developed in the Perl programming language to automate the authoring, maintenance, and updating of content in a dynamic quiz bank (DBQ). Four faculty members, one radiology resident, and two undergraduates majoring in computer science volunteered to create questions for the DQB and to evaluate ease of authoring. RESULTS: Faculty members with various levels of computer proficiency were able to establish a comprehensive DQB of more than 1,000 interactive questions. These radiologists reported the scripts reliable and easy to use. The DQB, offered in a pathology course for 2nd-year medical students, was used by 151 students and may have played a role in improving standardized test scores. Eighty-seven percent (n = 131) of the students believed that the DQB was extremely useful as an educational tool. CONCLUSION: The DQB software program facilitated access to, and authoring and maintenance of, Web-based educational materials developed in the departments of radiology and pathology.

Computer-Assisted Instruction↗
PubMed2002

Protein identification by MALDI-TOF-MS peptide mapping: a new strategy.

A new strategy for identifying proteins by MALDI-TOF-MS peptide mapping is reported. In contrast to current approaches, the strategy does not rely on a good relative or absolute mass accuracy as the criterion that discriminates false positive results. The protein sequence database is first searched for all proteins that match a minimum five of the submitted masses within the maximum expected relative errors when the default or externally determined calibration constants are used, for instance, +/-500 ppm. Typically, this search retrieves many thousand candidate sequences. Assuming initially that each of these is the correct protein, the relative errors of the matching peptide masses are calculated for each candidate sequence. Linear regression analysis is then performed of the calculated relative errors as a function of m/z for each candidate sequence, and the standard deviation to the regression is used to distinguish the correct sequence among the candidates. We show that this parameter is independent of whether the mass spectrometric data were internally or externally calibrated. The result is a search engine that renders internal spectrum calibration unnecessary and adapts to the quality of the raw data without user interference. This is made possible by a dynamic scoring algorithm, which takes into account the number of matching peptide masses, the percentage of the protein's sequence covered by these peptides and, as new parameter, the determined standard deviation. The lower the standard deviation, the less cleavage peptides are required for identification and vice versa. Performance of the new strategy is demonstrated and discussed. All necessary computing has been implemented in a computer program, free access to which is provided in the Internet.

Algorithms↗
PubMed1997

New methodology for profiling combinatorial libraries and screening sets: cleaning up the design process with HARPick.

Combinatorial chemistry is a tool of increasing importance in the field of ligand design, as it can yield huge increases in the number of compounds available for screening. Unfortunately, it is often the case that the number of molecules which could theoretically be constructed greatly exceeds potential synthesis and screening capacity. For this new technology to be fully exploited, it will become vital to design libraries with reference to the properties of compounds already in existence, if the added value of each new molecular collection is truly to be maximized. Similarly, if we are to take full advantage of the potential of combinatorial chemistry in lead optimization, it is important that our library design paradigms are flexible, with diversity scoring functions that can be modified to suit particular projects. Here these challenges are addressed through the introduction of a novel computer-aided library design tool known as HARPick (heuristic algorithm for reagent picking). The program is accessible to the bench chemist, and incorporates several significant advances over currently available approaches. These include product-based diversity calculations that can be constrained at the reagent level; diversity measures constructed from multiple descriptors; improved pharmacophore key information and full pharmacophore profiling of entire molecular databases. The potential of these improvements to aid in diversity profiling is illustrated through comparison with established methodology, and possible further enhancements are discussed.

Algorithms↗
PubMed1999

Use of social services by pregnant Medicaid eligible women in Baltimore.

OBJECTIVES: To use linked health and social service databases to determine differences in the use of social services by pregnant women in different managed care systems. METHODS: Comparison of service use by women enrolled in a fee-for-service primary care case management program (Maryland Access to Care or MAC), in a capitated health maintenance organization (HMO), or not assigned to managed care using six state databases. Participants included 5181 women receiving Medical Assistance (MA) and delivering in Baltimore City in 1993. Outcome measures were receipt of WIC, AFDC, and Food Stamps. RESULTS: The overall proportions of women receiving WIC, AFDC, and Food Stamps at delivery were 52.7%, 89.2%, and 62.7%, respectively. Women enrolled in an HMO at delivery were less likely to be receiving WIC (adjusted odds ratios, 0.8, 95% CI, 0.69 to 0.93), AFDC (OR, 0.20; CI, 0.03 to 0.43 for women with prior children and OR 0.13; CI, 0.09 to 0.20 for women without prior children), and Food Stamps (OR 0.77; CI, 0.59 to 0.95 for women with prior children and OR, 0.49; CI, 0.35 to 0.67 for women without prior children) than their MAC counterparts. Women not assigned to managed care also generally were less likely than their MAC counterparts to receive WIC (OR 0.55; CI, 0.46, 0.66), AFDC (OR 1.07; CI 0.83, 1.30 for women with prior children and OR 0.24; CI 0.18, 0.34 for women without prior children), and Food Stamps (OR 0.31; CI 0.08, 0.55 for women with prior children and OR 0.31; CI 0.23, 0.41 for women without prior children). CONCLUSIONS: Although many low-income pregnant women qualify for select social services, receipt of WIC and Food Stamps was low. Increasing efforts are needed by managed care systems and public health agencies to ensure delivery of appropriate services for women.

Adolescent↗
PubMed2004

Seton Hall university doctor of science degree program: clinical doctorate in audiology.

This article provides an overview of the clinical doctoral program in audiology at Seton Hall University. It is a full-time, 4-year program that includes academic course work, clinical practica, and research experience. In concert with the university mission, the program is designed to enable students to develop the skills they need to be leaders in the field of audiology, providing assessment and intervention to individuals with hearing problems and enhancing the knowledge base of the profession. As part of the School of Graduate Medical Education, students in the program have access to a wealth of resources in related health professions. The close proximity to New York City provides many opportunities for outstanding clinical education with a diverse population.

Audiology↗
PubMed1998

The metabotropic glutamate receptor mGlu5 controls the onset of developmental apoptosis in cultured cerebellar neurons.

Cultured cerebellar granule cells grown in medium containing 10 mM K+ undergo apoptosis after 4-5 days in vitro (DIV), and, at that time, the activity of metabotropic glutamate (mGlu) receptors coupled to polyphosphoinositide (PI) hydrolysis begins to decline. In granule cells at 4 DIV, the mGlu receptor subtype mGlu5 was expressed at high levels. The expression of another PI-coupled mGlu receptor, the mGlu1a, was low at 4 DIV but increased during the following days. In cultures at 4-5 DIV, the few cells that already showed an apoptotic phenotype were devoid of mGlu5 receptors, but they all expressed mGlu1a receptors. The development of apoptosis was accelerated after treating the cultures with: (i) mGlu5 antisense oligonucleotides; (ii) the mixed mGlu receptor antagonist, (+)-alpha-methyl-4-carboxyphenylglycine; or (iii) the glutamate depleting enzyme, alanine aminotransferase. In contrast, an induced overexpression of mGlu5 receptors protected cultured granule cells against apoptotic death. We suggest that the activity of mGlu5 receptors supports cell survival, and a decline in the expression of mGlu5 receptors gives access to programmed cell death in cerebellar granule cells developing in primary cultures.

Animals↗
PubMedDate not supplied

The psychosocial impact of interactive computer use within a vulnerable elderly population: a report on a randomized prospective trial in a home health care setting.

Quality of care for vulnerable elderly clients makes it important to consider the psychosocial effects of interactive computer use as a means to communicate for social, functional, and/or health care purposes in a home health care setting. In a 3-month randomized prospective trial, telecommunications terminals were installed in the private residences of computer-illiterate persons, 65-years-of-age and older, providing visiting nurses the opportunity to teach computer use with three different training methods. The control group had similar weekly nurse visits, but no computer terminal use. Pre-posttests using the Rosenberg Self-Esteem Scale and the Geriatric Depression Scale compared change in self-esteem and depression scores of computer-use clients with the scores of the control group clients. Interactive computer use, alone, did not significantly change scores. Compared to the control group, however, there was a significant change toward improved self-esteem and depression when interactive computer use was accompanied with weekly nurse computer training. Weekly training with a significant other, as a substitute for the nurse trainer, significantly improved self-esteem scores but not depression scores. Interactive computer use was not associated with decreased self-esteem or increased depression. Attitude changes and responses to the particular telecommunication service used in this study were mixed, suggesting future research should be based on improved telecommunication systems with access to programs that have greater practical application to the needs of elderly clients.

Aged↗
PubMed2003

Cost-effectiveness of automated external defibrillator deployment in selected public locations.

OBJECTIVE: The American Heart Association (AHA) recommends an automated external defibrillator (AED) be considered for a specific location if there is at least a 20% annual probability the device will be used. We sought to evaluate the cost-effectiveness of the AHA recommendation and of AED deployment in selected public locations with known cardiac arrest rates. DESIGN: Markov Decision Model employing a societal perspective. SETTING: Selected public locations in the United States. PATIENTS: A simulated cohort of the American public. INTERVENTION: Strategy 1: individuals experiencing cardiac arrest were treated by emergency medical services equipped with AEDs (EMS-D). Strategy 2: individuals were treated with AEDs deployed as part of a public access defibrillation program. Strategies differed only in the initial availability of an AED and its impact on cardiac arrest survival. RESULTS: Under the base-case assumption that a deployed AED will be used on 1 cardiac arrest every 5 years (20% annual probability of AED use), the cost per quality-adjusted life year (QALY) gained is $30,000 for AED deployment compared with EMS-D care. AED deployment costs less than $50,000 per QALY gained provided that the annual probability of AED use is 12% or greater. Monte Carlo simulation conducted while holding the annual probability of AED use at 20% demonstrated that 87% of the trials had a cost-effectiveness ratio of less than $50,000 per QALY. CONCLUSIONS: AED deployment is likely to be cost-effective across a range of public locations. The current AHA guidelines are overly restrictive. Limited expansion of these programs can be justified on clinical and economic grounds.

Cost-Benefit Analysis↗
PubMed2003

Native arteriovenous fistula blood flow and resistance during hemodialysis.

BACKGROUND: Measurement of vascular access flow (Qa) has been proposed as the ideal method for surveillance of native fistulae. However, debate exists about the influence of blood pressure (mean arterial pressure [MAP]) on Qa during dialysis. METHODS: During three consecutive dialysis treatments, 10 patients had paired measurements of Qa and MAP performed at 30, 60, 120, 180, 210, and 240 minutes. Access resistance (AR; in peripheral resistance units, PRUs) was calculated from MAP and Qa values. RESULTS: Overall pooled coefficients of variation (CVs) for MAP, Qa, and AR were 8.4%, 12.3%, and 12.9%, respectively. A significant reduction in Qa and MAP occurred throughout the dialysis treatment (Qa, 104 mL/min; P = 0.008; MAP, 10.4 mm Hg; P = 0.007). Mean percentages of change in Qa for the first third compared with the middle and last thirds of the session were -4.6% +/- 11.15% (SD) and -9.6% +/- 10.5%, respectively. Thus, Qa varied between 11.4% and -30.6% from baseline during the last hour of dialysis treatments. A stronger correlation between MAP and Qa was seen in radiocephalic (r2 = 0.55; P < 0.0001) compared with brachiocephalic fistulae (r2 = 0.06; P = 0.023). Mean AR was unchanged during the dialysis session (0.23 PRU; P = 0.358). AR for radiocephalic fistulae was significantly greater compared with brachiocephalic fistulae (6.03 +/- 3.90 versus 3.00 +/- 1.11 PRU; P < 0.0001). CONCLUSION: Qa could decrease up to 30% from baseline, potentially impairing the ability of Qa to predict impending vascular access failure. AR remained stable during the treatment and may be a more useful measure of vascular access performance as part of an access surveillance program.

Arm↗
PubMed1985

From micro to mainframe. A practical approach to perinatal data processing.

A new, practical approach to perinatal data processing for a large obstetric population is described. This was done with a microcomputer for data entry and a mainframe computer for data reduction. The Screen Oriented Data Access (SODA) program was used to generate the data entry form and to input data into the Apple II Plus computer. Data were stored on diskettes and transmitted through a modern and telephone line to the IBM 370/168 computer. The Statistical Analysis System (SAS) program was used for statistical analyses and report generations. This approach was found to be most practical, flexible, and economical.

Computers↗
PubMed1998

Strategies to encourage mammography use among women in senior citizens' housing facilities.

BACKGROUND: This randomized trial evaluated the impact of mammography-enhancing interventions implemented in 40 senior citizens' housing facilities in Pennsylvania and North Carolina. METHODS: After stratification of the facilities according to the socioeconomic status and racial backgrounds of their residents, they were randomly assigned to one of four groups to receive the following: 1) standard care--a Medicare mammography benefit flier; 2) education--the flier and a community education program; 3) access--the flier, mammography appointments, and transportation; 4) combined--all interventions. Telephone surveys, conducted prior to any intervention, identified mammography-eligible women, who were re-surveyed six months later to ascertain mammography use. RESULTS: Logistic regression analyses identified mammography intention, age, and the interaction between ever having had mammography and being in the combined intervention group to be significant predictors of mammography use at six months. However, no significant main effect was found for any of the interventions. CONCLUSIONS: These results suggest that the combination of community-directed mammography education and access to mammography appointments encourages mammography use primarily by women who are already predisposed to having mammography. However, individually targeted and tailored interventions may be needed to encourage mammography use among women who have never had mammography and/or express no intention of having it done.

Aged↗
PubMedDate not supplied

Development and evaluation of the Families, Cultures and Augmentative and Alternative Communication (AAC) multimedia program.

PURPOSE: The Families, Cultures and AAC Project was designed to provide professionals and families with accurate, culturally sensitive information about augmentative communication technologies and decision-making strategies through an innovative, user-friendly format. METHODS: The project resulted in the development of the first interactive bilingual CD-ROM designed to be used by professionals at the pre- or in-service level, and family members from diverse cultures to develop AAC decision-making competencies. RESULTS: The Interactive Health Communication (IHC) model provided an effective structure for conceptualizing, developing and evaluating the program. The program also incorporated universal access design concepts. The program was evaluated in the following 10 categories: usability, visual appearance, consistency, error tolerance, navigation, feedback, user control, redundant formats, content accuracy, and engaging styles. CONCLUSION: Reviewers of the program indicated that it was well designed and would be useful for the intended purpose.

Adult↗
PubMed2005

Home blood glucose prediction: validation, safety, and efficacy testing in clinical diabetes.

BACKGROUND: Patients with diabetes do daily self-monitoring of blood glucose (SMBG). For such patients, we devised an engine that predicts not only the expected blood glucose level at the next meal but also the pending risks of hypoglycemia. The purpose of this study was to validate the predictions and provide evidence of the safety and efficacy of using predicted data in dosing decision support for routine patient care. RESEARCH DESIGN AND METHODS: The prediction engine is a computer program that accesses a central database into which daily records of self-monitored blood glucose data are captured by direct access either across the WWW or by an interactive voice response service on-line 24/7. Validation was done by comparison of predicted values to the subsequently observed data using a Clarke Error Grid. Safety focused on body weight and the frequency of hypoglycemia. Efficacy was judged according to glycated hemoglobin and daily insulin dosages. The experimental design contrasted patients in the tight control (TC) group who had been recently converted to intensified (basal-bolus) therapy with patients in the poor control (PC) group on conventional therapy and who were referred to begin intensified therapy. Both groups accessed the remote database to report their daily SMBG. Predicted glucose values were used in dosing decision support for the PC but not the TC group. RESULTS: Over the 6-month study period a total of 30,129 blood glucose levels were reported by the 54 study patients, and some 24,953 blood glucose predictions were made. Of these, 83% were in the clinically acceptable zones of the Clarke Error Grid. When these data were used for dosing decision support in the PC group, glycated hemoglobin levels fell significantly from 9.7 +/- 1.7% to 7.9 +/- 1.2%, and hypoglycemia dropped fourfold. Total daily insulin doses declined 22%, while body weight remained constant. In the parallel TC group (n = 24), glycated hemoglobin also fell, but only slightly from 7.6 +/- 0.9% to 7.2 +/- 1.1%, while daily insulin doses, rates of hypoglycemia and body weight remained constant. CONCLUSIONS: A novel engine is capable of generating meaningful predictions of blood glucose levels. Use of these validated predictions in decision support for managing medication doses proved safe and efficacious.

Algorithms↗
PubMed2006

Health behaviors among American Indian/Alaska Native women, 1998-2000 BRFSS.

BACKGROUND AND OBJECTIVE: Minority populations, including American Indians and Alaska Natives (AI/AN), in the United States generally experience a disproportionate share of adverse health outcomes compared with whites. The prevalence of risk behaviors associated with these adverse health outcomes among AI/AN women is not well documented, especially for those who live outside areas serviced by Indian Health Service. We sought to describe the prevalence of selected health risk behaviors among AI/AN women, document the disparities between AI/AN women and all U.S. women, and demonstrate the efforts needed for AI/AN women to reach Healthy People 2010 goals. METHODS: Age-adjusted prevalence estimates for selected sociodemographic characteristics, current smoking, obesity, lack of leisure time physical activity, and binge drinking were calculated using Behavioral Risk Factor Surveillance System (BRFSS) data from 1998 to 2000, combined. Comparisons were made between prevalence estimates for AI/AN women and all women who participated in the BRFSS and Healthy People 2010 goals. RESULTS: The prevalences of current smoking (27.8%) and obesity (26.8%) were significantly higher among AI/AN women than among all U.S. women. AI/AN women did not meet Healthy People 2010 goals for current smoking, obesity, leisure time physical activity, or binge drinking. CONCLUSIONS: These data highlight both disparities in health risk behaviors between AI/AN women and all U.S. women and improvements needed for AI/AN women to meet Healthy People 2010 goals. This project demonstrates the overwhelming need for culturally appropriate and accessible prevention programs to address health risk behaviors associated with the leading causes of death among urbanized AI/AN women.

Alcohol Drinking↗