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PubMed2001

Successful Medicaid managed care organizations: it is not an oxymoron.

Success as a Medicaid health plan is achieved by those plans with a clear understanding of Medicaid program requirements. Executives of Medicaid health plans identify four common elements that result in winning plans: (1) Leadership must have significant experience with, or otherwise develop knowledge of, the Medicaid program's regulations and populations covered; (2) the plan must have an internal managed care culture and system that integrates finance, operations, and medical management; (3) management must have access to highly specialized information and data analysis capability; (4) leadership must have well-developed relationships with key stakeholders. While these elements seem intuitive, health plans often enter the marketplace without needed groundwork firmly in place.

Database Management Systems↗
PubMed1995

Extending a clinical repository to include multiple sites.

With the consolidation of health care organizations and services, a clinical repository comprising data from a single site is no longer sufficient. Individual patient data are now spread across multiple sites comprising a single enterprise. Users require an integrated view, or at least a common view, of these clinical data across multiple sites. Many issues arise when one tries to merge data from multiple, distinct organizations into an existing schema. We have addressed these issues while extending our clinical repository for Barnes Hospital with data from Jewish Hospital, both of which are members of the recently formed BJC Health System. We describe the architecture of our existing repository, approaches and issues in extending this repository to include multiple sites, and the specific issues we addressed in our system.

Computer Communication Networks↗
PubMed2001

Point-of-care testing.

Point-of-care testing technology rapidly is changing the way physicians practice medicine by facilitating the availability of biochemical parameters immediately or almost immediately. The constant evolution and developments in [figure: see text] microchemistry and computer technology will make this area a dynamic part of medicine with the constant emergence of improved and newer technologies. Clinicians must not forget, however, that the best analyzer and monitor is the physician, nurse, or other health care worker in direct contact with the patient, constantly reassessing, re-examining, and integrating all of the physiologic and biochemical data in the context of the history and physical examination. If POC testing is implemented, its goal should be to improve and assist in patient care.

Blood Transfusion↗
PubMed2004

The Social Transition in the North: collection and data access protocols.

OBJECTIVE: These protocols were designed to provide access to the Social Transition in the North (STN) collection and data set. METHOD: Staff at the (UAA) Institute for Circumpolar Health Studies (ICHS) reviewed, organized, inventoried, and cataloged the STN collection. RESULTS: Most of the materials in the collection are available from the UAA Archives and Manuscripts Department, Consortium Library. Documents and data containing sensitive information are maintained by ICHS to assure confidentiality of research participants. CONCLUSION: These access protocols allow researchers to obtain access to this valuable data set consistent with US research policy while protecting the integrity of the data and the confidentiality of the participants.

Alaska↗
PubMed1999

Women dwelling with violence.

PURPOSE: To explore the Heideggerian concept of dwelling as revealed in the lives of women who have experienced sexual violence. Sexual violence against women by men known to them is a significant health problem, yet little is known about how such violence affects women's everyday experience. METHODS: Phenomenologic, integrating (a) data collected in 1996 and 1997 from 10 American women who had experienced sexual violence, (b) Heideggerian philosophy, (c) other literature, and (d) excerpts from the communications media. In-depth, open-ended interviews with women, followed by analysis of transcripts using Heideggerian hermeneutics. FINDINGS: Women "dwelling with violence" were living among and inseparable from violence, abuse, and maltreatment. Violence resulted in their "living-in-exile"--feeling uprooted, unsettled, unprotected, and distrustful. Yet their stories were about "preserving and sparing amidst violence"--caring for things they value, creating a safe place for themselves, guarding that which is essential to their nature, and seeking to protect others. CONCLUSIONS: Sexual violence can profoundly affect the lives of women. Women's narratives indicate complex and creative response to living in a violent environment. Nurses who seek to understand the effects of violence on a woman's daily life should focus not only on symptomatic responses to a single violent event, but also should consider her life history, the social context of her daily experiences, the degree to which violence has alienated her from others, and her unique way of responding to violence.

Adaptation, Psychological↗
PubMed1996

Reactions of salaried physicians to hospital decline.

OBJECTIVE: To examine the Exit, Loyalty, Voice, and Neglect (ELVN) reactions of full-time salaried physicians to the decline of their employing hospital, and to explore factors possibly associated with the choice of reactions. DATA SOURCE: The study analyzes data collected in a larger survey of work attitudes of 703 hospital physicians, constituting a representative national sample of (every tenth) salaried hospital physicians in Israel. DATA COLLECTION: Data were collected through a self-administered mail questionnaire with return envelopes attached. STUDY DESIGN: A survey design was used. Survey questionnaires included composite measures of the ELVN reaction as well as of the main predictors of reaction choice: job satisfaction, hospital commitment, job investment, alternatives, tenure, and managerial and senior positions. PRINCIPAL FINDINGS: The reactions of salaried physicians to hospital decline include the whole range of ELVN reactions. The choice of each reaction was found associated with a different set of disposition, situation, and position predictors. CONCLUSIONS: The ELVN typology is relevant for examining physicians' reactions to hospital decline, which appear to extend beyond the simple stay/leave dichotomy commonly used. The reactions of Exit, Loyalty, Voice, and Neglect are different in nature, and appear to reflect the different sets of circumstances that salaried physicians may face. Implications of these results for coping with hospital decline, hospital-physician relationships, and integration strategies are discussed.

Attitude of Health Personnel↗
PubMed2004

[An epidemiological model of genital herpes for assessment of potential impact of therapy and prophylaxis: application to France].

OBJECTIVES: This study was performed to quantify the development of the number of cases of genital herpes and to assess the impact of different treatment strategies in France. METHOD: A model for the natural history of herpes simplex virus genital infection is presented and applied to the French population. The model encompasses infection by herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2), first episodes, recurrences, viral shedding and the effect of treatment on infected individuals. RESULTS: In the Year 2000, 270,000 individuals would have suffered from genital herpes in France. A total annual cumulated number of 1.5 million episodes of recurrence and 23 million days of viral shedding were estimated. Seventy percent of viral shedding occurred in sub-clinical seropositive individuals. The expected number of attributable neonatal deaths remained very low. Systematic treatment of clinical episodes might reduce the number of days with lesions (- 27 p. 100), and is also effective on viral shedding (symptomatic: - 50 p. 100). Continuous treatment of the most severe patients (>or=6 recurrences per Year) might reduce viral shedding slightly more (- 85 p. 100). Antiviral treatment might have a major impact on the quality of life of these patients but would only slightly curb the number of new infections. DISCUSSION: This model tries to integrate the various data currently available at international level on the epidemiology of genital herpes. However, many aspects are still not well documented and remain uncertain. It is therefore necessary to define various assumptions in order to simulate the natural history of the disease in a population. The lack of French data especially on the HSV-1 and HSV-2 seroprevalence profiles reinforces these uncertainties. Our results should hence be considered as exploratory. However, this modeling approach is the only possible way to integrate the multiple parameters describing the pathology and predicting of the public health impact of different interventions. This model is an open tool which may be modified when new data become available.

Adolescent↗
PubMed2004

Economic evaluation of treatments for cancer in childhood.

Treatment of cancer in childhood is an expensive undertaking for the health-care system and for the affected families. As there is a substantial burden of treatment-related morbidity, it is important to determine whether the effects of treatment are worth these monetary costs, especially from a societal perspective. Economic evaluation affords a comparison of the costs and consequences (effects) of relevant therapeutic alternatives. Preference-based measures of health-related quality of life are particularly useful for assessing the effects of treatment, for these tools integrate mortality and morbidity. These measures provide utility scores that can be used as weights on survival data to compute quality-adjusted life years (QALYs). Costs are incurred both within and outside of the health-care system. The former should include those in front-line patient care departments (e.g. nursing); the pro-rated share of the expenses of service departments (e.g. materials management) to those in the front line; and the fully allocated costs for capital invested in lands, building and equipment. The latter are costs borne by families that are both out-of-pocket (e.g. for over-the-counter drugs) as well as related to time spent in providing care, which may involve foregone income. Costs and consequences should be subject to discounting; a process for converting those items incurred in the future into contemporary equivalents. Economic evaluation provides estimates of incremental discounted costs per discounted QALY gained. By almost any interpretative standard this appears attractive with respect to cancer in childhood. Examples are provided with the encouragement that economic evaluation be undertaken in more clinical trials in paediatric oncology.

Child↗
PubMed2002

Ecotoxicological monitoring of remediation in a coke oven soil.

Assessment of contaminated sites is usually based on chemical analyses of hazardous compounds in soil. This is enough either to assess the environmental hazard of contaminated soil nor to evaluate the efficiency of applied remediation techniques. Information on the bioavailability of complex mixtures of xenobiotics and degradation products cannot be provided by chemical analytical data, but results from bioassays can integrate the effects of pollutants in mixtures. In the preservation of human health and environmental quality, it is important to evaluate ecotoxicological effects of contaminated industrial soils to complement the techniques of analytical chemistry. The monitoring of a coke oven soil and the evaluation of the landfarming treatment technique, conducted on-site in a pilot scale installation, was done by a battery of ecotoxicological tests: acute, chronic, and genotoxicity tests. Contaminated soil samples revealed toxic effects for different species mainly due to high concentrations of polycyclic aromatic hydrocarbons (PAHs). After landfarming treatment, soil samples presented significant reduction in toxicity, confirming the effectiveness of the landfarming process pointed out by a significant reduction in low molecular weight PAH concentrations. Comparative analysis of the different ecotoxicological tests allowed the establishment and validation of a more suitable procedure for the monitoring of PAH contaminated soils.

Animals↗
PubMed2000

Can radiologic images be incorporated into the electronic patient record?

As radiology makes advances toward filmlessness, all of medicine is headed, just as rapidly, toward paperless transmission of patient information. While there are obvious advantages to this electronic approach, and several standards to conform to for the transmission of textual (Health Level 7 [HL-7]) and image (Digital Imaging and Communications in Medicine [DICOM]) data, it is the integration of these two data sets that is clinically essential and yet poorly defined. This report defines an approach for, and the successful implementation of, the integration of radiologic image data with textual data contained within the electronic patient record (EPR) through the use of standard internet protocols. Incorporation of medical images in the EPR has proven to be critical to the successful deployment of picture archiving and communications systems (PACS) and the reduction of film consumption at Massachusetts General Hospital (MGH). Since the installation of the first internet-based Image Data Repository (IDR) at MGH in 1995, the system has adequately served to meet the needs of clinical requests by both radiology-only browser users and users of the EPR. It has drastically reduced the need for film and provided concurrent display of images and text throughout the institution and beyond.

Computer Systems↗
PubMed2002

[Arteriosclerosis -- a lifelong challenge].

BACKGROUND: Effective prevention of cardiovascular diseases is of utmost importance in Western civilizations as they are on top of mortality statistics. PRIMARY PREVENTION: Physical exercise plays an important role in optimizing the individuals cardiovascular risk profile. However in the absence of scientifically based studies the potential benefit of physical exercise is often being discussed. Recently by several population-based studies it has been proven that physical exercise is inversely related to long-term cardiovascular mortality in both man and women of all age groups, even after adjustment for other risk factors. SECONDARY PREVENTION: Even for secondary prevention in clinical studies and meta-analyses a reduction of all causes and cardiovascular mortality of 20-45% was found after physical exercise. TYPE OF SPORTS: At present it is being discussed controversially which type of sports would be most beneficial. Recent studies have shown that cardiovascular risk reduction is not only the consequence of vigorous exercise, especially endurance training, but can also be achieved by moderate training programs like walking or increased daily activities. CONCLUSION: Current epidemiological data reveal the necessity to perform more physical activity/exercise training, which would best be integrated in a health-oriented lifestyle. An early beginning, even in childhood, is important.

Arteriosclerosis↗
PubMed2002

Moving from recommendation to implementation and audit: part 2. Review of interventions and audit.

There are multiple interventions available that may help to control the development and spread of resistance to antimicrobial agents in bacteria implicated in community-acquired respiratory tract infections. Unfortunately, very few studies have assessed the effectiveness of these interventions using objective end-points, such as reduction in resistance rates and improvement in clinical outcomes. Most interventions are centered on reducing inappropriate or unnecessary use of antibiotics; others focus on reducing disease burden and bacterial colonization. With regard to antibiotic use, efforts should be concentrated at both the prescriber and consumer levels. Interventions that target prescribers include: provision of educational materials; strategies and tools to improve diagnosis; implementation of practice guidelines; personalized interactive sessions with feedback on the practice profile; and use of delayed prescription and alternative prescribing strategies. Optimal results are usually obtained when these interventions are combined with consumer education. Regulatory interventions (e.g. licensing regulations and controlled access to drugs), restrictions in the use of agents for growth promotion in animals, and use of nonantimicrobial therapies (e.g. probiotics) may help further to reduce inappropriate antibiotic use and thereby decrease the selective pressure for development of resistance. Infection-control strategies, public health measures, vaccination programs, and new antibiotics all have a role in minimizing the spread of resistant organisms. Ideally, resistance-control programs should include predefined criteria for success and integral audit processes based on objective end-points (antibiotic use, resistance trends, and health outcomes). Standardization of data collection is imperative so that the relative merits of various interventions can be compared. Effective implementation and audit of interventions is often difficult in developing countries owing to poor health-care infrastructures, lack of resources, poor education/training, and minimal regulatory controls on the supply and quality of antimicrobials. Substantial support from governments and health-care organizations across the globe is required to initiate and sustain effective intervention programs to control antimicrobial resistance.

Anti-Bacterial Agents↗
PubMedDate not supplied

Research integrity: a government perspective.

What is research integrity? At the United States Environmental Protection Agency (U.S. EPA) research integrity can be defined as conducting and fostering research to define, anticipate, and understand environmental problems; and generating sound, appropriate, credible, and effective solutions to those problems. Whether in government, academia, or industry, integrity is required at all stages of research--from data generation to data analysis. What constitutes research integrity? Simply put, Did we do the right thing? Did we do it the right way? Did we honestly document what we did? This is especially important if the research is used as a basis for public policy. The extensive and intensive use of the results of science in EPA's standard setting, regulatory, and enforcement responsibilities means that scientific misconduct can lead to costly and inappropriate actions through unnecessary expenditure or inadequate protection. The soundness, effectiveness, and credibility of EPA's regulations ultimately rest on the scientific and technical bases for these actions. Careful attention to research record keeping can help ensure data quality and integrity. The U.S. Environmental Protection Agency, its research requirements, and the work of the National Health and Environmental Effects Research Laboratory are discussed below.

Environmental Monitoring↗
PubMed2006

The ToxCast program for prioritizing toxicity testing of environmental chemicals.

The U.S. Environmental Protection Agency (EPA) is developing methods for utilizing computational chemistry, high-throughput screening (HTS), and various toxicogenomic technologies to predict potential for toxicity and prioritize limited testing resources toward chemicals that likely represent the greatest hazard to human health and the environment. This chemical prioritization research program, entitled "ToxCast," is being initiated with the purpose of developing the ability to forecast toxicity based on bioactivity profiling. The proof-of-concept phase of ToxCast will focus upon chemicals with an existing, rich toxicological database in order to provide an interpretive context for the ToxCast data. This set of several hundred reference chemicals will represent numerous structural classes and phenotypic outcomes, including tumorigens, developmental and reproductive toxicants, neurotoxicants, and immunotoxicants. The ToxCast program will evaluate chemical properties and bioactivity profiles across a broad spectrum of data domains: physical-chemical, predicted biological activities based on existing structure-activity models, biochemical properties based on HTS assays, cell-based phenotypic assays, and genomic and metabolomic analyses of cells. These data will be generated through a series of external contracts, along with collaborations across EPA, with the National Toxicology Program, and with the National Institutes of Health Chemical Genomics Center. The resulting multidimensional data set provides an informatics challenge requiring appropriate computational methods for integrating various chemical, biological, and toxicological data into profiles and models predicting toxicity.

Animals↗
PubMed1995

Organizing for nursing home quality.

This article explores the relationship between job, work group, and organizational design and the quality of nursing home care. Contingency theorists contend that effective organizations develop structures that support the nature of their production processes and complement their environment. Within the same facility, units with differing care requirements should be structured differently to achieve quality outcomes. Efforts to improve quality can be integrated through the practice of total quality management and facilitated by using the Health Care Financing Administration Minimum Data Set.

Efficiency, Organizational↗
PubMed1996

Environmental public health surveillance.

A holistic and collaborative approach needs to be taken in the development of environmental public health surveillance systems. Exposure and hazard surveillance integrated with outcome-based surveillance will blend fragmented strands of data into streams of information. Adequate resources and strong leadership are essential to the creation of such surveillance systems.

Child↗
PubMed2005

Measuring the effect of a large reduction in welfare payments on mental health service use in welfare-dependent neighborhoods.

BACKGROUND: Major social policy changes were implemented in Canada in the last decade with few efforts to examine their potential health effects. OBJECTIVES: We sought to determine the impact of a large reduction in welfare benefits on use of ambulatory physician mental health services in areas with high levels of welfare dependency relative to areas with low levels of welfare dependency. METHODS: The setting was Toronto, Canada. Data sources included census, provincial health insurance, and municipal welfare data. We used generalized estimating equations to compare ambulatory mental health service rates by neighborhood level of welfare dependency before and after a 21.6% reduction in welfare payments. RESULTS: There were no long-term relative differences by welfare dependency in mental health service use before compared with after the policy change. There was a very small short-term increase in mental health visits to generalists in the 6 months after the policy change. We demonstrated a marked gradient in psychiatric service use with low welfare dependency areas having significantly higher rates of use than high welfare dependency areas. CONCLUSIONS: We demonstrated a mismatch between known levels of need for care and levels of psychiatric use. We conclude that where use of services is not tightly linked to need for services, utilization data may be unsuitable for evaluating programs or policies. Social policy changes with potential health effects should have integrated evaluations planned at the time of policy implementation.

Community Mental Health Services↗
PubMed2006

Lack of ethnic disparities in adult immunization rates among underserved older patients in an urban public health system.

BACKGROUND: In some settings, immunization rates for ethnic minorities are less than those of non-Hispanic white populations. This study examines demographic differences in the rate of pneumococcal and influenza immunization in an ethnically diverse older patient population seeking care at an urban primary care clinic system. METHODS: The setting is an integrated system of 11 federally qualified community health centers serving approximately 100,000 unduplicated patients annually. We linked data from chart audits performed in 2001-2003 for quality assurance purposes with patient registration data to evaluate vaccination rates in 740 patients age 66 years and older who had at least 3 primary care visits in the previous 2 years. RESULTS: Factors significantly associated with receipt of pneumococcal vaccination in multivariable analysis were Hispanic ethnicity (odds ratio [OR] 1.66-1.77, P = 0.01), medical comorbidities (OR 1.48, P = 0.03), psychiatric comorbidities (OR 2.0, P = 0.001), use of a family medicine versus internal medicine clinic (OR 2.3, P < 0.001), and age (OR 1.04 for 1 year increase, P = 0.004). Factors significantly associated with influenza vaccination were having insurance (OR 2.25, P = 0.014), medical comorbidities (OR 1.71, P = 0.036), age (OR 1.03 for 1 year increase, P = 0.045), later year of audit (OR 1.68-1.73, P = 0.015), and a greater number of clinic visits (OR 1.69, P = 0.006). CONCLUSIONS: Among older regular users of our public community health centers, minority populations have equal or higher immunization rates compared with non-Hispanic whites.

Age Factors↗