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PubMed1981

Strategies for evaluating the outcome of community services for the chronically mentally ill.

A growing number of community support services are being designed for the chronically mentally ill with the goal of improving this population's adjustment to noninstitutional settings. Program planners anticipate that a comprehensive array of psychiatry and other human services will also benefit families of the mentally ill, staff working with the mentally ill, and communities in which these persons reside. Given this complex services delivery model the authors discuss strategies that must be established for evaluating the effectiveness of community support services. They analyze the methodological issues in designing pertinent outcome studies and suggest research priorities for studying the various target populations and other variables.

Chronic Disease↗
PubMed1990

Strategies for modifying sexual behavior for primary and secondary prevention of HIV disease.

Sexual behavior change is needed for both the primary and secondary prevention of HIV disease. Remarkable progress has been made in modifying high-risk behaviors in selected populations (e.g., gay men living in the epicenters of the epidemic). However, many at-risk populations (e.g., gay men living outside these epicenters, homosexual men who are young or Black, ethnic minorities--especially women of childbearing age, and persons over age 50) have received relatively little research attention and may be at risk for further infection. A community-level approach to behavior change represents one kind of comprehensive strategy to achieve significant reduction in the spread of HIV. Effective approaches at this level require component interventions that are effective in changing behavior and acceptable to target populations. Also needed is an infrastructure to support behavioral change efforts. Lacking at present is a comprehensive and coordinated structure to conceptualize, stimulate, and support the continuum of behavioral research needed for the control of HIV and other sexually transmitted diseases.

Acquired Immunodeficiency Syndrome↗
PubMedDate not supplied

[The "Lower Saxony/Northern Rhine-Westphalia" Neuroblastoma Screening Project: on the need for epidemiologic comparison].

The proof for the general evolution of metastatic neuroblastoma from localized disease by a low-speed process is lacking. The epidemiological approach would require the decrease of neuroblastoma related mortality by reduction of the number of metastatic cases per population unit as a result of a screening program. During 1983 through 1990 the neuroblastoma incidence in the FRG was 0.85-1.09 cases per 100,000 children less than 15 years of age. The mortality rate ranged between 0.25 and 0.49 deaths per 100,000 children. The project "Niedersachsen/Nordrhein-Westfalen" started April 1st, 1992 and is investigating urinary catecholamine metabolite excretion in infants at the age of 10-12 months and for a second time in toddlers at 17-19 months. The target population includes 24.7 million inhabitants with 267,000 births per year. The urine sampled on filter paper is analyzed using thin layer chromatography. Positive and questionable positive results are confirmed by HPLC and GC-MS. The aim of the study is to demonstrate the feasibility of the chosen approach. Furthermore first epidemiological data will be obtained. Until a population-based study on neuroblastoma mortality in screened versus controlled populations has proven the usefulness of the screening it cannot be recommended as a general service to the public.

Adolescent↗
PubMed1999

Controlled drug misuse by Certified Registered Nurse Anesthetists.

The primary purpose of this study was to determine the prevalence of controlled drug misuse among actively practicing Certified Registered Nurse Anesthetists (CRNAs). A second purpose was to determine variance in controlled drug misuse by the variables of age, sex, population and geographic area of residence, type of anesthesia position currently held, and number of years in anesthesia practice. The research data were obtained through self-administered surveys mailed to 2,500 actively practicing CRNAs throughout the United States. With a response rate of 68.4% (1,709 of 2,500), the survey instrument allowed for stratification according to admitted misuse of controlled drugs commonly used in the clinical practice of anesthesia. The established prevalence of controlled drug misuse in the target population was found to be 9.8% of the sample (167 of 1,709 respondents), with the majority indicating a distinct proclivity for polydrug misuse. The survey results were comparable with those of studies involving anesthesiologists and registered nurses with the notable exception of the preferred drugs for misuse. A strong relationship existed between sex, number of years in clinical anesthesia practice, and the likelihood for controlled drug misuse, thus indicating a potential predictor of which CRNAs may misuse controlled drugs. In addition, a significant relationship existed between recency of controlled drug misuse and drug(s) of choice (P = .05). Recommendations include specific tactics for strengthening drug misuse education and prevention. Also, modifications in research design and additional studies in the research area are suggested.

Adult↗
PubMed1988

A screening programme for cervical cancer that worked.

In three of the Nordic countries there are nationwide population based screening programmes for cervical cancer. These organized programmes have resulted in a substantial decrease in the incidence of and mortality from cervical cancer. In Finland the reduction in the incidence due to screening has been about 60-70% and it was most substantial for women around the ages of 35 to 50 years, which were screened most intensively. Similar changes occurred in the mortality. It seems that the prerequisites for a successful programme are, for example, to identify the target population, to send personal invitations to attend the screening and to give the results to the women screened. Quality control and evaluation of the programme are also assumed to be part of the programme. The programmes are consuming few resources. In Finland screening is repeated every five years, resulting in only six or seven smears in a lifetime.

Adult↗
PubMed2000

Community-based epidemiological study of glucose tolerance in Kin-Chen, Kinmen: support for a new intermediate classification.

In this population-based survey, we investigated the prevalence of varying degrees of glucose tolerance among residents of Kin-Chen, Kinmen, as well as the association of glucose tolerance status with potential risk factors for type 2 diabetes and cardiovascular disease (CVD). We focused particularly on subjects with normal 2-h postload glucose level (<7.8 mmol/l) but persistent fasting hyperglycemia (PFH) (5.6-7.8 mmol/l), to examine whether PFH represents an intermediate state between normal glucose tolerance (NGT) and impaired glucose tolerance (IGT). The target population comprised 6346 residents aged 30 years and older. A total of 4354 subjects could be classified into categories of NGT, PFH, IGT, new diabetes, and known diabetes according to medical history, fasting plasma glucose levels, and the results of a 75-g oral glucose tolerance test (OGTT). The potential cardiovascular risk factors assessed included age, obesity (general and central), systolic blood pressure, and fasting levels of insulin, C-peptide, triglyceride, cholesterol, and high-density lipoprotein cholesterol (HDL-C). The age-standardized prevalences of PFH, IGT, new diabetes, and known diabetes were 2.9%, 3.5%, 4.0%, and 3.0%, respectively. Among nondiabetic subjects, the cardiovascular risk factor profiles worsened with decreasing glucose tolerance, with most values differing significantly among the NGT, PFH, and IGT groups. Subjects with PFH, who would be classified as having NGT according to conventional WHO criteria, had physical and biochemical features between those of the NGT and IGT groups. These findings support our previous observation that PFH may be a transition state between NGT and IGT in the progression toward type 2 diabetes.

Adult↗
PubMed2000

Improving diabetes care in a large health care system: an enhanced primary care approach.

OBJECTIVE: The objective of this study was to evaluate the impact of a multifaceted improvement strategy on diabetes quality of care in a defined population of patients. STUDY DESIGN: A multifaceted improvement strategy to enhance diabetes care was deployed to 18 primary care clinics serving 170,000 adults. Interventions empowered patient self-management, supported care team decision making, redesigned office systems, and maximized use of available information technology. Specific goals were to improve glycemic control and reduce cardiovascular risk in all adult diabetes patients. DATA SOURCE AND COLLECTION: Diabetes was identified through pharmacy and diagnostic data (estimated sensitivity 0.91, positive predictive value 0.94), and the target population ranged from 6,542 to 7,037 members over time. Trends in glycosylated hemoglobin (HbA1c) and low-density lipid LDL-cholesterol were analyzed monthly throughout 1999 in both cohorts and serial cross-sections. RESULTS: During 12 months, mean HbA1c improved from 7.86% to 7.47%, and the proportion of patients with HbA1c levels < 8% rose from 60.5% to 68.3%, and the proportion with HbA1c > 10% fell from 10.3% to 7.2%. The LDL test rate rose from 47.4% to 57.4%, and mean LDL fell from 120 mg/dl to 116 mg/dl. The proportion with acceptable lipid control (LDL < 130 mg/dl, or < 100 mg/dl with coronary artery disease) rose from 48.9% to 57.7%. All changes were significant at p < 0.01 or less. CONCLUSION: Clinically significant population-based improvements in diabetes care were observed during a 1-year period using a multifaceted "enhanced primary care" strategy.

Adult↗
PubMed1999

Pretesting Spanish-language educational radio messages to promote timely and complete infant immunization in California.

California's Hispanic infants have lower immunization levels than non-Latino white infants, 53.7% versus 65.2%, respectively. Spanish-language radio is an effective mass media venue for imparting information to Latino populations. It has been demonstrated that lack of parental knowledge of infant immunization timing is associated with delayed immunization coverage. In an effort to improve Latino parent knowledge of immunization timing, two Spanish-language radio commercials were developed to be used in conjunction with community-based educational efforts. In order to gage the potential educational impact of the two commercials, they were pretested with a group of low-income Spanish-speaking Latino parents who represented members of the target population for whom the commercials were created. Both commercials were rated favorably by parents, and elicited immunization-specific responses. Although correct recall of the simplified, basic immunization schedule was low, the level of immunization response consistency and overall approval of both commercials appear to support their use as part of Latino infant immunization educational outreach in California.

Adult↗
PubMed2001

Study of biochemical prevalence indicators for the assessment of iodine deficiency disorders in adults at field conditions in Gujarat (India).

The main objective of this study was to assess the severity of iodine deficiency disorders (IDD) in the adult populations of the Baroda and Dang districts from Gujarat, western India using biochemical prevalence indicators of IDD. The other aim of this study was to establish a biochemical baseline for adequate iodine intake as a result of program evolution in the face of multiple confounding factors, like malnutrition and goitrogens responsible for goiter. A total of 959 adults (16-85 years) were studied from two districts (Baroda and Dang) and data was collected on dietary habits, anthropometric and biochemical parameters such as height, weight, urinary iodine (UI) and blood thyroid stimulating hormone (TSH). Drinking water and cooking salt were analyzed for iodine content. All subjects, irrespective of sex and district, showed median UI = 73 microg/L and mean blood TSH +/- SD = 1.59+/-2.4 mU/L. Seven per cent of the studied population had blood TSH values > 5 mU/L. Females in Baroda and males from Dang district were more affected by iodine deficiency as shown by a lower median UI. Mean TSH was significantly higher in women from both districts as compared to men (P = 0.001). The blood spots TSH values > 5 mU/L were seen in 20% of women from Dang. The normative accepted WHO values for UI and TSH for the severity of IDD as a significant health problem are not available for target population of adults. Urinary iodine normative limits and cut-offs are established for school-aged children. Blood spot TSH upper limit and cut-off values are available for neonate populations. The IDD has not been eliminated so far, as more than 20% of both male and female subjects had UI < 50 microg/L. Males were more malnourished than females in both districts (P < 0.05). Pearl millet from Baroda contained flavonoids like apigenin, vitexin and glycosyl-vitexin. Dang district water lacked in iodine content. Iodine deficiency disorder is a public health problem in Gujarat, with the Baroda district a new pocket of IDD. High amounts of dietary flavonoids in Baroda and Dang, malnutrition and an additional lack of iodine in Dang water account for IDD.

Adolescent↗
PubMed1997

alpha-Spectrin is required for ovarian follicle monolayer integrity in Drosophila melanogaster.

To understand the role of the spectrin-based membrane skeleton in generating epithelial polarity, we characterized the distribution of membrane skeletal components in Drosophila ovarian follicle cells and in somatic clones of mutant cells that lack alpha-spectrin. Immunolocalization data reveal that wild-type follicle cells contain two populations of spectrin heterodimers: a network of alphabeta heterodimers concentrated on the lateral plasma membrane and an alphabetaH population targeted to the apical surface. Induction of somatic clones lacking alpha-spectrin leads to follicle cell hyperplasia. Surprisingly, elimination of alpha-spectrin from follicle cells does not appear to prevent the assembly of conventional beta-spectrin and ankyrin at the lateral domain of the follicle cell plasma membrane. However, the alpha-subunit is essential for the correct localization of betaH-spectrin to the apical surface. As a consequence of disrupting the apical membrane skeleton a distinct sub population of follicle cells undergoes unregulated proliferation which leads to the loss of monolayer organization and disruption of the anterior-posterior axis of the oocyte. These results suggest that the spectrin-based membrane skeleton is required in a developmental pathway that controls follicle cell monolayer integrity and proliferation.

Animals↗
PubMed2006

An audit of influenza vaccination rates.

BACKGROUND: Influenza immunisation confers benefits for the elderly. We attempted to increase the uptake of influenza vaccination in those aged 65 years and over in one general practice in Queensland. METHOD: We used four strategies: a computer search for the target population; telephone recruitment and booking by our receptionist; removal of cost by bulk billing; and using nurse led immunisation. We measured 2004 and 2005 influenza immunisation rates to determine a before and after difference, and sent a questionnaire to patients refusing vaccination. RESULTS: We increased the influenza vaccination rate among 580 patients aged 65 years and over from 77% in 2004 to 83% in 2005 (national rate 79% in 2004). The refusal rate was 10%. DISCUSSION: Influenza immunisation rates improved using a targeted approach. Nurse immunisers seemed to be efficient and offered a saving of doctors' time.

Aged↗
PubMed1998

Routine ultrasound screening for abdominal aortic aneurysm among 65- and 75-year-old men in a city of 200,000 inhabitants.

Unruptured abdominal aortic aneurysm (AAA) is seldom recognized. Thus it is difficult to know whether the incidence of AAA in the general population is high enough to warrant routine screening at least in men after a certain age. Ultrasound screening studies to evaluate the incidence of AAA have been carried out in several English-speaking and Scandinavian countries. The purpose of this report is to describe the results of a study carried out in Belgium. All 65- and 75-year-old men living in the city of Liege, Belgium, were given the opportunity to undergo a free ultrasound examination. Only 41% of the target population was examined. AAA defined as abdominal aortic diameter of >30 mm was observed in 28 subjects (incidence: 3.8%). Mean abdominal aortic diameter was 34.7 mm. A diameter >29 mm was observed in 33 subjects (incidence 4.5%). Mean abdominal aortic diameter was 30.4 mm. On the basis of epidemiological data collected, a high-risk population for AAA was identified. Arterial hypertension (p < 0.05), previous coronary artery surgery (p < 0.05), and smoking (p < 0.06) were more common in subjects with than without AAA. The overall cost of screening was $18.175. The cost per AAA diagnosed was $551.00.

Aged↗
PubMed2001

Implementing chronic disease management in the public healthcare sector in Singapore: the role of hospitals.

The public health care delivery system in Singapore faces the challenges of a rapidly ageing population, an increasing chronic disease burden, increasing healthcare cost, rising expectations and demand for better health services, and shortage of resources. It is also fragmented, resulting in duplication and lack of coordination between institutions. A disease management approach has been adopted by the National Healthcare Group (NHG) as a critical strategy to provide holistic, cost-effective, seamless and well-coordinated care across the continuum. The framework in the development of the disease management plan included identifying the diseases and defining the target population, organizing a multi-disciplinary team lead by a clinician champion, defining the core components, treatment protocols and evaluation methods, defining the goals, and measuring and managing the outcomes. As disease management and case management for chronic diseases are new approaches adopted in the healthcare delivery system, there is a lack of understanding by healthcare professionals. The leadership and participation of hospital physicians was sought in the planning, design and outcomes monitoring to ensure their 'buy-in' and the successful implementation and effectiveness of the program. The episodic diagnosis related group (DRG)-based framework of funding and subvention for healthcare, and the shortage of step-care care facilities, have been recognized by the Ministry of Health as an impediments to the implementation, and these are currently being addressed.

Case Management↗
PubMed1994

Planning oral health care for the elderly in Israel for the years 2000 and 2025.

The methodology and conclusions of this workshop are reported here because the problems requiring solution are not unique to Israel. They will increasingly have wide geographical and political application. The population of Israel since its establishment in 1948 has increased about sixfold. The numbers of the elderly (65+) have increased about tenfold. The current situation must be examined and estimates obtained for the next ten years. Only thus can the system be enabled to cope with the problem as it develops. The chosen method was a carefully preplanned, multisectorial workshop. Recommendations were discussed, amended and finalised. The recommendations of the workshop included: Baseline national data is urgently required. Guidelines are required for selecting specific target populations to which priority should be given. The current favourable situation of adequate oral health manpower in Israel makes it possible to encourage providers of oral health care towards treatment for the elderly. It is essential that the appropriate health authorities allocate sufficient funds for the following urgent purposes: the conduct of a national survey of the elderly population; the establishment of oral health units on a trial basis in some selected hospitals; support institutions of higher education to facilitate training in geriatric dentistry. CONCLUSIONS. The workshop was multidisciplinary because it was necessary to include all the expertise and experience available as vital elements of the policy making process. This type of workshop was found to be an effective tool for planning oral health services.

Aged↗
PubMed1985

Determining school programming needs of special population groups: a study of asthmatic children.

A study of the 4,382 children in the New Milford (Connecticut) Public School System was conducted to determine if upper respiratory conditions and other health problems may be related to school performance. Seven percent of the 4,036 respondents were found to be asthmatic. Correlations of school-related factors for 61 of 286 students who had high absenteeism did not appear to be dependent upon asthma for any identified health problem. As absenteeism increased, student grades decreased. Achievement testing in math and reading was related positively to IQ and appeared to be unaffected by absenteeism from school. On the basis of this study, special education programming was not recommended for the target population; however, parents and school personnel are much more aware of physical, emotional, and mental health problems and their possible implications for school performance.

Absenteeism↗
PubMed2000

Differential effects on socioeconomic groups of modelling the location of mammography screening clinics using Geographic Information Systems.

OBJECTIVE: To evaluate spatial access to mammography clinics and to investigate whether relocating clinics can improve global access. To determine whether any change in access is distributed equitably between different social groups. METHODS: The study was undertaken in Perth, Western Australia in 1996. It was an analysis of travel distances to mammography clinics, comparing distances to the pattern of existing clinics and modelled relocated clinics. The study population was the 151,162 women aged 40-64 years resident in Perth in 1991. RESULTS: Overall travel distances to the existing clinics was reduced by 14% when a GIS system was used to relocate them so as to minimise the travel distance for all women. The travel distance of the most disadvantaged groups fell by 2% and by 24% for the least disadvantaged group. CONCLUSIONS: GIS modelling can be used to advantage to evaluate potential locations for screening clinics that improve the access for the target population, however global analysis should be supplemented by analysis of special groups to ensure that no group is disadvantaged by the proposal. IMPLICATIONS: If new technology is not used to evaluate the placement of health services, population travel distances may be greater than necessary, with possible impacts on attendance rates.

Australia↗
PubMed1999

Identification of incident stroke in Norway: hospital discharge data compared with a population-based stroke register.

BACKGROUND AND PURPOSE: The validity of hospital discharge diagnoses is essential in improving stroke surveillance and estimating healthcare costs of stroke. The aim of this study was to assess sensitivity, positive predictive value, and accuracy of discharge diagnoses compared with a stroke register. METHODS: A record linkage was made between a population-based stroke register and the discharge records of the hospital serving the population of the stroke register (n=70 000). The stroke register (including patients aged 15 and older and with no upper age limit), applied here as a "gold standard," was used to estimate sensitivity, positive predictive value, and accuracy of the discharge diagnoses classification. The length of stay in hospital by stroke patients was measured. RESULTS: Identifying cerebrovascular diseases by hospital discharge diagnoses (International Classification of Diseases, 9th Revision [ICD-9], codes 430 to 438.9, first admission) lead to a substantial overestimation of stroke in the target population. Restricting the retrieval to acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436) gave an incidence estimate closer to the "true" incidence rate in the stroke register. Selecting ICD-9 codes 430 to 438 of cerebrovascular diseases gave the highest sensitivity (86%). The highest positive predictive value (68%) was achieved by selecting acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436), at the expense of a lower sensitivity (81%). Accuracy of ICD codes 430 to 438.9 (n=678) revealed the highest proportion of incident strokes identified by the acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436). Seventy-four percent of hospital discharge diagnoses classified as first-ever stroke kept the original diagnosis. Only 4.6% of the discharge diagnoses were classified as nonstroke diagnoses after validation. The estimation of length of stay in the hospital was improved by selection of acute stroke diagnoses from hospital discharge data (ICD-9 codes 430, 431, 434, and 436), which gave the same estimate of length of stay, a median of 8 days (2.5 percentile=0 and 97.5 percentile=56), compared with a median of 8 days (2.5 percentile=0 and 97.5 percentile=51) based on the stroke register. CONCLUSIONS: Hospital discharge data may overestimate stroke incidence and underestimate the length of stay in the hospital, unless selection routines of hospital discharge diagnoses are restricted to acute stroke diagnoses (ICD-9 codes 430, 431, 434, and 436). If supplemented by a validation procedure, including estimates of sensitivity, positive predictive value, and accuracy, hospital discharge data may provide valid information on hospital-based stroke incidence and lead to better allocation of health resources. Distinguishing subtypes of stroke from hospital discharge diagnoses should not be performed unless coding practices are improved.

Cerebrovascular Disorders↗
PubMed2004

Bridging the digital divide: reaching vulnerable populations.

The AMIA 2003 Spring Congress entitled "Bridging the Digital Divide: Informatics and Vulnerable Populations" convened 178 experts including medical informaticians, health care professionals, government leaders, policy makers, researchers, health care industry leaders, consumer advocates, and others specializing in health care provision to underserved populations. The primary objective of this working congress was to develop a framework for a national agenda in information and communication technology to enhance the health and health care of underserved populations. Discussions during four tracks addressed issues and trends in information and communication technologies for underserved populations, strategies learned from successful programs, evaluation methodologies for measuring the impact of informatics, and dissemination of information for replication of successful programs. Each track addressed current status, ideal state, barriers, strategies, and recommendations. Recommendations of the breakout sessions were summarized under the overarching themes of Policy, Funding, Research, and Education and Training. The general recommendations emphasized four key themes: revision in payment and reimbursement policies, integration of health care standards, partnerships as the key to success, and broad dissemination of findings including specific feedback to target populations and other key stakeholders.

Financing, Organized↗