Expanded access to experimental drugs: activists seek more open programs.
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Anti-HIV Agents↗
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Implications of structural deficits for patient education in Germany.
Several changes in health politics and legal settings in recent years have affected the structure and practice of health promotion and patient education in Germany. The current legal background and its implications for patient education are discussed. Based on examples from four selected areas (cardiovascular diseases, diabetes mellitus, chronic pain, and asthma) the current practice of patient education in Germany is summarized. While many well-structured programs exist that are based on state-of-the-art guidelines, there is a lack of high quality research that documents the long-term effectiveness and cost-effectiveness of such approaches. Structural problems and an insufficient number of highly trained personnel result in the fact that many patients do not have access to standardized programs. Persisting compliance problems indicate that there is still room for improvement of patient education interventions. As important for the future, necessary changes in the legal settings and possible implications for the education of the educators are discussed.
Asthma↗
The National Breast and Cervical Cancer Early Detection Program: a comprehensive public health response to two major health issues for women.
The passage of the Breast and Cervical Cancer Mortality Prevention Act established a nationwide, comprehensive public health program to increase access to breast and cervical cancer screening services for women who are medically underserved. This act created the first opportunity for state health agencies to build a public health infrastructure for cancer control at the state and community levels. The Congress appropriated $30 million in fiscal year 1991 for the first year of this program. In the summer of 1991, the Centers for Disease Control and Prevention (CDC) used a competitive application process to fund the first eight states to establish early detection programs. Since then, the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) has become a nationwide program with a budget of $100 million. Thirty-five states and nine American Indian Tribes are supported to implement comprehensive screening programs. Fifteen states, three territories, and the District of Columbia receive planning and infrastructure grants as part of the Capacity Building Program. The NBCCEDP surveillance data through January 31, 1995 shows that 556,003 screening tests have been provided to women who are medically underserved. The success of NBCCEDP has contributed to the growing pressure on state health agencies to focus more attention and resources on chronic disease prevention and control.
Adult↗
Effectiveness of a parent education intervention for at-risk families.
ISSUES AND PURPOSE: Although many parenting programs exist to prevent child maltreatment, few are supported by research evidence. This study explored whether parents who completed the Bavolek Nurturing Program improved their parenting attitudes. DESIGN AND METHODS: Secondary analysis of data from a larger study involved a convenience sample of 154 families from 15 county child maltreatment prevention councils. RESULTS: On the pretest, parents demonstrated scores associated with maladaptive parenting practices. Posttest scores were consistent with nurturing parenting attitudes. PRACTICE IMPLICATIONS: Effective and readily accessible parent education programs are highly indicated for prevention of child maltreatment. It is important for nurses to have the information either to provide effective parent education interventions or to be able to refer parents to effective programs.
Adolescent↗
TBI State Demonstration Grants.
In July 1996, the Congress enacted Public Law 104-166, "to provide for the conduct of expanded studies and the establishment of innovative programs with respect to traumatic brain injury" (TBI). Under the Law, the Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB) is charged with implementing a State Demonstration Grant Program to improve access to health and other services for individuals with TBI and their families. The National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC) have also been delegated responsibilities in the areas of research, surveillance and prevention, respectively. Traumatic brain injury (TBI) is defined as an insult to the brain from some externally inflicted trauma to the head that results in significant impairment to an individual's physical, psychosocial, and/or cognitive functional abilities. Motor vehicle crashes, falls, violence, and sport-related injuries are the major causes of TBI; the number one killer and cause of disability for young people in the United States. The Centers for Disease Control and Prevention has identified that approximately 5.3 million Americans live with the effects of TBI. About half the estimated 1.9 million Americans who experience traumatic brain injuries each year incur at least short-term disability; 52,000 people die as a result of their injuries; and more than 90,000 people sustain severe brain injuries leading to debilitating loss of function. The direct medical costs for treatment of TBI have been estimated at more than $4 billion annually. There are two program categories in the TBI State Demonstration Grant Program: Planning and Implementation. The planning category provides support to those States that need assistance in developing an infrastructure for individuals with TBI in their families. The implementation category supports the development and expansion of activities that will improve or enhance access to services for individuals with TBI and their families, within the current service delivery system.
Brain Injuries↗
Emergency preparedness and bioterrorism response: development of an educational program for public health personnel.
Public health departments are under increasing pressure to provide emergency preparedness and bioterrorism response education to public health personnel. The challenge that health departments face is to provide cost-efficient, timely education to a large number of multidisciplinary personnel. This article describes an innovative strategy for providing this education to public health personnel using the health department's intranet system. The intranet system provided confidential information specific to the staff role and allowed for concurrent access to the program by multiple individuals at different service sites. Knowledge acquisition was tested through short multiple-choice questions that followed the specific information modules. The intranet system faced a number of challenges during the pilot-testing phase, primarily related to changes in the role of the public health nurse and limitations in funding and public health staff to maintain and monitor the bioterrorism response program and the intranet system. The design of the program may prove useful for other public health organizations when a need exists for quick delivery of information to a large number of personnel. It may especially be useful in providing basic emergency preparedness and bioterrorism education to new personnel in health departments.
Attitude of Health Personnel↗
Medicaid managed care reimbursement for HIV and its implications for access to care.
The rapid growth of managed care in state Medicaid programs has raised concerns about access to care for people living with HIV and AIDS (PLWH). Even the highest capitation rates that most programs pay to managed care organizations (MCOs) for disabled enrollees are substantially lower than the costs of care, especially when costly protease inhibitor therapy is taken into account. A national study has shown that Medicaid beneficiaries did not have the same level of access to protease inhibitors as did privately insured HIV patients in 1996 and 1997. Low capitation rates can limit access to care for PLWH by discouraging MCOs from having experienced HIV physicians on their provider panels and from enrolling PLWH. Since 1997, however, Medicaid programs in several states have adopted strategies to reduce the financial risks facing MCOs caring for PLWH and enrollees with other high-cost conditions. These strategies include global health-based (risk-adjusted) payment systems, AIDS-specific reimbursement rates, carve outs from capitation rates for medications and other services, risk pools for high-cost enrollees, risk corridors, and stop-loss insurance policies through which Medicaid programs share financial liability with MCOs for catastrophic losses. In addition, several programs have developed HIV centers of excellence. Most state Medicaid programs have yet to adopt any of these strategies. However, the growing numbers and types of experimental approaches to capitating services for PLWH may provide models for other states whose low reimbursement rates currently limit access to care.
Capitation Fee↗
Cerebellar lesions impair context-dependent adaptation of reaching movements in primates.
To produce accurate movements when conditions change suddenly, the brain must be capable of learning multiple versions of a given motor task and must be able to access the appropriate program using sensory information linked to the context of the movement. The neural basis for context-dependent motor learning is uncertain, but the cerebellum is thought to play a fundamental role. In this study, we examined the effect of lesions of the dorsal vermal and paravermal cerebellar cortex on the adaptation of reaching movements produced by modified visual feedback and accessed with a visual cue. Two rhesus monkeys were trained to point to targets displayed on a video monitor while viewing monocularly with either eye. During the experimental sessions, visual information received by one eye (the "modified" eye) was displaced horizontally, while the information received by the other ("normal") eye remained unaltered. In the first set of experiments (noncontextual paradigm), the animals pointed to targets while viewing with the modified eye. This paradigm resulted in a gradual improvement in pointing accuracy when viewing with that eye, but also produced a shift in pointing responses of equivalent size when viewing with the normal eye. In the second set of experiments (contextual paradigm), the animals alternated six blocks of reaches while viewing monocularly with the modified eye with six blocks viewing with the normal eye. This paradigm improved the pointing accuracy when viewing with the modified eye, but produced only a small shift in pointing responses when viewing with the normal eye. After the dorsal vermal and paravermal cerebellar cortex were resected, no change occurred in the pattern of adaptation produced by the noncontextual paradigm. The contextual paradigm, however, no longer selectively adapted pointing responses for each eye, but rather produced a pointing shift of equivalent size when viewing with either eye. The results indicate that pointing responses can be differentially adapted for each viewing eye, which is a form of context-dependent motor learning. This capability was lost after focal lesions of the dorsal vermal and paravermal cerebellar cortex, suggesting that these regions of cerebellar cortex are required to learn or store multiple representations of a movement, or to retrieve the appropriate motor program in a given sensory context.
Adaptation, Physiological↗
Screening in liver disease: report of an AASLD clinical workshop.
This report summarizes an AASLD Clinical Workshop that was presented at Digestive Diseases Week 2003 on screening in liver diseases. As newer diagnostic tests become available, many liver diseases and complications of liver disease can be detected at an early asymptomatic stage. In many cases, early detection can lead to earlier treatment and an improved outcome. However, screening for liver diseases in asymptomatic persons has the potential for adverse consequences, including discrimination and stigmatization. The cost of screening programs is significant, and access to screening tests varies in different countries. Future screening programs require careful planning and implementation to balance the benefits, risks, and cost-effectiveness. This review outlines the concepts of screening and their application to a broad range of liver diseases.
Cost-Benefit Analysis↗
Population explosion and population control programmes in Bangladesh: an overview.
"The authors discuss in detail efforts made by [the] Bangladesh Government to control its population through planned efforts since 1953. Covering persistent setbacks and reasons thereof in governmental efforts, the authors highlight shifts in policies and strategy.... The [government family planning] programme provides a wide range of contraceptive choice to eligible couples in a manner as acceptable and convenient as possible to the client. The programme is totally voluntary and the government is firmly opposed to coercion or pressure on couples to accept contraception. As a strategy, the programme has integrated health and [family planning] while various ministries have attempted to encourage the acceptance of low-fertility behaviour through socio-economic incentives and educational motivation programmes."
Asia↗
Hospice referral practices for children with cancer: a survey of pediatric oncologists.
PURPOSE: To examine hospice referral patterns among pediatric oncologists and identify barriers to referral. METHODS: A self-administered survey was sent to 1,200 pediatric oncologists who are members of Children's Oncology Group. Two electronic mail messages followed by traditional mail surveys were sent to eligible physicians. Pediatricians and pediatric oncologists developed, pretested, and modified the survey for item clarification. RESULTS: Of 944 eligible pediatric oncologists surveyed, 632 replied, yielding a response rate of 67%. Most respondents reported having access to palliative care programs (65%) and hospice services (85%), but few (27%) had access to inpatient hospice services. More respondents reported feeling comfortable managing end-of-life pain than psychological issues (86% v 67%, respectively). Many pediatric oncologists (62%) reported that half or more of their patients died in the hospital. In multivariate analysis, physicians with access to hospice that accepts patients receiving chemotherapy had more patients die at home than in hospital compared with physicians without access to such services (P = .007). The probability of hospice referral was positively associated with the presence of a hospice facility (P < .001) and with a larger size oncology group (P = .024). Only 2.5% of respondents referred patients at the time of relapse. Continued therapy was cited as the most common reason for not making a referral, and was significantly higher when hospice did not admit children receiving chemotherapy (P = .002). CONCLUSION: Hospice referral for children with cancer is usually made late in the course of their disease and might improve if hospice admits patients who are actively receiving chemotherapy.
Adult↗
Future financial viability of rural hospitals.
Policymakers are concerned that some rural hospitals have suffered significant losses under the Balanced Budget Act (BBA) of 1997 and that access to inpatient and emergency care may be at risk. This article projects that the median total profit margin for rural hospitals will fall from 4 percent in 1997 to between 2.5 and 3.7 percent after the BBA, Balanced Budget Refinement Act (BBRA) of 1999, and Benefits Improvement and Protection Act (BIPA) of 2000 are fully implemented in 2004. The Critical Access Hospital (CAH) Program is expected to prevent reductions in inpatient and outpatient prospective payments from causing an increase in rural hospital closures.
Aged↗
The EPIGRAM computer program for analyzing mortality and population data sets.
EPIGRAM is a computer program designed to improve access to State-level underlying cause mortality data. The program produces results for population, deaths, death rate, age-adjusted death rate, years of potential life lost (YPLL), YPLL rate, and confidence intervals. Results can be compared variously among age groups, counties, causes of death, races, regions, and years. The program's menu-driven interface facilitates the selection or modification of analysis parameters. Current selections are retained so the user can modify one parameter at a time. Based on the parameters that the user selects, the program produces a series of tables, one for each instance of a particular parameter. Each output table has columns for male, female, and both sexes combined, and an indefinite number of user-defined rows for age groups, causes of death, counties, races, regions, or years. EPIGRAM has major advantages over other methods for analyzing mortality and population data. The program uses relatively small amounts of memory and disk space, executes rapidly, is flexible, can be used by inexperienced computer users, provides online help screens and tutorials, and runs under DOS or UNIX without modification. The program currently is used to analyze mortality and population data for Texas. Although it is not currently available for distribution, support is being sought for its evaluation and possible implementation in State health departments to analyze data for other States, or other data sets, such as hospital discharge data or cancer incidence data.
Cause of Death↗
Family planning program effects on the fertility of low-income U.S. women.
Under rigorous statistical controls, it has been shown that the larger the proportion of lower SES women enrolled in organized family planning programs, the lower their fertility. Program effects independent of other social, economic and cultural factors were shown for lower SES whites and blacks, and for most age groups. The potential of a fully implemented program to reduce fertility differentials between upper and lower SES groups was assessed, using 1969-1970 fertility rates and the estimates of 1969 program impact. Although we believe that the program's impact has increased in magnitude over time, even these estimates from an early point in U.S. program development provide impressive documentation that the program reduces fertility in the subpopulation served by the program, and, by implication, that there is a genuine need for organized family planning services, even in an industrialized nation like the United States. If there were no need, there could be no program effect. The family planning program was one of the major new health and social programs introduced in the mid-1960s. This study shows that, far from failing, the program was succeeding very well in attaining its objectives. The program works because it gives women of lower socioeconomic status access to modern and effective methods of contraception that they would not otherwise have. As a result, the rates of unwanted and mistimed pregnancy of patients are lower than those of comparable women who lack access to organized clinic programs.
Adolescent↗
Analysis of ethnic variations in developmental disability prevalence and household economic status.
Prevalence of developmental disabilities among the three largest U.S. racial and ethnic groups was estimated. Groups were compared on household economic status and access to welfare programs. Secondary analyses were conducted on 1990 and 1991 panels of the Survey of Income and Program Participation, a nationally representative data base of the demographic and economic status of U.S. households. Estimated prevalence rate was 1.1% (June through December 1991), with the highest rate (1.4%) among Blacks. Households with a family member with developmental disabilities had significantly lower income and greater dependence on means-tested income support. Minority status exacerbated differences in earned income and access to welfare. Results were discussed in the context of general U.S. demographic trends.
Adolescent↗
Further results of incorporating innovative procedures in a surgical residency.
The instruction in precipitously advancing surgical technologies remains a real challenge to every surgery program. Our institution's ongoing experience with an identified center for student and resident education and clinical investigation provides an option for addressing these needs in a general surgery residency. Over the past 8 years, we have developed and described previously the Center for Advanced Surgical Technologies (CAST) in a joint undertaking of the Department of Surgery and the Norton Hospital, an affiliated hospital on our medical school campus. The idea behind this program has been to focus and develop high-quality skills in the hospital in many areas of advanced technology. CAST has subsequently provided a vehicle for excellent clinical research as well as the development of specially focused advanced surgical technologies, fellowships, and a large number of publications that have often focused on new, advanced methods for imaging surgical disease and minimal access treatment. This program has had a very positive impact on the general surgery residency as a whole and has permitted a steadily advancing agenda of new technologies, while relegating recently emerged but perfected technologies into the central aspect of our accredited general surgery residency.
Education, Medical, Graduate↗
What do patients do with access to their medical records?
We sought to study the phenomenon of patients having access to their own medical records in order to determine the impact on them and on their relationship with their health care providers. We created the Patient Clinical Information System (PatCIS) to interface with the clinical data repository at New York Presbyterian Hospital to allow patients to add to and review their medical data. We also provided educational resources and automated advice programs. We provided access to the system to thirteen subjects over a nineteen-month period and reviewed their activities in the system's usage log. We also collected data via questionnaire and telephone interview. We found that patients varied in their use of the system, from once a month or less to one or more times per day. All patients primarily used the system to review laboratory results. Both they and their physicians believed that use of the system enhanced the patients' understanding of their conditions and improved their communication with their physicians. There were no adverse events encountered during the study.
Adult↗
The patient clinical information system (PatCIS): technical solutions for and experience with giving patients access to their electronic medical records.
As health records evolve into electronic form, increasing demand is being made to provide patients with access to them. We sought to study the character and impact of such access to determine how patients use such records, what cognitive effects it has on them, and how it affects their relationship with their health care providers. We created the Patient Clinical Information System (PatCIS) to interface with the clinical data repository at New York Presbyterian Hospital (NYPH) to allow patients to add to and review their medical data. We also provided educational resources and automated advice programs. We provided access to the system to thirteen subjects over a 36-month period and reviewed their activities in the system's usage log. We also collected data via questionnaire and telephone interview. We collected data for a total of 223 patient months. We found that patients varied in their use of the system, from once a month or less to one or more times per day. All patients primarily used the system to review laboratory results. Both they and their physicians believed that use of the system enhanced the patients' understanding of their conditions and improved their communication with their physicians. There were no adverse events encountered during the study.
Adult↗