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PubMed2003

[Primary care policies and health reforms: an evaluative approach based on an analysis of the Family Health Program in Florianópolis, Santa Catarina, Brazil, 1994-2000].

This article discusses the evaluation of primary health care policies based on a case study of the Family Health Program in Florianópolis, Santa Catarina, Brazil. The results are presented in two stages. First, the Program is placed in the context of the Municipality's policies, identifying perceptions of the Program at the administrative level. Second, the author studied the Program's practices based on a sample of five family health care teams using an evaluative framework including variables on accessibility and comprehensiveness. The Program began relatively late in the State capital, but developed a unique model. There is a greater supply of services available to the population not covered by private health plans, although there is a major diversity of practices. The degree of implementation is moderately adequate: the care provided is more comprehensive, but there are problems with access (in the ratio between staff and number of families covered). It is suggested that such proposals for reorienting health care models tend towards rationalization, political legitimization, or democratization of services. The accessibility policy can set the predominant direction.

Brazil↗
PubMed2004

Improved access and quality of care after enrollment in the New York State Children's Health Insurance Program (SCHIP).

BACKGROUND: Although many studies have noted that uninsured children have poorer access and quality of health care than do insured children, few studies have been able to demonstrate the direct benefits of providing health insurance to previously uninsured children. The State Children's Health Insurance Program (SCHIP), enacted as Title XXI of the Social Security Act, was intended to improve insurance coverage and access to health care for low-income, uninsured children. With limited state and federal resources for health care, continued funding of SCHIP requires demonstration of success of the program. As yet, little is known about the effectiveness of SCHIP on improving access and quality of care to enrollees. OBJECTIVES: To measure the impact of the New York State (NYS) SCHIP on access, utilization, and quality of health services for enrolled children. DESIGN SETTING: NYS, stratified into 4 regions. The NYS SCHIP is modeled on commercial insurance (32 managed care plans) and at the time of the study had 18% of SCHIP enrollees nationwide. STUDY DESIGN: For the study group, the design used pre/poststudy telephone interviews of parents of children enrolling in the NYS SCHIP, with baseline interviews soon after enrollment and follow-up interviews 1 year after enrollment. Baseline interviews reflected the child's experience during the 1-year period before enrollment in SCHIP. The follow-up interviews reflected the 1-year period after enrollment in SCHIP. For the comparison group, the design used baseline interviews of a comparison group enrolled 1 year after the study group to test for secular trends; these interviews reflected the 1-year period before enrollment in SCHIP. SUBJECTS: Children (n = 2644) 0 to 18 years of age who enrolled in the NYS SCHIP for the first time (November 2000 to March 2001), stratified by age (0-5, 6-11, and 12-18 years), race/ethnicity (white non-Hispanic, black non-Hispanic, and Hispanic; others excluded), and region of NYS. The comparison group consisted of 400 children. Telephone interviews were conducted in English or Spanish throughout the day and evening, 7 days per week, to obtain measures. MAIN OUTCOME MEASURES: Demographic and health measures (child and family characteristics, health status, presence of a special health care need, and prior health insurance), access (usual source of care [USC] and unmet needs for health care), utilization (visits for specific health services), and quality (continuity with USC and measures of primary care interactions). Analyses included bivariate tests, comparing the pre-SCHIP period to the 1-year period after enrollment in SCHIP. Multivariate models were computed to generate standardized populations comprised of key characteristics of the sample to test for differences in measures (after SCHIP versus before SCHIP), controlling for demographic characteristics. RESULTS: Of the 2644 study-group children who completed the initial interview, 2290 (87%) completed the follow-up interview. Key measures for the pre-SCHIP period and short-term "postenrollment" measures for the study group were not statistically different from measures for the comparison group, suggesting no major secular trends. Participants were non-Hispanic white (25%), non-Hispanic black (31%), and Hispanic (45%). Fifty-one percent of the parents were single, and 61% had a high school education or less; 81% of families had income <160% of the federal poverty level. Sixty-two percent of the children were uninsured > or = 12 months before the NYS SCHIP; of those insured, 43% previously had Medicaid. The proportion of children who had a USC increased after enrollment in the NYS SCHIP (86% to 97%). Two measures of accessibility (difficulty getting a medical person by telephone and difficulty getting an appointment) improved after enrollment in SCHIP. The proportion of children with any unmet health care needs decreased (31% to 19%). Specific types of unmet need also were reduced after enrollment; for example, among SCHIP enrollees who had a need for specific type of care, unmet needs wds were significantly lower postenrollment versus pre-SCHIP for specialty care (-15.5% in unmet need), acute care (-10.1%), preventive care (-9.6%), dental care (-13.0%%), and vision care (-13.2%). Emergency and total ambulatory visits did not change, but the proportion of children with a preventive care visit increased (74% to 82%). The proportion of children who used their USC for most or all visits increased (47% to 89%), demonstrating increased continuity of care. Several indicators of health care quality improved, including an overall rating of quality, the 4 indicators of physician-patient interaction used by the Consumer Assessment of Health Plans Survey, and a measure of parental worry about their child's health. Improvements were noted among major subgroups of children, with the greatest improvements for those with the lowest baseline levels. For example, at baseline, a lower percentage of children living at <160% of the federal poverty level had a presence of a USC or continuity with their USC than children living in families at >160% of the federal poverty level, and these poorer children experienced the greatest gains in having a USC or having continuity with their USC after enrollment in SCHIP. CONCLUSIONS: Enrollment in the NYS SCHIP was associated with 1) improved access, continuity, and quality of care and 2) a change in the pattern of health care, with a greater proportion of care taking place within the usual source of primary care.

Adolescent↗
PubMed1984

Delila system tools.

We introduce three new computer programs and associated tools of the Delila nucleic-acid sequence analysis system. The first program, Module, allows rapid transportation of new sequence analysis tools between scientists using different computers. The second program, DBpull, allows efficient access to the large nucleic-acid sequence databases being collected in the United States and Europe. The third program, Encode, provides a flexible way to process sequence data for analysis by other programs.

Base Sequence↗
PubMedDate not supplied

Access to colposcopy services for high-risk Canadian women: can we do better?

BACKGROUND: Despite overall decreasing mortality from cervical cancer, selected groups of Canadian women continue to have suboptimal access to diagnostic and treatment interventions for cervical cancer. In this paper, we present an evaluation of a colposcopy program developed to improve attendance for colposcopy in a lower socio-economic and immigrant population. METHODS: All women attending the North Hamilton Community Health Centre (CHC) who required colposcopic assessment and were referred to a newly developed colposcopy program based at the CHC were evaluated. Attendance rates for consultation, follow up and treatment in women referred for colposcopy were compared retrospectively for the CHC-based colposcopy program and concurrently with the regional colposcopy clinic (RCC). RESULTS: Women referred to the CHC colposcopy program had a significant reduction in their no-show rate after the introduction of the locally based colposcopy program (17.2% vs. 1.3%, p<0.01). Comparing the same time periods, there was no significant reduction in the default rate at the RCC (2.5% vs. 3.3%, p=0.21). Despite serving a population of women who were at higher risk for non-attendance, patients at the CHC had a default rate for appointments similar to that of the RCC (1.3% vs. 3.3%, p=0.55) after the introduction of the local colposcopy program. CONCLUSIONS: Lower socio-economic status and immigrant women receiving care from a CHC-based colposcopy program had a significant decrease in their no-show rate for colposcopic evaluation after the introduction of the on-site program. Consideration must be given to locating diagnostic colposcopy programs in settings more accessible to women who require these services the most.

Adolescent↗
PubMed1995

Making the health care system 'safe' for persons with HIV infection or AIDS.

If health care reform is implemented in states and nationally, the safety of this process needs to be examined for persons with human immunodeficiency virus (HIV) infection or the acquired immunodeficiency syndrome (AIDS). Reform should assure ongoing prevention and transmission control of HIV and continuous coverage of medical costs for persons ill with HIV or AIDS. These persons currently benefit from various state and federal categoric programs designed to assure access to preventive and personal care services. Washington State has passed health care reform legislation that envisions integrating these programs to provide a system of population-based and personal health care. This legislation was analyzed using existing epidemiologic and entitlement information about persons with HIV infection or AIDS in the state to assess its effect. The relationship between public health and personal care services will be a central concern for those with HIV infection or AIDS, and complete coverage of this group may be achieved relatively late in the process of implementing health care reform. Health personnel planning under health care reform will affect the delivery of HIV- and AIDS-related services. Including treatment of AIDS in the basic benefit package merits particular attention. These issues parallel those being faced by the nation as a whole as it seeks to ensure epidemic disease control and compassionate care for long-term disabling illness if health care reform is implemented.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Reconsidering the effect of Medicaid on health care services use.

OBJECTIVE: Our research compares health care use by Medicaid beneficiaries with that of the uninsured and the privately insured to measure the program's effect on access to care. DATA SOURCES/STUDY SETTING: Data include the 1987 National Medical Expenditure Survey and the Survey of Income and Program Participation for 1984-1988. STUDY DESIGN: We predict annual use of ambulatory care and inpatient hospital care for Medicaid beneficiaries receiving AFDC cash assistance and compare it to what their use would be if uninsured or if covered by private insurance. Comparisons are based on multivariate models of health care use that control for demographic and economic characteristics and for health status. Our model distinguishes among Medicaid beneficiaries on the basis of eligibility to account for the poor health of beneficiaries in some eligibility groups. PRINCIPAL FINDINGS: AFDC Medicaid beneficiaries use considerably more ambulatory care and inpatient care than they would if they remained uninsured. Use among the AFDC Medicaid population is about the same as use among otherwise similar, privately insured persons. Use rates differ substantially among different Medicaid beneficiary groups, supporting the expectation that some beneficiary groups are in poor health. CONCLUSIONS: Although Medicaid has increased access to health care services for beneficiaries to rates now comparable to those for the privately insured population, because of lower cost sharing in Medicaid we would expect higher service use than we are finding. This suggests possible barriers to Medicaid patients in receiving the care they demand. Enrollment of less healthy individuals into some Medicaid beneficiary groups suggests that pooled purchasing arrangements that include Medicaid populations must be designed to ensure adequate access for the at-risk populations and, at the same time, to ensure that private employers do not opt out because of high community-rated premiums.

Adolescent↗
PubMed2004

CHIP: new opportunities in adolescent health care delivery.

Children's Health Insurance Programs (CHIP), usually targeted to infants, toddlers, and school-aged children, have been expanded to include adolescents. Adolescents need some form of health insurance in order to access needed care. Moreover, programs and services that provide them with health care must be adolescent-friendly, adolescent-focused and adolescent-sensitive, and include specialized training for primary care providers. Translating this philosophy into a successful health care delivery program involves addressing the psychological, institutional and financial barriers that make it difficult for adolescents to access health care. Overcoming these barriers, especially the financial ones, requires that primary care providers advocate for teenagers and take advantage of resources made available for them. CHIP provides a critical opportunity for policy-makers and health care providers to further improve adolescent health care and to more fully integrate adolescents into the health care system.

Adolescent↗
PubMed2000

Health and health care among housestaff in four U.S. internal medicine residency programs.

BACKGROUND: Although there have been many studies of the health care services that resident physicians provide, little is known about the health care services they receive. OBJECTIVE: To describe residents' perceptions of the health care they receive. DESIGN: Anonymous mailed survey. SUBJECTS: All 389 residents in four U.S. categorical internal medicine training programs. MAIN RESULTS: Three hundred sixteen residents responded (83%). In aggregate, 116 (37%) reported having no primary care physician, and 36 (12%) reported that they are their own primary care physician. These figures varied substantially across the four programs. Most residents reported receiving basic screening and preventive services; however, their attitudes toward their health and health care differed across postgraduate level, gender, and program. Many residents reported that their long and unpredictable hours interfered with their ability to schedule clinician visits, that their health had declined because of residency, that programs and other residents were unsupportive of residents' health care needs, and that residency raised special issues of privacy that limited access to health care. CONCLUSIONS: Despite high rates of receipt of preventive services, these internal medicine residents identified several barriers that limited their access to health care. Program directors should explore these barriers and, at the same time, reevaluate the messages being sent to resident physicians about maintaining their health and health care.

Adult↗
PubMed2006

The impact of realized access to care on health-related quality of life: a two-year prospective cohort study of children in the California State Children's Health Insurance Program.

OBJECTIVE: To examine the effect of realized access to care (problems getting care, access to needed care) on health-related quality of life (HRQOL) in the California State Children's Health Insurance Program. STUDY DESIGN: This was a prospective cohort study (n = 4,925; 70.5% [3438] had complete data). Surveys were taken at enrollment and after 1 and 2 years in the program. Parents and children reported HRQOL (PedsQL 4.0 Generic Core Scales). Repeated-measures analysis accounted for within-person correlation and adjusted for baseline PedsQL, baseline realized access, race/ethnicity, language, chronic health condition, and having a regular physician. RESULTS: Realized access to care during the prior year was related to HRQOL for each subsequent year. Foregone care and problems getting care were associated with decrements of 3.5 (P < .001) and 4.5 (P < .001) points for parent proxy-report PedsQL and with decrements of 3.2 (P < .001) and 4.4 (P < .001) points for child self-report PedsQL. Improved realized access resulted in higher PedsQL scores, continued realized access resulted in sustained PedsQL scores, and foregone care resulted in cumulative declines in PedsQL scores. CONCLUSIONS: Realized access to care is associated with statistically significant and clinically meaningful changes in HRQOL in children enrolled in the California State Children's Health Insurance Program.

Adolescent↗
PubMed1998

Consideration of factors prior to implementing a smoking cessation program.

This small feasibility study evaluated access, recruitment, and retention of pregnant African-American teens for a subsequent smoking cessation intervention program. A clinic and a school site were selected to assess these factors. Only the school site proved successful. Strengths of the school site included: structure and routine for students, a comfortable and familiar setting, recruitment by school personnel who had a relationship with students, and full support by administrators and staff.

Adolescent↗
PubMed1997

Computer supported decision making in therapy of arterial hypertension.

Therapy of hypertension is still more or less empirical. Several classes of antihypertensive medications are known, the effect of which is based on different mechanisms. The efficacy of the treatment is not always a reliable indication of the appropriate selection as a good therapeutical response can sometimes be achieved at the expense of humoral simulation. This can lead to harmful increased synthesis of trophic hormones. The program for PC called HYPERTENZE supports decision making in therapy of arterial hypertension. It gives a sequence of decisions based on clinical experience using a series of parameters. The program is using the Microsoft Access language of the Access database system and due to the Access Developers Toolkit it does not require Access to be installed on the user's computer. The program HYPERTENZE offers the user essential information and explanation of the decisions in a graded form. The price list of equivalent medications can be updated by the user himself. It seems that this program might be very useful for Czech general practitioners.

Antihypertensive Agents↗
PubMedDate not supplied

A library-site asthma education program for inner-city communities.

Asthma education programs are reportedly effective for children and adolescents. Urban and minority children continue to have poor asthma outcomes and limited access to asthma education programs. The purpose of this study was to determine whether a library-based asthma education program, the Columbus Ohio Partnership for Inner-City Asthma Education (COPICAE), offered to urban and minority children (with their parents) could improve asthma-related outcomes and reduce billing claims for asthma-related hospital visits. A prospective/observational study was conducted to evaluate asthma-related outcomes of 87 children who completed 6 hours of asthma education using telephone follow-up at 12 and 24 months with a scored Living With Asthma Survey (LWAS). Hospital billing claims for asthma as the primary diagnosis were compared over a 24-month period for 64 children who completed 6 hours of asthma education with an age and zip code match control. Two separate focus groups with Spanish-speaking and English-speaking parents who completed 6 hours of asthma education with their children obtained parental perspectives about the asthma education classes. LWAS follow-up data were obtained on 67% of the participants at year 1 and 43% at year 2. Compared to pre-intervention mean scores, there were decreases in scores to all LWAS items. Parents reported improvements in compliance with asthma medication use and overall control of their child's asthma. Parents also found the information from the asthma education classes to be "beneficial." Total asthma-related billing claims for children who completed 6 hours of asthma education decreased 63.2%, while those for age and zip code matched controls increased 0.7%. Inner-city and minority children (with their parents) who attended 6 hours of asthma education offered in a public library showed improvements in asthma-related outcomes over a 24-month period and decreased billing claims for asthma-related hospital visits. Parents found 6 hours of asthma education to be beneficial in gaining basic knowledge about asthma and improving their child's illness control and self-esteem in living with asthma.

Adolescent↗
PubMed1998

Oral health status of Canadian-born and immigrant adolescents in North York, Ontario.

Studies from a number of countries, including Canada, have demonstrated that the oral health status of immigrants is worse than that of their native-born counterparts and that they make less use of dental services. To date, however, little information is available which documents changes in immigrant oral health following immigration. This paper reports the results of a study conducted in the City of North York, Ontario, that examined the oral health status of Canadian-born and immigrant adolescents aged 13 and 14 years. The former had better oral health than the latter on all parameters assessed and made more use of dental services. Within the immigrant population, there was a significant association between oral health and time since immigration. Those who had been in Canada 6 or more years were significantly healthier than those who had arrived within the preceding 2 years. While changing patterns of immigration may account for part of these differences, the data suggest that access to dental public health programs, delivered to students between the ages of 4 and 14 years, have been effective in improving the oral health of those born outside Canada. Since these programs cease at age 13 or 14 years, barriers to accessing the private dental care sector may mean that the residual inequities and inequalities evident in the data widen as these individuals age.

Adolescent↗
PubMed2005

Get Connected: an HIV prevention case management program for men and women leaving California prisons.

Individuals leaving prison face challenges to establishing healthy lives in the community, including opportunities to engage in behavior that puts them at risk for HIV transmission. HIV prevention case management (PCM) can facilitate linkages to services, which in turn can help remove barriers to healthy behavior. As part of a federally funded demonstration project, the community-based organization Centerforce provided 5 months of PCM to individuals leaving 3 state prisons in California. Program effects were measured by assessing changes in risk behavior, access to services, reincarnation, and program completion. Although response rates preclude definitive conclusions, HIV risk behavior did decrease. Regardless of race, age, or gender, those receiving comprehensive health services were significantly more likely to complete the program. PCM appears to facilitate healthy behavior for individuals leaving prison.

Adult↗
PubMed2006

A feedback model for applied research on tobacco control.

Although the health communication program feedback cycle is frequently referenced, the steps for moving between or within the sections of the model in a public health environment are rarely described. We detail the process by which the Texas Tobacco Research Consortium implemented the stage of "assessing effectiveness and making refinement" and expanded it to include a program assessment feedback model. Tools were developed to move the consortium through five stages of the expanded program assessment feedback model: 1) formulate research questions using logic models to identify key evaluation items, 2) format data displays from multiple data sources to address research questions, 3) use a facilitated group process to present and review research findings, 4) prepare group recommendations, and 5) involve local partners to translate recommendations into practice. The process allowed us to sift through a large volume of information and prepare data-based program recommendations. A Web-based reporting system provided timely access to community-based program activity data and process indicators that, when linked to logic models, provided actionable items for program improvement. Partnerships among researchers and state and local practitioners created the conditions for implementing the recommendations. Program changes included revisions to program materials, target audiences, and evaluation instruments for a community-based tobacco-cessation campaign. The systematic approach allowed translation of research into practice and should be applicable to other areas of population-based health promotion.

Health Education↗
PubMed1991

Health access America--strengthening the US health care system.

Although Americans remain generally satisfied with the health care provided to them, sufficient access to high-quality, affordable health care for citizens without health care insurance has become an increasing problem in the last decade. Using the policy development process of the American Medical Association, Health Access America was conceived by the Association to improve access to affordable, high-quality health care. The proposal consists of six fundamental principles and 16 key points. This article specifically focuses on the five points that, if enacted into law, would improve access to health care for Americans who are, for various reasons, without health insurance.

Aged↗
PubMed2005

Youth tobacco sales-to-minors and possession-use-purchase laws: a public health controversy.

Tobacco use among youth remains one of our nation's most significant public health problems, and yet available evidence from prevention and cessation person-centered approaches has been mixed. Given these disappointing outcomes, some have recommended more public health approaches, and these include tobacco sales-to-minors and possession-use-purchase laws. While community members and police officials have endorsed these types of public health initiatives, many within the public health community have been either guarded or even oppositional to such approaches. The primary reasons for this controversy are reviewed in this article. Outcome studies indicate that sales-to-minors laws can be an effective step toward the reduction of youth access to commercial sources of tobacco. However, even with these laws in place, many youth indicate that they continue to have easy access to tobacco, often by means of social sources. Advocates of these approaches have argued that more comprehensive public health interventions are needed, such as programs that combine youth access and possession-use-purchase laws. This article reviews the ongoing debate behind these types of public health efforts, and examines the evidence of such programs to reduce youth tobacco use.

Adolescent↗