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PubMed2005

Educational and health services innovation to improve care for rural Hispanic communities in the USA.

BACKGROUND: Access to comprehensive and quality healthcare services is difficult for socioeonomically disadvantaged groups in rural regions. Barriers to health care for rural Latinos include lack of insurance, language barriers and cultural differences. For the Latino immigrant population in rural areas, barriers to access are compounded. HEALTH NEEDS OF RURAL AREAS: THE CASE OF WALHALLA, SC: The town of Walhalla, South Carolina, USA, is a rural community located in Oconee County, the northwest corner of the state. Disparities exist between rural and urban residents in several health categories, and these disparities illustrate the need to provide competent, appropriate and affordable healthcare to rural populations. The Hispanic population of Oconee has dramatically increased in the past decade, and the majority of these immigrants have no health insurance and have limited access to health services. DESIGNING A PROGRAM TO FIT THE COMMUNITY--THE "WALHALLA EXPERIENCE": The purpose of the Accessible and Culturally Competent Health Care Project (ACCHCP) is to provide care for underserved populations, in Oconee County, South Carolina while providing rural educational opportunities for health services students. Funded by the Health Resources and Services Administration of DHHS, the program is designed to offer culturally appropriate, sensitive, accessible, affordable and compassionate care in a mobile clinic setting. In this interdisplinary program, nurse practitioners, health educators, bilingual interpreters, medical residents and Clemson University students and professors all played key roles. Women in the community also serve as promotoras or lay health advisors. The program is unique in using educational initiatives and innovative strategies for bringing health care to this underserved community and offers important information for rural healthcare initiatives targeting minority groups. This article reports on the challenges and successes in the development and implementation of the ACCHCP program in Walhalla, South Carolina.

Adolescent↗
PubMed1979

Increased access to medical care: the impact on health.

Many federally financed programs have been launched to improve the access of the poor to medical care, under the assumption that this will improve their health. The effectiveness of these programs, however, has generally been measured by increased utilization rather than by improved health. The few studies which have considered health status have shown small or negative effects. Here, data are presented from a project which provided fully prepaid care to near poor families through existing sources in the community. A group of 748 enrollees was found to report worse health on four of five health indicators after one year of enrollment in the program; further, they appeared sicker on all five measures than a group without free medical care. It is suggested: 1) that the impact of health programs on the health of a population is a complex and poorly understood issue; and 2) that increasing access to health care may not be an effective way to improve health.

Adolescent↗
PubMed1986

AIDS risk reduction: a community health education intervention for minority high risk group members.

During the past year, members of the Detroit Health Department health education staff have developed an Acquired Immunodeficiency Syndrome (AIDS) community education intervention. The intervention was designed in response to the growing public health problem of AIDS and the need to provide the community with accurate information regarding the transmission and prevention of the disease. The gap in AIDS education and information was particularly evident in the black community. In attempting to develop a comprehensive health education program, the staff encountered a number of barriers. Traditional antagonisms between the high-risk groups, homosexual and bisexual males and intravenous drug abusers, and the health department hampered the ability of the intervention team to design a clinic centered program. Concurrently, lack of access to the high-risk population and reactionary public sentiment toward the disease posed serious problems for developing community support for the implementation of an effective community-based program. The intervention team also found that traditional methodologies of health education program planning were inadequate. The staff lacked sufficient data on the beliefs and attitudes of the high-risk populations necessary to design relevant risk reduction activities. Recognizing our limited awareness and accessibility to the high risk groups, a strategy was developed to encourage members of the high-risk population to assume a leadership role in the development and implementation of the community-based program. The success of the Community Health Awareness Group (C-HAG) is, in part, a result of the willingness of high risk individuals to assume some responsibility in educating themselves and others. It also speaks to the efficacy of collaborative relationships between health workers and target populations when designing public health interventions.

Acquired Immunodeficiency Syndrome↗
PubMed1998

The Ottawa telehealth project.

OBJECTIVE: To examine the telehealth system as a means of improving access to cardiac consultations and specialized health services in remote areas of Ontario. METHODS: The University of Ottawa Heart Institute has set up a telehealth test program, Healthcare and Education Access for Remote Residents by Telecommunications (HEARRT), in collaboration with industry and the provincial and federal government, as well as several remote clinical test sites. The program makes off-site cardiology consultations possible. History taking and physical examinations are conducted by video and electronic stethoscope. Laboratory results and echocardiograms are transmitted by document camera and VCR. The technology is being tested in both stable outpatient and emergency situations. Various telecommunications bandwidths and encoding systems are being evaluated, including satellite and terrestrial-based asynchronous transfer-mode circuits. Patient satisfaction and cost-effectiveness are also being assessed. RESULTS: Bandwidths from as low as 384 kbps using H.320 encoders to 40 Mbps using digital transport of NTSC video signals have been evaluated. Although lower bandwidths are sufficient for sending echocardiographic and electrocardiogram data, bandwidths with transport speeds of 4 to 6 Mbps appear necessary to capture the nuances of the cardiac physical examination. A preliminary satisfaction survey of 19 patients noted that all felt that they could communicate effectively with the cardiologist by video, and each had confidence in the advice offered. None reported that he or she would rather have traveled to the doctor in person. Initial and projected examination of the costs suggested that telehealth will effectively reduce overall health care spending while decreasing travel expenses for rural patients. CONCLUSION: Telehealth technology is sufficiently sophisticated to allow off-site cardiology assessments. Preliminary results suggest there is a sound business case for the implementation of telehealth technology to meet the needs of remote residents in northern Ontario. Working closely with government and industry, we will develop a marketing and commercialization plan to support the use of this technology throughout Ontario and expand application to patient education and continuing medical education.

Cardiology↗
PubMed1994

OLGCG: an OPEN LOOK interface to the GCG sequence analysis package.

We have developed a graphical user interface (GUI) to the Genetics Computer Group (GCG) Sequence Analysis Package using the OPEN LOOK interface. The software consists of pulldown menus and window interfaces to the GCG programs. This provides experienced users with methods to expedite the entry of complex commands and inexperienced users easy mouse-driven access to the GCG programs using both IBM-compatible machines and Macintoshes running X server software.

Computer Graphics↗
PubMed2005

The State Children's Health Insurance Program.

PURPOSE OF REVIEW: The State Children's Health Insurance Program expanded public health insurance to children who are ineligible for Medicaid yet unable to afford private health insurance. The program was a natural experiment, offering the opportunity to study the effects of expanding health insurance to a large population of children who would otherwise be uninsured. The State Children's Health Insurance Program is reviewed in the context of program goals, evaluation dimensions, past and current findings, and future directions. The studies and findings fall into five dimensions: (1) outreach/enrollment/uptake and profile of enrollees, (2) impact on insurance coverage and uninsured rates, (3) coverage dynamics, (4) impact on outcomes, and (5) costs. RECENT FINDINGS: Older studies focused on outreach, enrollment, characteristics of enrollees, disenrollment, and coverage dynamics. Current studies report the impact of the program on outcomes--including access to care, quality, satisfaction, unmet need, and health outcomes--for the overall population of children and for vulnerable subgroups, including racial and ethnic minorities and children with chronic illness. A smaller number of studies address costs. SUMMARY: The State Children's Health Insurance Program is evolving with demonstrated successes and areas for improvement. This information can enhance practicing pediatricians' understanding of barriers that face low-income children and families in seeking care for their children, can offer insight into what health insurance can and cannot do in terms of ameliorating those barriers, can provide insight into the prior experiences and current medical needs that a new enrollee in the program might have at the first visit to a practitioner, and can illuminate the challenges that low-income children and families may face in obtaining and maintaining health insurance coverage.

Child↗
PubMed2025

Global considerations for lifelong management and therapeutic development for phenylketonuria.

Phenylketonuria (PKU) is an inherited metabolic disorder characterized by the accumulation of toxic phenylalanine levels in the brain that can lead to neurocognitive impairment if untreated. This review evaluates unmet needs in PKU, the importance of newborn screening (NBS), and considerations for chronic treatment options. An international group of experts reviewed the available literature across ethnicities and geographies to identify unmet needs of individuals with PKU. Treatment was assessed in a global context to address patient benefit. Reflecting challenges to the worldwide PKU community, some countries have been unable to implement NBS programs and/or do not apply a treatment-for-life approach. Ongoing challenges for individuals with PKU include maintaining adherence to treatment guidelines for patient- and practice-specific reasons, such as inadequate access to low-cost treatment, insufficient social support, limited clinical staffing, and disease burden. Dietary interventions may not adequately address all symptoms, and some of the current pharmacotherapies may be associated with limited efficacy or adverse events. Several new therapies are being evaluated for the treatment of PKU, offering the potential to address unmet needs. Global availability of NBS programs, access to treatments, and a tenacious commitment to treatment-for-life are expected to improve outcomes for individuals with PKU across geographic regions.

Humans↗
PubMed1998

Managed care and people with disabilities: framing the issues.

A physical, cognitive, or mental disability presents significant challenges to an individual in gaining access to a coordinated program of preventive, primary, and secondary health care services. This article describes the health care needs of people with disabilities and discusses how the financial incentives in managed care may threaten access to the health care services they need to maintain their health and functional independence. We argue that despite the shortcomings of present models, managed care has the potential to improve the health care of people with disabilities. Moreover, as health plans become increasingly accountable to consumers (and begin to compete on the basis of quality), they will not be able to ignore the distinct health care needs of people with disabilities.

Persons with Disabilities↗
PubMed2005

Educational and health services innovation to improve care for rural Hispanic communities in the US.

BACKGROUND: Access to comprehensive and quality health care services is difficult for socioeconomically disadvantaged groups in rural regions. Barriers to health care for rural Latinos include lack of insurance, language barriers and cultural differences. For the Latino immigrant population in rural areas, barriers to access are compounded. HEALTH NEEDS OF RURAL AREAS: THE CASE OF WALHALLA, SC: The town of Walhalla, South Carolina is a rural community located in Oconee County, the northwest corner of the state. Disparities exist between rural and urban residents in several health categories, and these disparities illustrate the need to provide competent, appropriate and affordable healthcare to rural populations. The Hispanic population of Oconee has dramatically increased in the past decade, and the majority of these immigrants have no health insurance and have limited access to health services. DESIGNING A PROGRAM TO FIT THE COMMUNITY--THE "WALHALLA EXPERIENCE": The purpose of the Accessible and Culturally Competent Health Care Project (ACCHCP) is to provide care for underserved populations in Oconee County, South Carolina while providing rural educational opportunities for health services students. Funded by the Health Resources and Services Administration of DHHS, the program is designed to offer culturally appropriate, sensitive, accessible, affordable and compassionate care in a mobile clinic setting. In this interdisciplinary program, nurse practitioners, health educators, bilingual interpreters, medical residents and Clemson University students and professors all played key roles. Women in the community also serve as Promotoras or lay health advisors. The program is unique in using educational initiatives and innovative strategies for bringing health care to this underserved community and offers important information for rural health care initiatives targeting minority groups. This paper reports on the challenges and successes in the development and implementation of the ACCHCP program in Walhalla, South Carolina.

Adult↗
PubMed2005

Conversion of tunneled hemodialysis catheter-consigned patients to arteriovenous fistula.

OBJECTIVE: Despite their high incidence of complications, costs, morbidity, and mortality, nearly 27% of the chronic hemodialysis (HD) patients are receiving treatment via a tunneled hemodialysis catheter (TDC). METHODS: In this prospective analysis, an interventional nephrology team employed an organized program consisting of vascular access (VA) education and vascular mapping (VM) to TDC-consigned patients. A full range of surgical approaches for arteriovenous fistula (AVF) creation, including vein transpositions, was exercised. Physical examination was performed every 1 to 2 weeks after surgery to assess the development of the AVF. Fistulas that failed to develop adequately to support HD (early failure) underwent salvage [percutaneous transluminal angioplasty (PTA), accessory vein obliteration (AVL)] procedures. RESULTS: One hundred twenty-one TDC-consigned patients received VA education. Eighty-six (71%) agreed to undergo VM. Two groups were identified. Group I (N= 66; using TDC for 7.2 +/- 1.8 SD months) had never had an arteriovenous access; group II (N= 20; using TDC for 12.3 +/- 4.0 months) had a history of one or more previously failed arteriovenous accesses. Upon VM, 64/66 (97%) in group I and 18/20 (90%) in group II were found to have adequate veins for AVF creation. Seven patients (11%) in group I and 3 (17%) in group II refused surgery. In group I, 57 (89%) received an arteriovenous access (radiocephalic AVF = 15, brachiocephalic AVF = 35, transposed brachiobasilic AVF = 3, brachiobasilic AVG = 4). In group II, 15 (83%) received a transposed AVF (radiobasilic = 2, brachiobasilic = 13). Sixteen fistulas (30%) in group I and 8 (53%) in group II had early failure. All except for one fistula in each group were salvaged using PTA and/or AVL. All 70 accesses (AVF = 66, AVG = 4) remain functional, with a mean follow-up of 8.5 +/- 3.6 months. CONCLUSION: These results demonstrate that an organized approach based upon a comprehensive program utilizing VA counseling, VM, application of full range of surgical techniques, and salvage procedures can be very successful in providing optimum vascular access to the catheter-dependent patient.

Adult↗
PubMed1990

Development of a computer-aided reference system for differential diagnostics support.

In a situation of uncertain diagnosis, physicians may spend valuable time consulting relevant literature, often with unsatisfactory results. Therefore, our aim was to develop a computer system which supports differential diagnostics via rapid and comprehensive searches through information in literature. Based on entered signs and symptoms our prototype is able to offer probable diagnoses. Subsequently, further examinations and tests are suggested to confirm or exclude a certain disease. Thus, the final diagnosis is made gradually by differentiation of possible diseases. Our first attempt consisted in representing knowledge in a rule-based PROLOG system. However, because nearly all information for a sign-oriented differential diagnosis can be represented with very few relations only, we turned to a fact-oriented representation of signs and diseases. Access was possible via PROLOG or an imperative programming language. The index-sequential access on a fact-oriented representation of knowledge was suitable to manage a large knowledge base, which is necessary for a thorough differential diagnosis. A pointer structure was recently examined in order to handle different object-to-object relations. Efficient information processing is now possible which provides short response times using even broad knowledge bases.

Diagnosis, Computer-Assisted↗
PubMed1982

Access to medical care under Medicaid: differentials by race.

The Medicaid program was designed to help correct for the unequal access to medical care by income and race in pre-1965 America. Previous evaluations of the program have claimed that on average the eligible poor have enjoyed considerable gains in access, but that the benefits of Medicaid have not been shared equally by blacks and whites. We reexamined the evidence on differential access by race early in the program (1969) and evaluate that claim for the mature program (1976). Our evaluation is conducted within the context of multivariate models of physician and hospital utilization designed to control for a variety of socioeconomic, health status, and resource supply characteristics. While earlier evaluations overstated the extent of racial differentials in 1969, blacks who were not chronically ill had significantly lower levels of ambulatory care--both within and outside of the South. Between 1969 and 1976 all race, region, and health status groups of nonelderly Medicaid recipients experienced increases in physician visits that far outpaced those of the entire nonelderly U.S. population. By 1976 blacks clearly achieved equality with whites in Medicaid ambulatory care use. The only statistically significant shortfall we find is in hospital utilization among Southern blacks in good health.

Black or African American↗
PubMed2000

Minimally invasive surgical training solutions for the twenty-first century.

Despite the tremendous impact of laparoscopic cholecystectomy on the practice of surgery over the past 9 years, minimally invasive surgery faces many challenges that must be addressed. SAGES and the American College of Surgeons already have defined guidelines that, if properly implemented, could eliminate most of these challenges. Medical educators must formulate a detailed program as to how these guidelines can be widely deployed with acceptable effectiveness. The current educational philosophies and techniques will not ensure widespread access to a standardized program that would support the achievement of the goals set forth by major surgical governing bodies. Therefore, new educational strategies and techniques that are assisted with the integration of cost-effective technology are needed. Suggested solutions include the deployment of a standardized, objective-based skill-development program that has a large database to evaluate the progress of participants. Next, the Internet, with its ability to transfer content with the click of a mouse, will play an increasing role in distant education. Video and audio streaming techniques will allow the deployment of content previously shackled to a CD-ROM platform. CD-ROM interactive technology also can help in developing clinical judgment with innovative strategies, such as Objective-Based Clinical Competency Evaluation Scenarios. Telecommunications will fuse the components of a coordinated distant learning strategy. Also, telecommunications will allow the availability of new training capabilities in the form of teleproctoring and telementoring to hospitals, no matter what their size or location. All of these components combined enable the realization of a continuing education program in minimally invasive surgery that is readily available to hospitals worldwide. Last, institutions, resident training programs, and individual surgeons must commit the time to partake in these cutting-edge programs for challenges facing us to be completely eliminated. A high priority must be placed on the resolution of these issues.

Education, Medical↗
PubMed2005

A health professional students' cultural competence and attitudes toward the poor: the influence of a clinical practicum supported by the National Health Service Corps.

To provide quality health care today, practitioners must be culturally competent. Funding sources, such as the federal government, recognize the need to prepare culturally competent clinicians. The mission of the National Health Service Corps (NHSC), a federal program, is to increase access to primary care services and reduce health disparities by assisting in the preparation of community-responsive, culturally competent primary care clinicians. This study evaluated an NHSC program that funded, in part, health professional students' educational programs. Following their participation in an NHSC-supported clinical experience, students were assessed on their cultural competence, perceptions of the poor, and intention of serving in an underserved community. Health professional students completed a survey before and after the clinical practicum. Participants included students who were studying to be physicians, physician assistants, social workers, and nurse practitioners. Results of the study found no change in students' cultural competence after their clinical practicum. Although they remained in the "culturally aware" stage, they were not considered either "culturally proficient" or "culturally competent." However, their attitudes toward those in poverty were more positive than in previous studies of health professionals. The greatest impact from the students' clinical experience was their increased intention to practice in an underserved community following their practicum. They found their experience with the underserved to be rewarding, challenging, and humbling. Documenting the influence that government-funded programs have on health professional students is extremely important in studies such as this.

Attitude of Health Personnel↗
PubMed2000

Secondary structure prediction and in vitro accessibility of mRNA as tools in the selection of target sites for ribozymes.

We have investigated the relative merits of two commonly used methods for target site selection for ribozymes: secondary structure prediction (MFold program) and in vitro accessibility assays. A total of eight methylated ribozymes with DNA arms were synthesized and analyzed in a transient co-transfection assay in HeLa cells. Residual expression levels ranging from 23 to 72% were obtained with anti-PSKH1 ribozymes compared to cells transfected with an irrelevant control ribozyme. Ribozyme efficacy depended on both ribozyme concentration and the steady state expression levels of the target mRNA. Allylated ribozymes against a subset of the target sites generally displayed poorer efficacy than their methylated counterparts. This effect appeared to be influenced by in vivo accessibility of the target site. Ribozymes designed on the basis of either selection method displayed a wide range of efficacies with no significant differences in the average activities of the two groups of ribozymes. While in vitro accessibility assays had limited predictive power, there was a significant correlation between certain features of the predicted secondary structure of the target sequence and the efficacy of the corresponding ribozyme. Specifically, ribozyme efficacy appeared to be positively correlated with the presence of short stem regions and helices of low stability within their target sequences. There were no correlations with predicted free energy or loop length.

Algorithms↗
PubMed2005

Use of a program-specific website to disseminate surveillance data obtained from the Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) Study.

The Meropenem Yearly Susceptibility Test Information Collection (MYSTIC) Program is a multicenter, longitudinal surveillance study initiated in 1997 that compares the activity of meropenem and comparator antimicrobials in centers that are actively prescribing meropenem. Antimicrobial surveillance programs, such as MYSTIC, provide important information on the emergence of bacterial resistance and the nature of the underlying mechanisms in different geographical regions. Data concerning these mechanisms and patterns of antimicrobial resistance allow the implementation of changes in antimicrobial prescribing practices and infection control interventions. Therefore, it is important that data from surveillance programs be analyzed and accessible to clinicians within reasonable, clinically useful, intervals. In this article, the use of a website designed to disseminate data collected from the MYSTIC program is described. This web-based program allows specific surveillance data to be examined in a timely manner and can assist the clinician when choosing the most appropriate antibiotic for the situation encountered and hopefully maximize successful clinical outcomes.

Anti-Bacterial Agents↗
PubMed2005

Making a home in the community for the academic medical center.

Academic medical centers (AMCs) have traditionally provided primary care for low-income and other underserved populations. However, they have had difficulty developing lasting partnerships with other organizations serving the same populations. This article describes an exception to the rule, in which an academic division was created at Duke University Medical Center to develop effective collaborations with health care and social service providers in Durham, North Carolina, including both public agencies and private organizations. Together, the division and its partners have created and operate programs that improve health outcomes and access to care for those at risk. These programs share a number of characteristics: they are designed to meet the needs of the patient, not the provider; they are based in the community, not in the AMC; they bring services to people's homes, schools, and neighborhoods; they are multidisciplinary, combining health, social, and even mental health services; and, once established, they are revenue-generating and can be made self-supporting when grant funding ends. These programs are also innovative. They are designed to model and test new ways of organizing and delivering care. Preliminary indications suggest that they also strengthen the AMC's relationships with the surrounding community.

Academic Medical Centers↗
PubMed2004

School-based mental health services.

More than 20% of children and adolescents have mental health problems. Health care professionals for children and adolescents must educate key stakeholders about the extent of these problems and work together with them to increase access to mental health resources. School-based programs offer the promise of improving access to diagnosis of and treatment for the mental health problems of children and adolescents. Pediatric health care professionals, educators, and mental health specialists should work in collaboration to develop and implement effective school-based mental health services.

Adolescent↗