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PubMedDate not supplied

Leading change: Retrospective evaluation of a nurse-led initiative in vascular access options for autologous stem cell transplant recipients ranging from Hickman catheters to peripherally inserted central catheters.

Central venous access is essential for patients undergoing autologous hematopoietic stem cell transplantation (ASCT). Traditionally, tunneled silastic catheters have been inserted in these patients. However, changes in resource allocation, resulting in reduced surgery and surgeon time and decreasing toxicity associated with ASCT, have caused changes in venous access needs and options. This led the advanced practice nurse in the transplant program to evaluate other central access devices, which resulted in the introduction of peripherally inserted central catheters (PICCs) for this patient population. This study reports the results of a retrospective analysis comparing efficacy and complication profiles between 50 patients with the traditional Hickman catheter and 70 patients with PICCs.

Adult↗
PubMed1987

The importance of considering alternative structural equation models in evaluation research.

The availability of the LISREL computer program and similar software (for example, COSAN, EQS) have made structural equation modeling accessible to researchers interested in program evaluation. An article was published in the December 1985 issue of this journal that used LISREL to investigate the relationship between family medicine residents' moral reasoning and their clinical performance with patients (Sheehan et al., 1985). We present a reanalysis of the data from that study to illustrate the importance of considering alternative structural equation models in evaluation research.

Ethics, Medical↗
PubMedDate not supplied

iMPACT3: Internet-based development and administration of utility elicitation protocols.

iMPACT3 (Internet Multimedia Preference Assessment Instrument Construction Tool, version 3) is a software development environment that helps researchers build Internet-capable multimedia utility elicitation software programs. The program is a free, openly accessible Web site (http.// preferences.ucsd.edu/impact3/asp). To develop a utility elicitation software program using iMPACT3, a researcher selects modular protocol components from a library and custom tailors the components to the details of his or her research protocol. iMPACT3 builds a Web site implementing the protocol and downloads it to the researcher's computer. In a study of 75 HIV-infected patients, an iMPACT3-generated protocol showed substantial evidence of construct validity and good internal consistency (logic error rates of 4% to 10% and procedural invariance error rates of 10% to 28%, depending on the elicitation method) but only fair 3- to 6-week test-retest reliability (intraclass correlation coefficient= 0.42 to 0.55). Further work may be needed on specific utility assessment procedures, but this study's results confirm iMPACT3's feasibility in facilitating the collection of health state utility data.

Adult↗
PubMed2000

Articulation of pre-registration nursing courses in Western Sydney.

This paper will describe a project, undertaken in 1996-1997, which sought to develop formal articulation arrangements between nursing education courses provided by Technical and Further Education (TAFE) institutions in Greater Western Sydney and the University of Western Sydney (UWS). The project sought to facilitate the access of TAFE-trained Enrolled Nurses (ENs) to UWS's Bachelor of Nursing (BN) courses and eliminate costly duplication in programs of study. Although conducted in Australia, the project generated insights of utility to colleagues in the UK, the USA and New Zealand, in particular, who are dealing with the effects of the 'knowledge explosion' and reductions in government funding to universities. The project comprised two stages. Stage 1 involved a statewide survey of all stakeholders, using individual telephone interviews and focus groups, of practices and perceptions with respect to formal articulation arrangements. The findings demonstrated an overwhelming consensus with respect to both the benefits of and barriers to formal articulation arrangements. These benefits and barriers will be described. Stage 2 involved the TAFE-UWS collaborative design and implementation of 2 EN-BN bridging programs which allow, differentially, ENs to access UWS's BN programs with 1 and 2 semesters block credit. This paper includes details of the project's background, survey methods and findings, bridging courses' contents and courses' implementation evaluative data.

Curriculum↗
PubMed1989

Federal programs affecting rural perinatal health care.

Access to perinatal health care in rural communities often depends on such factors as the availability, cost, and acceptability of services. The federal government has been providing rural perinatal health care both directly and indirectly, through grants for service delivery or research and through direct payment for service. The various federal programs supporting perinatal health care in rural communities are described, and what may need to be done in the future is discussed.

Female↗
PubMed2001

On duties to provide basic health and dental care to children.

Children around the world suffer from poor health outcomes due to a lack of basic health and dental care, even in affluent countries. Yet duties exist to provide children these services when a society can afford to do so based on the importance of promoting (a) social utility, (b) autonomy and equality of opportunity, (c) children's well-being or best interest due to their vulnerability, and (d) compassion, sympathy, empathy and solidarity. In addition, (e) these considerations show that, in general, if competent adults should have access to federal- or state-funded health care goods, services, or benefits, then so should children. This argument has limitations; nonetheless, it can help identify systematic biases against children in federal- or state-supported health care programs and gain children access to better basic health and dental care.

Child↗
PubMed2006

Outcome of fetuses in women with pregestational diabetes mellitus.

OBJECTIVE: To investigate the effects of pregestational diabetes on pregnancy outcome. METHODS: Data of 126 women with pregestational diabetes prospectively collected and controlled in a single tertiary center. HbA(1C) levels at early pregnancy were registered. Adverse pregnancy outcome was defined as spontaneous abortion, congenital defect, stillbirth, or neonatal death. RESULTS: There were 10 spontaneous abortions (7.9%) and 17 fetuses with congenital anomalies (13.4%), including 8 major malformations (6.3%). Compared with pregnancies with a favorable outcome, a higher HbA(1C) concentration in early pregnancy was observed in pregnancies with adverse perinatal outcome [mean (SD): 6.3 (1.6) vs. 7.2 (1.7), P=0.001]. A positive correlation between increased maternal HbA(1C) levels and the rate of fetal malformations was observed, and the group of women with poor metabolic control (early maternal HbA(1c) concentration >7%) showed a 3 to 5-fold increase in the major malformation rate. Cardiovascular and genitourinary defects accounted for 58.8% of the anomalies, and the ultrasound examinations detected seven of them (41.2%). For major malformations, the detection rate was 50% (4/8). Perinatal mortality rate was 26 per thousand (3/116). There was almost 5-fold increase in the total pregnancy loss rate in the poor control group compared with the group with fair control [22.2% vs. 5.3%, OR (95% CI): 5.1 (1.4-17.1)]. Only 11.9% of mothers used a preconception care program. CONCLUSIONS: Pregestational diabetes mellitus is a significant risk factor for the developing fetus. Spontaneous abortions and congenital defects are more common when a poor metabolic control is present in early pregnancy. It is most important to improve access to preconception care programs for achieving a good metabolic control in early pregnancy. Ultrasound examinations have a low performance for detecting congenital defects in diabetic pregnancies.

Abortion, Spontaneous↗
PubMed1988

Child survival in Indonesia.

The 1980 infant mortality rate of 107/1000 live births in Indonesia was 2 to 3 times the average rate in surrounding Asian countries. Provincial rates vary from 187 in West Nusa Tenggara to 62 in Yogyakarta. This variation is explained in part by female education levels, access to health facilities, and the impress of health aid and system programs, especially family planning. In addition, mortality rates and the usage of modern health care continue to reflect historical and cultural imprints. A program strategy for improvements in infant and child mortality focus on 4 basic elements: 1) growth monitoring, 2) oral rehydration therapy, 3) breast feeding, and 4) immunization. These efforts are delivered largely through the Expanded Immunisation Programme and the Family Nutrition Programme. A potential major breakthrough in primary health care has been realized with the development of a network of integrated health posts (posyandu) which deliver multiple services more efficiently in rural areas.

Asia↗
PubMed1999

Crowd out: evidence from the Florida Healthy Kids Program.

OBJECTIVE: To determine the percentage of children who had insurance coverage in the 12 months preceding enrollment in a state-subsidized program; the percentage of parents who had access to employer-based family coverage; and the cost of the families' share of the premium per month. METHODS: We randomly selected 930 families whose children were enrolled in the Florida Healthy Kids Program for a period of between 1 and 3 months and conducted telephone interviews with them in 1998 about their children's insurance coverage before program entry and their access to employer-based family coverage. There were 653 families in the final sample. RESULTS: Only 5% of the children had employer-based coverage before program enrollment. However, 26% had access to family coverage through their employers with the family share of the premiums representing on average 13% of their incomes. Access to employer-based coverage varied significantly by family income. CONCLUSIONS: Throughout the development of the State Children's Health Insurance Program legislation, policy analysts expressed concern that families may crowd out or substitute a subsidized state plan for employer-based coverage. This substitution could result in fewer improvements in access to care and health status than were anticipated, because families are simply moving to a different form of health insurance. There is some degree of crowd out in the Healthy Kids Program. The economic burden to near-poor families to purchase employer-based coverage is significant. Some degree of substitution may need to be tolerated to ensure that children receive needed health insurance.

Child↗
PubMedDate not supplied

Use of an intercostal vein for central venous access in home parenteral nutrition: a case report.

A key factor in the success of a home parenteral nutrition program is prolonged and safe access to the central venous system. There are some patients, however, in whom the cephalic, external jugular, internal jugular, subclavian, and saphenous veins cannot be used. In these patients, cannulation of an intercostal vein can be useful for central venous access. Such a patient was recently presented to our medical care facility with bilateral subclavian vein thrombosis, left external iliac vein thrombosis, and superior vena cava obstruction above the level of the azygous vein. A Broviac catheter was successfully introduced via a right intercostal vein cutdown with the catheter tip lying in the azygous arch. This is the first known description in an adult patient in the use of an intercostal vein to gain access into the central venous system.

Adult↗
PubMed1995

Gender and developmental differences in exercise beliefs among youth and prediction of their exercise behavior.

This study examined gender and developmental differences in exercise-related beliefs and exercise behaviors of 286 racially diverse youth and explored factors predictive of exercise. Compared to males, females reported less prior and current exercise, lower self-esteem, poorer health status, and lower exercise self-schema. Adolescents, in contrast to pre-adolescents, reported less social support for exercise and fewer exercise role models. In a path model, gender, the benefits/barriers differential, and access to exercise facilities and programs directly predicted exercise. Effects of grade, perceived health status, exercise self-efficacy, social support for exercise, and social norms for exercise on exercise behavior, were mediated through the benefits/barriers differential. Effect of race on exercise was mediated by access to exercise facilities and programs. Continued exploration of gender and developmental differences in variables influencing physical activity can yield valuable information for tailoring exercise promotion interventions to the unique needs of youth.

Adolescent↗
PubMed2001

Implementing supported employment as an evidence-based practice.

Supported employment for people with severe mental illness is an evidence-based practice, based on converging findings from eight randomized controlled trials and three quasi-experimental studies. The critical ingredients of supported employment have been well described, and a fidelity scale differentiates supported employment programs from other types of vocational services. The effectiveness of supported employment appears to be generalizable across a broad range of client characteristics and community settings. More research is needed on long-term outcomes and on cost-effectiveness. Access to supported employment programs remains a problem, despite their increasing use throughout the United States. The authors discuss barriers to implementation and strategies for overcoming them based on successful experiences in several states.

Community Mental Health Centers↗
PubMedDate not supplied

A closer look at the role of a spiritual approach in addictions treatment.

Twelve Step Programs such as AA play a major role in addictions treatment, and their members are increasingly accepting of psychotherapy and medication. However, many clinicians question the role of an approach defined by these Programs as spiritual. This paper explores the nature, indications, and limitations of a spiritual approach to addiction and the implications for collaboration with mental health professionals. It suggests that Twelve Step Programs not only provide accessible group support and a clear ideology regarding addiction but address individuals' needs for identity, integrity, an inner life and interdependence within a larger social and moral, or spiritual context. It examines the ways in which the religious connotations of the Program remain an obstacle for many patients and clinicians. Clarification of the different needs met by modalities such as AA can improve the specificity and the comprehensiveness of treatment for patients with substance use disorders.

Adult↗
PubMedDate not supplied

Expansion of an existing program for the prevention and reversal of heart disease.

The expansion of the heart-disease-prevention and -reversal program within the Alegent Health System has been met with enthusiasm by the public, physicians, and hospital administration. The expansion was developed to effectively and efficiently utilize existing staff whenever possible in order to maintain costs. The additional delivery site allows additional access to this valuable program and promotes Alegent Health as a true "system," with the health of the community as its driving force. The development of the Cardiac College provides a much-needed educational program for the public with the intent of reducing suffering and death due to heart disease.

Behavior Therapy↗
PubMed1999

Surveillance for use of preventive health-care services by older adults, 1995-1997.

PROBLEM/CONDITION: In 1995, a total of 55 million persons aged > or =55 years lived in the United States. The members of this large and growing segment of the population are major consumers of health care. Their access to medical and dental preventive services contributes to their likelihood of healthy later years and influences their long-term impact on the health-care delivery system. REPORTING PERIOD: 1995-1997. DESCRIPTION OF SYSTEMS: This report summarizes data from the National Health Interview Survey (NHIS), the state-based Behavioral Risk Factor Surveillance System (BRFSS), and the Medicare Current Beneficiary Study (MCBS) to describe national, regional, and state-specific patterns of access to and use of preventive services among persons aged > or =55 years. RESULTS: During 1995-1997, approximately 90% of persons aged > or =55 years living in the United States reported having a regular source of health-care services. However, only 75%-80% reported receiving a routine checkup during the preceding 2 years. The estimated percentage of persons who reported not being able to receive medical care because of cost was highest for those aged 55-64 years. Within this age group, the percentage was highest among Hispanics (4%) and persons without a high school diploma. Approximately 11% of Medicare beneficiaries reported delaying care be cause of cost or because they had no particular source of care. Percentage estimates varied according to age, race/ethnicity, and sociodemographic status. Approximately 95% of persons aged > or =55 years reported having their blood pressure checked during the preceding 2 years, but only 85%-88% had received a cholesterol evaluation during the preceding 5 years. The percentage of women receiving breast and cervical cancer screening decreased with increasing age, and the percentage of persons aged > or =55 years who had received some form of screening for colorectal cancer was low approximately 25% for fecal occult blood testing (FOBT) and 45% for endoscopy. State-specific rates of compliance with vaccination recommendations among persons aged > or =65 years were higher for influenza vaccine (range: 54%-74%) than for pneumococcal vaccine (range: 32%-59%), and compliance increased with advancing age. State-specific estimates of the percentage of annual dental visits varied 40%-75%, and 41%-88% of persons aged > or =65 years reported not having dental insurance. INTERPRETATION: Access to medical services among adults living in the United States is greater for persons aged > or =65 years, compared with those aged <65 years, presumably because of Medicare coverage. In contrast, use of dental services decreased, despite increased need for preventive and restorative dental care. Although Medicare covers many medical services for older adults, financial, personal, and physical barriers to both medical and dental care create racial, regional, and sociodemographic disparities in health status and use of health services in the United States. PUBLIC HEALTH ACTION: Continued surveillance of access to and use of health services among older adults (i.e., persons aged > or =65 years), as well as among persons aged 55-64 years, will help health-care providers target underserved groups, make Medicare coverage decisions, and develop public health programs to ensure equitable access to services and improve the health of older adults.

Aged↗
PubMed1977

The prevalence of tapeworms in dogs during the Hydatid Limitation program in Tasmania.

The hydatid Limitation Program in Tasmania began in 1965 with the annual purging of dogs to identify areas of high prevalence of Echinococcus granulosus combined with a strong educational program aimed at preventing access to offal by dogs. From 1969 to 1975 aenia spp detected in dog purges were submitted for identification and changes in annual prevalences analysed for each species. Despite a significant reduction in the prevalence of E. granulosus since the beginning of the program, the control measures involved have apparently not predisposed to any significant change in the prevalence of T. ovis and T. hydatigena during the period of this survey.

Animals↗
PubMed1999

Community decision-making about critical access hospitals: lessons learned from Montana's Medical Assistance Facility Program.

Limited-service hospitals have been used as a means of maintaining health care services in rural communities with full-service hospitals at risk of closure. The Medical Assistance Facility (MAF) limited-service hospital model has been implemented in 12 communities in Montana and has been evaluated by the Health Care Financing Administration as a viable alternative to a full-service hospital in frontier communities. The 1997 federal Critical Access Hospital (CAH) legislation is the most recent nationwide alternative for maintaining health care in rural communities, and it incorporates many of the features of the MAF model. The purpose of this study was to examine rural community decision making regarding MAF conversion from the perspectives of key informants who were involved in the decision-making process. A descriptive multiple case study design was used. Data were obtained through interviews with community members during site visits. The research focused on identification of local issues that were influential in the decision to convert to or reopen as an MAF, features of the MAF model that made it a locally acceptable alternative, and elements that characterized the decision-making process. The issues found to be influential in the conversion decision and the features that made the MAF locally acceptable were those that made the provision of basic services more stable and sustainable. The study suggests that programs to maintain health care services in isolated communities should allow for and encourage an expanded role for nonphysician providers. The lessons learned from the communities included in this study are instructive to rural communities nationwide that are considering a CAH as well as to policy-makers, researchers, and regional and national health care decision makers.

Community-Institutional Relations↗
PubMed2003

Michigan Medicaid's Healthy Kids Dental program: an assessment of the first 12 months.

BACKGROUND: In 2000, Michigan's Medicaid dental program initiated Healthy Kids Dental, or HKD, a demonstration program offering dental coverage to Medicaid-enrolled children in selected counties. The program was administered through a private dental carrier at private reimbursement levels. The authors undertook a study to determine the effect of these changes. METHODS: The authors obtained enrollment and utilization data for four groups: children covered in the first 12 months of HKD in 22 counties, children with private dental coverage in the same 22 counties in the same 12 months, Medicaid-enrolled children in the same 22 counties for 12 prior months, and Medicaid-enrolled children in 46 counties who were not included in the HKD program at any time. The authors compared access to care, dentists' participation, treatment patterns, patient travel distances and program cost. RESULTS: Under HKD, dental care utilization increased 31.4 percent overall and 39 percent among children continuously enrolled for 12 months, compared with the previous year under Medicaid. Dentists' participation increased substantially, and the distance traveled by patients for appointments was cut in half. Costs were 2.5 times higher, attributable to more children's receiving care, the mix of services shifting to more comprehensive care and payment at customary reimbursement levels. CONCLUSIONS: By increasing reimbursement levels and streamlining administration, the HKD demonstration program has shown that substantial improvements can be made to dental access for the Medicaid-enrolled population. PRACTICE IMPLICATIONS: The findings of this assessment suggest that appropriate attention to administration and payment levels can rapidly improve access for Medicaid-enrolled patients using existing dental personnel. By cooperating with state officials to design a program that addresses multiple issues, dental providers can help create a Medicaid dental program that is attractive to both providers and patients.

Adolescent↗