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Using the hygiene visit to deliver a tobacco cessation program: results of a randomized clinical trial.

To examine the effectiveness of advising patients who use tobacco to quit, the authors conducted a randomized clinical trial to test a brief office-based intervention with all tobacco users in 75 fee-for-service dental practices in Oregon. The authors found that the dental hygienist-delivered intervention was effective in getting smokeless tobacco users to quit at three and 12 months and to sustain abstinence at both three and 12 months. They found that the program was not effective for cigarette smokers. The authors discuss the public health implications of program dissemination and widespread program adoption.

Attitude to Health↗

Federal immunization policy and funding: a history of responding to crises.

BACKGROUND: This article outlines the history of federal immunization policy and funding, with a focus on discretionary federal funding under Section 317 of the Public Health Service Act, paying particular attention to the role of Congress in shaping the program in the past 2 decades. This review of funding trends and initiatives indicates that when both a presidential administration and key congressional actors viewed immunization as a priority and made sufficient funds available to support the public health delivery system and its infrastructure, coverage levels would continue to rise and disease levels continue to decline. From the beginning, immunization financing was explicitly structured as a federal-state-private-sector partnership. Section 317 program's statute has not changed much in 35 years, despite significant changes to the health care delivery system, other federal immunization activities, and rates of immunization coverage. Although the creation and implementation of the Vaccines for Children (VFC) program in the mid-1990s resulted in some congressional deliberations over immunization policies, no explicit restructuring of the 317 program occurred as a result. The Section 317 program retains its traditional authority and mission to address urgent needs, sustain public delivery systems, and provide funds for purchase of vaccines. The question remains whether the resources to sustain progress in immunization can be secured during times with no crisis, to ensure constant "readiness" in immunization (as in defense), or whether another epidemic must occur before the federal government is willing to commit optimal resources.

Centers for Disease Control and Prevention, U.S.↗

A preliminary study of partial hospital management of severe obsessive-compulsive disorder.

OBJECTIVE: The study examined the effectiveness of a partial hospital treatment program combining behavioral therapy, medication, and psychosocial intervention for severe and treatment-resistant obsessive-compulsive disorder. METHODS: A total of 58 patients with a primary diagnosis of obsessive-compulsive disorder who underwent treatment in a partial hospital program were assessed at baseline, at program discharge, and at six-, 12-, and 18-month follow-ups. Obsessive-compulsive symptoms, depression, anxiety symptoms, and global functioning were rated. RESULTS: The majority of patients (71 percent) met the criterion for a successful outcome, which was a 25 percent decrease in score on the Yale-Brown Obsessive Compulsive Scale (YBOCS). Fifty-five percent finished the program with YBOCS scores of 16 or less, indicating only mild symptoms. Most of these patients sustained their improvement at six, 12, and 18 months after discharge, and many showed further improvement with continued outpatient management. CONCLUSIONS: The partial hospital treatment program for obsessive-compulsive disorder appears to be an effective intervention that should be implemented and investigated further.

Adolescent↗

A platform for population-based weight management: description of a health plan-based integrated systems approach.

OBJECTIVES: To describe an integrated, operational platform from which mail- and telephone-based health promotion programs are implemented and to specifically relate this approach to weight management programming in a managed care setting. APPROACH: In-depth description of essential systems structures, including people, computer technology, and decision-support protocols. The roles of support staff, counselors, a librarian, and a manager in delivering a weight management program are described. Information availability using computer technology is a critical component in making this system effective and is presented according to its architectural layout and design. Protocols support counselors and administrative support staff in decision making, and a detailed flowchart presents the layout of this part of the system. This platform is described in the context of a weight management program, and we present baseline characteristics of 1801 participants, their behaviors, self-reported medical conditions, and initial pattern of enrollment in the various treatment options. CONCLUSION: Considering the prevalence and upward trend of overweight and obesity in the United States, a need exists for robust intervention platforms that can systematically support multiple types of programs. Weight management interventions implemented using this platform are scalable to the population level and are sustainable over time despite the limits of defined resources and budgets. The present article describes an innovative approach to reaching a large population with effective programs in an integrated, coordinated, and systematic manner. This comprehensive, robust platform represents an example of how obesity prevention and treatment research may be translated into the applied setting.

Decision Support Techniques↗

Evolution of a companywide validation program.

A successful computer validation program requires a solid foundation of policies, guidelines, and procedures. An unstructured approach to validation may yield adequate results for a specific computerized system, but it will not sustain ongoing, consistent computer validation activities over time. The evolution of a strong computer validation program starts with an awareness of the need for such a program and builds on that established base. One approach is a step-by-step method in which each new step builds on the results of one or more of the previous steps. However, the order of events is not as important as the ultimate completion of all the building blocks. A strong computer validation program requires a companywide policy and an administrator who provides oversight and chairs the computer validation committee. The committee should be established to provide departmental leadership and to develop company guidelines for computer validation. Committee members will also create system inventories and classify and prioritize those systems in terms of the need for validation. Departmental standard operating procedures must be developed to provide standardized methods for routine validation activities. Finally the quality assurance unit should have procedures in place that provide for its involvement in the computer validation process.

Computer Systems↗

The Army's Community-Based Health Care Initiative: an innovative military case management program.

As more Army National Guard and U.S. Army Reserve soldiers are called to active duty, there has been a rise in injuries sustained or aggravated by deployment. This increase caused an overwhelming explosion in the number of soldiers requiring prolonged medical care. The U.S. Army developed a program to address Army National Guard and U.S. Army Reserve soldiers requiring extended recuperation periods. This article addresses the Army's Community-Based Health Care Initiative. This initiative entails case management through the use of technology involving fax, phone, and e-mail and focuses on reduction in the number of medical holdover soldiers at military treatment facilities. Community-based healthcare organizations allow Army National Guard and Army Reserve soldiers to receive medical care in their hometown while living at home, working for the military, and continuing to receive full benefits as an active duty soldier.

Adult↗

Diffusion of an integrated health education program in an urban school system: planet health.

OBJECTIVE: Assessed the feasibility, acceptability, and sustainability of Planet Health, an interdisciplinary, integrated health education curriculum implemented in six public middle schools. METHODS: Workshops on Planet Health implementation were attended by 129 teachers (language arts, math, science, and social studies) over three school years (1999-2000, 2000-2001, and 2001-2002). Questionnaires were administered post-implementation and in the fall and spring of each year. Outcomes were dose, acceptability, feasibility, and intent to continue use. RESULTS: The average number of lessons taught per teacher per year was 1.7 to 3.1, compared to a goal of 2 to 3. Each year, teachers reported high acceptability and perceived feasibility of the intervention, and the majority indicated they intended to continue using the curriculum. CONCLUSIONS: Planet Health was feasible and acceptable in a participatory research model involving a public school-university partnership, and it was also sustainable independent of the research effort.

Boston↗

Community rating and sustainable individual health insurance markets in New Jersey.

The New Jersey Individual Health Coverage Program (IHCP) was implemented in 1993; key provisions included pure community rating and guaranteed issue/renewal of coverage. Despite positive early evaluations, the IHCP appears to be heading for collapse. Using unique administrative and survey data, we examined trends in IHCP enrollment and premiums. We found the stability of the IHCP to be fragile in light of improving opportunities for job-related health insurance. We also found that it is retaining high-risk enrollees. Institutional realities and the difficulty of identifying a control group preclude attributing causality to the plan's pure community rating and open enrollment provisions.

Data Collection↗

Ethics and immunization policy: promoting dialogue to sustain consensus.

The societal consensus that has supported the United States' universal childhood immunization programs for the past 50 years shows signs of eroding. This article proposes a systematic approach to evaluate immunization policy options. Through a unifying framework that combines epidemiologic, economic, and ethical concerns, this approach promotes a clearer understanding of underlying issues and inherent tradeoffs between alternative policies. Such a systematic examination of policy options could facilitate the public dialogue necessary to continually recreate a broad consensus on immunization practices and enable us to choose policies most in accord with our fundamental values.

Ethics, Medical↗

Assessing the role of influential mentors in the research development of primary care fellows.

PURPOSE: To assess the association between mentorship and both subsequent research productivity and career development among primary care research fellows. METHOD: In 1998, using a self-administered questionnaire, the authors surveyed 215 fellows who graduated from 25 National Research Service Award (NRSA) primary care research programs between 1988-1997 to assess quantitative aspects and qualitative domains of their mentorship experience during fellowship training. RESULTS: A total of 139 fellows (65%) responded to mentorship questions a median of four years after their fellowship. Thirty-seven fellows (26.6%) did not have an influential mentor, 42 (30.2%) reported influential but not sustained mentorship, and 60 (43.2%) had influential and sustained mentorship. Individuals with influential mentorship spent more time conducting research (p =.007), published more papers (p =.003), were more likely to be the principal investigator on a grant (p =.008), and more often provided research mentorship to others (72.5% versus 66.7% of those with unsustained mentorship, and 36.4% of those with no influential mentor, p =.008). After controlling for other predictors, influential and sustained mentorship remained an important determinant of career development in research. On qualitative analysis, fellows identified three important domains of mentorship: the relationship between mentor and fellow (such as guidance and support), professional attributes of the mentor (such as reputation), and personal attributes of the mentor (such as availability and caring). CONCLUSIONS: Influential and sustained mentorship enhances the research activity of primary care fellows. Research training programs should develop and support their mentors to ensure that they assume this critical role.

Adult↗

The UMKC medical education experiment. An alternative pathway to physicianhood.

The UMKC plan for medical education offers an alternative pathway for motivated high achievers with early evidence of health care commitment. Essentially, such a program is an honors program for the academically elite. The UMKC plan makes a large, sustained effort to influence attitude. In our descriptive literature and in our curriculum content, we have emphasized that we seek health care talent at the earliest age possible and that we use these formative years to enhance, to influence, and to inculcate the qualities of compassion, sensitivity, honesty, integrity, dependability, and responsibility. The reason for early admission is to influence attitude. We hold to the national standards in terms of science and technology, and all graduates have been required to pass Parts I and II of the National Board of Medical Examiners examinations. The graduate of this program, using performance in the first postgraduate year as a measure, is comparable with the product of the traditional eight-year concept, with a dividend of two extra years of career time. The UMKC program is not for all students; it is not offered as a replacement for the traditional American system. However, a proper distribution of medical admissions spaces should be made that takes advantage of the high level of ability, commitment, and dedication already present in the best of our high school students. A program such as the UMKC plan offers the prospect of educating American physicians, fully prepared technically but especially concerned with the important attitudinal values sought by the American public. Ward Darley, MD, was a consultant and guide during the founding years of this medical school. In his words, "The UMKC program is aimed at humanizing medicine, lowering the cost per student for education, providing a pool of dedicated physicians educated broadly enough to provide community leadership for future changes in the function and structure of society." Dr Darley's anticipation that this six-year program would lower the cost of medical education was always inherent in the simple arithmetic of six years compared with eight. These fiscal savings have been realized by our students and their parents. The additional bonus of two years of medical career is another kind of cost savings. However, the economy of the UMKC program is not the merit by which to judge. Instead, it should be judged on the basis of the opportunity to influence attitude and conduct and to inculcate an unusual quality of caring.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗

The Pawtucket Heart Health Program: community changes in cardiovascular risk factors and projected disease risk.

OBJECTIVES: Whether community-wide education changed cardiovascular risk factors and disease risk in Pawtucket, RI, relative to a comparison community was assessed. METHODS: Random-sample, cross-sectional surveys were done of people aged 18 through 64 years at baseline, during, and after education. Baseline cohorts were reexamined. Pawtucket citizens of all ages participated in multilevel education, screening, and counseling programs. RESULTS: The downward trend in smoking was slightly greater in the comparison city. Small, insignificant differences favored Pawtucket in blood cholesterol and blood pressure. In the cross-sectional surveys, body mass index increased significantly in the comparison community; a similar change was not seen in cohort surveys. Projected cardiovascular disease rates were significantly (16%) less in Pawtucket during the education program. This difference lessened to 8% posteducation. CONCLUSIONS: The hypothesis that projected cardiovascular disease risk can be altered by community-based education gains limited support from these data. Achieving cardiovascular risk reduction at the community level was feasible, but maintaining statistically significant differences between cities was not. Accelerating risk factor changes will likely require a sustained community effort with reinforcement from state, regional, and national policies and programs.

Adolescent↗

Exercise for postcoronary patients: an assessment of infrequent supervision.

Forty-nine patients who had been attending a regular weekly physician-supervised exercise program for a year or more following a myocardial infarction were transferred to an experimental regimen based on a personal activity prescription, reinforced by attendance at the physician-supervised exercise class once every 8 weeks. Data were compared with the responses of 31 patients who continued to attend the standard rehabilitation program. Ten of the 49 experimental patients showed a deterioration of cardiorespiratory fitness over the ensuing year. Of the remaining 39, 23 who had already reached a training plateau sustained their condition, while 16 showed small continuing gains of aerobic power. The infrequently supervised program proved safe, but its therapeutic effectiveness is doubtful; relative to the patients receiving standard treatment, gains of aerobic power were small, and there was some deterioration of the exercise electrocardiogram over the year of study.

Body Composition↗

Sustained effectiveness of an atrial antitachycardia pacemaker during follow-up.

Atrial antitachycardia pacemakers are indicated for medically refractory atrial tachyarrhythmias. To confirm long-term device effectiveness, we studied diagnostic data obtained in 17 patients with atrially-placed Intermedic "Intertach" pacemakers. The unit has programmable primary (P mod) and secondary (S mod) antitachycardia response protocols. Success of the P mod was defined as a P mod response first with no subsequent S mod response. Follow-up was for 595 days (+/- 302 days). The P mod was utilized first 88.2 +/- 102 times per patient interrogation with subsequent S mod use 21.1 +/- 53 times (P less than 0.0001). Results were also significant when P mod was compared to S mod in the first versus the last half of follow-up (both P less than 0.0001). These results suggest that the programmed P mod of the atrial "Intertach" tachycardia reversion pacemaker has sustained effectiveness in the treatment of medically refractory atrial tachyarrhythmias.

Atrial Flutter↗

Sustained ventricular tachycardia in chronic chagasic myocarditis: electrophysiologic and pharmacologic characteristics.

Sustained ventricular tachycardia (VT) develops in many patients with chronic Chagasic myocarditis. Programmed stimulation was used to study the electrophysiologic characteristics of VT in 15 patients with Chagas' cardiomyopathy. Nine patients were in New York Heart Association functional class I, 5 were in class II and 1 patient was in class III. The average ejection fraction was 56 +/- 7%, which is somewhat better than that reported in patients with VT owing to idiopathic cardiomyopathy. In 11 patients VT could be reproducibly initiated and terminated by programmed stimulation. Intravenous mexilitene prevented induction of VT in 7 of 8 patients; amiodarone did not prevent induction in 3 of 4 patients. Our data indicate that the mechanism of VT is likely to be reentrant in many patients, and therefore VT can be produced by extrastimuli. Electrophysiologic study is therefore useful for establishing the diagnosis of sustained VT and may be useful for guiding initial therapy in selected cases of Chagas' disease.

Adolescent↗

The People with Arthritis Can Exercise (PACE) program: a qualitative evaluation of participant satisfaction.

INTRODUCTION: Developed by the Arthritis Foundation, People with Arthritis Can Exercise is a community-based exercise program for individuals with arthritis. This qualitative study was designed to assess participant satisfaction with the program and examine motivators and barriers to attending program classes. METHODS: We conducted an 8-week randomized controlled trial of People with Arthritis Can Exercise among 347 participants residing in 18 urban and rural communities across North Carolina. Semistructured telephone interviews were conducted with 51 of the participants. Participants were asked about their overall satisfaction with the program. Motivating factors and barriers to attending the classes, including content, instructor, location, and schedule, were examined. RESULTS: Of the 51 participants interviewed, 96% were female, with an average age in years of 67 (range, 32-90 years). Participants reported deriving considerable social support from exercising in a group with others who have arthritis. They identified two main factors that motivated them to continue participating in the exercise class: ability to work at their own pace during the class and confidence that they could do different kinds of exercise safely. Participants also reported that the instructor played a vital role in sustaining their motivation to exercise. Among the participants, noncompleters of the program reported arthritis-related illness or insufficient physical challenge as key barriers to class participation. CONCLUSION: This study suggests that a group exercise program for older adults with arthritis promotes a sense of social support and increases self-efficacy for exercise by allowing participants to work at their own pace.

Adult↗

Quality of care among Jamaican private physicians offering family planning services.

The National Family Planning Board is the agency of Government empowered to prepare, carry out and promote family planning programs in Jamaica. The Board has prioritized the expansion and sustainability of family planning services in large part through encouraging the participation of the private sector. To enhance the availability, acceptability and effectiveness of private physician family planning services, information was collected on the service practices of 90% of physicians, through face to face interviews. Bruce's framework was used to evaluate the findings of the study. The study indicated that: A wide variety of contraceptives are available - Basic equipment and adequate supplies are in place for the provision of services - Provider bias, inappropriate contraindicators and process and scheduling hurdles exist. The major recommendations relate to the: Revision of norms and guidelines for all contraceptives - Continuation of contraceptive technology updates for private physicians - Revision of legal/regulatory barriers which restrict access to some contraceptives for certain target groups.

Adolescent↗