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PubMed2006

Anemia management program reduces transfusion volumes, incidence of ventilator-associated pneumonia, and cost in trauma patients.

BACKGROUND: Strategies to restrict transfusions are gaining acceptance in critical care. We implemented an anemia management program (AMP) for trauma patients in the Surgical Intensive Care Unit. AMP was based on a transfusion trigger of 7 g/dL hemoglobin once hemodynamic sufficiency was achieved. We hypothesized that AMP would decrease the transfusion of packed red blood cells (PRBCs) and cost without detriment in clinical outcomes. METHODS: Transfusion data were retrospectively collected for all trauma patients treated in our Surgical Intensive Care Unit between July 2002 and December 2003. AMP was implemented in a step-wise fashion during a 6-month period (January to June 2003). Data were compared for the 6-month period before (Group I, July to December 2002) and after (Group II, July to December 2003) complete AMP implementation. Blood transfusion volumes were compared using negative binomial regression. Clinical outcomes (length of stay [LOS], death, myocardial infarction [MI], and ventilator-associated pneumonia [VAP]) were compared using risk ratios. Age, sex, and injury severity score (ISS) were examined as potential confounders. RESULTS: In all, 514 trauma patients were treated during the study period (n = 270 in Group I and n = 244 in Group II). Group I and Group II were similar in age (mean: 43.6 versus 42.9) and ISS (mean: 18.3 versus 17.0). Mean PRBCs per patient transfused decreased from 23.1 units to 17.1 units (p = 0.057), reflecting a 22.5% reduction adjusted for confounders (p = 0.097). Outcome data revealed no differences in LOS (mean: 6.4 versus 5.9, p = 0.920), risk of death (4.1% versus 6.1%, p = 0.158), or MI (0.7% versus 0.8%, p = 0.974), but a significant reduction in the incidence of VAP (8.1% versus 0.8%, p = 0.002). Total PRBC cost decreased during the study period from 503,000 dollars to 397,000 dollars. CONCLUSIONS: An anemia management program appears to be safe when applied in the acute ICU phase of trauma care. Implementation of AMP in the ICU reduced the volume of PRBCs transfused with significant cost savings. No significant differences in length of stay, mortality rate, or MI rate were seen. The significant decrease in the rate of VAP requires further elucidation. Further long-term and larger studies are indicated.

Aged↗
PubMed2003

A community-based thalassemia prevention and control model in northern Thailand.

OBJECTIVE: To describe a community-based model for prevention and control of thalassemias and haemoglobinopathies in northern Thailand. DESIGN: Operational research composed of two components. First, a model to test whether thalassemic cases and carriers could be retrospectively detected from school children. Second, a model for prevention of prospective cases of thalassemic babies among pregnant women. SETTING: Phan District of Chiang Rai Province in northern Thailand. SUBJECTS: Component one: 5,617 preschool children and 21,123 school children were screened during May and July 1997. Component two: 256 pregnant women, 16 weeks or less gestation were screened during January and December 1997. MATERIAL AND METHOD: Component one: Sub-district public health officers and school teachers were trained to use pictures and simple clinical examination to detect suspected thalassemics among preschool and school children. Suspected cases were then referred for further clinical examination and blood testing. Blood smear examination was done at the Phan Community Hospital but Hb typing lusing on electrophoresis was done at the provincial hospital. The cellulose acetate was sent for re-reading at the Department of Medical Sciences. Component two: Osmotic fragility (OF) and dichlorophenol-indolephenol (DCIP) tests were abol in pregnant women (< or = 16 weeks of gestation) in the Phan Community Hospital. If OF test was positive, Hb typing was done at a regional medical sciences center. Their spouses were also located and tested for Hb typing. Prenatal diagnosis was done and therapeutic abortion was offered, if indicated. MAIN OUTCOME MEASURES: Cases, carriers, suspected cases, Hb typing, OF and DCIP tests. RESULTS: In Component one: 26,740 children were screened of whom 893 cases were suspected. Out of those suspected, 296 (33.2%) were normal, 140 (15.6%) were diseased, and 457 (51.2%) were carriers. 56 cases had major thalassemia diseases. Their parents were counseled. Forty couples were determined to need some form of family planning and 39 (97.5%) accepted. In Component two: 256 pregnant women were screened and 56 were found to be carriers. Only 45 husbands could be located and Hb typed. Five couples were determined to require prenatal diagnosis (PND). One happened to undergo therapeutic abortion because of HIV infection in the mother without PND. Of the four who underwent PND, one was found to have a fetus with major thalassemia. However, this couple refused therapeutic abortion because of religious reasons. CONCLUSION: This study combined both prospective and retrospective approaches and can be considered successful. However, as the only available option for pregnant women with affected fetuses is therapeutic abortion, this makes it difficult to expand the program because abortion may not be acceptable in certain communities. In addition, this model requires PND and other laboratory and clinical facilities as backups. Such backups may not be available in certain settings.

Adult↗
PubMedDate not supplied

A balancing act: the tension between case-finding and primary prevention strategies in New York State's voluntary HIV counseling and testing program in women's health care settings.

This study sought (1) to identify factors that influence women's willingness to accept voluntary HIV counseling and testing at New York State Family Planning Programs (FPPs) and Prenatal Care Assistance Programs (PCAPs) and (2) to evaluate the effectiveness of such a voluntary counseling and testing program. Telephone interviews elicited organizational-level data from 136 agencies; a combination of telephone and face-to-face interviews was used to gather provider data from 98 HIV counselors; and client data were gathered from 354 women in face-to-face interviews at counseling sites. Slightly fewer than 60% of women agreed to be counseled, and, of those, under half consented to an HIV test at the counseling site. Approximately two thirds of the women who were tested returned for their results and posttest counseling. Clients' recall of pretest counseling content was relatively poor. Bivariate and regression analyses suggest that client, provider, and organizational factors are all associated with rates of pretest counseling and testing. The current voluntary counseling and testing program is achieving only moderate success. Although a substantial number of clients accept HIV counseling, many women remain reluctant to consent to HIV testing, and many who accept testing do not return for their results. Moreover, among those who receive pretest counseling, many do not recall important informational content, which suggests variation may exist in the quality of counseling or that one-time HIV counseling interventions are insufficient to communicate complex information. Medical Subject Headings (MeSH): AIDS, HIV serodiagnosis, women's health, patient education.

AIDS Serodiagnosis↗
PubMed1979

Combination of school-based primary and secondary preventive dental programs in the United States and other countries.

School-based programs in the United States are very limited. Other countries in the world have established programs for many years which provide comprehensive services to school-age children. In this country philosophical and professional pressures have maintained school-based programs only in the area of primary prevention. Most treatment programs involving secondary prevention are not school-based and are targeted at specific population groups rather than all children. The basic questions of whether primary and secondary preventive school-based programs can be successful have been examined in this paper. The evidence based on the pilot program presented here is that these programs can be successful. They are well accepted by parents and children, they provide quality care at a reasonable cost, and, most importantly, they can reduce dental disease. It's time for a committment by the profession and the nation to establish school-based dental programs for the health and welfare of our children.

Child↗
PubMed1995

Parents' attitudes and beliefs about HIV/AIDS prevention with condom availability in New York City public high schools.

In 1991, the New York City Board of Education expanded HIV/AIDS education to include condom availability in every public high school. The evaluation was designed to examine the impact of the program on students and monitor changes in parent's knowledge, attitudes, and beliefs. Findings are reported from the first wave of data from the parent survey, 716 parents from 12 randomly chosen NYC high schools and 81 parents from 12 focus groups held at six of the schools. Sixty-nine percent of parents believed students should be able to receive condoms at school, although nearly half felt they should have the right to keep their children from doing so. Most believed making condoms available would result in safer sex practices among students who were sexually active. Data suggest parents support the school's role in reducing HIV/AIDS transmission among adolescents and believe making condoms available represents an acceptable component of an HIV/AIDS prevention program.

Adolescent↗
PubMed1995

New York City's 1993 child immunization day: planning, costs, and results.

OBJECTIVES: This study evaluates New York City's Child Immunization Day (1993), with emphasis on the cost and effects of a mass campaign and the use of strategies from developing nations in an inner-city context. METHODS: The methodology was designed to (1) document the planning and implementation process, (2) analyze the number and characteristics of children in the target group, and (3) estimate costs. RESULTS: Neither the social mobilization nor the political will that characterize successful campaigns in developing nations occurred in New York City's campaign. Despite substantial time and effort from both private and public agencies, turnout for the event was low. In total, 2647 families and 5237 children were assessed for health care and insurance needs, 2949 children were immunized at a cost of about $279 per immunized child, and 7236 vaccines were administered. CONCLUSIONS: The differences between inner cities and developing nations have a bearing on strategies used in planning and implementing mass campaigns. New strategies need to be forged from a blending of these contexts to create effective campaigns in industrialized inner cities.

Child Health Services↗
PubMed2003

Comparison of eight computer programs for receiver-operating characteristic analysis.

BACKGROUND: ROC analysis is widely accepted to assess and compare diagnostic validity of laboratory tests. Within the last few years, many new ROC programs have become available but have not been systematically evaluated. The aim of this study was to assess different ROC programs regarding their ease of use, mathematical correctness, final output, and their compatibility with other graphics programs. METHODS: Eight available programs running under Windows (AccuROC, Analyse-It, CMDT, GraphROC, MedCalc, mROC, ROCKIT, and SPSS) were evaluated. ROC analyses of prostate-specific antigen and related values were performed from a dataset of 928 men with prostate cancer and benign prostatic hyperplasia and corresponding subsets. Criteria such as data input, data output, and correctness and completeness of results were used to evaluate the practicability of the programs. RESULTS: Although the programs produced equivalent results (areas under the curves and their characteristics), we observed deficiencies concerning input of data, processing of the output data, and completeness of the results. Analyse-It, AccuROC, and MedCalc exhibited good performance, but each program had different shortcomings. Only GraphROC could compare curves at a certain sensitivity or specificity cutoff. CONCLUSIONS: Adequate ROC analysis and ROC plotting cannot be performed with a single program. Analyse-It, AccuROC, and MedCalc can be recommended with certain limitations. Further improvements of the programs are necessary.

Area Under Curve↗
PubMedDate not supplied

A program to reduce pesticide spraying in the indoor environment: evaluation of the 'Roach Coach' project.

PURPOSE: To assess the effectiveness of a pilot integrated pest management (IPM) program in controlling cockroaches in an apartment complex, without pesticide sprays. METHODS: A brief educational session and booklet were provided to tenants. Non-spray pest control methods were promoted. A telephone questionnaire was administered at pre- and post-test to assess knowledge, attitudes and practices of tenants. Cockroach counts were determined at pre- and post-test. The type and frequency of pesticide treatments were monitored prior to and during the 8-month IPM demonstration period. RESULTS: Overall, the knowledge, attitudes and practices of tenants improved after the IPM intervention. There was a significant shift in treatment type away from spraying towards more paste/gel treatments. Cockroach levels tended to be lower after IPM compared with before. CONCLUSION: A brief educational session and booklet can influence building residents to accept and comply with an IPM program. This program can be effective in controlling cockroaches without pesticide sprays.

Adult↗
PubMed1991

A technology for program maintenance: programming key researcher behaviors in a student housing cooperative.

Behavioral researchers play critical, but often unanalyzed, roles in the programs they develop. Unless they replace their key activities with standardized procedures, their continued participation may be essential to program success--a situation that is often not only impractical but may be prohibitively expensive and disliked by local staff. This study was conducted in a student housing cooperative that is dependent on close researcher supervision for its continued health and survival. A key activity of the co-op researchers was to provide public recognition for good job performance by co-op members. The purposes of this study were (a) to replace that idiosyncratic recognition with systematic procedures so members, instead of the researchers, would provide public recognition to each other for good job performance; and (b) to evaluate those procedures by comparing job performance when member-delivered recognition was provided and when it was not. When the procedures were in place, job performance increased and fines for poor job performance and complaining at meetings decreased. This study suggests that procedures can be developed to reduce program reliance on the researcher that are effective, inexpensive, sustainable, and acceptable to the participants--a first step toward developing a technology of program maintenance.

Activities of Daily Living↗
PubMed2000

Education as a clinical tool for self-dialysis.

Therapeutic compliance and patient education are presently considered crucial parts of end-stage renal disease (ESRD) therapy. In the center where Italian home and self-care dialysis treatment started, an education program was designed as multi-step pathway--following patients from chronic renal failure to dialysis and eventual graft--employing lessons, booklets, and books. Each step was validated in various subsets of patients. Lessons involved two hours of informal discussion on the main aspects of ESRD and renal replacement therapy (RRT); booklets were created from tape recordings of the lessons. Patient participation was good, with 28 of 33 patients on charge in the center for 6 months or more taking part in more than one lesson in 1999. In 16 of 16 patients who answered a questionnaire after two lessons, expressed opinion was "good" to "fair." All asked for further material. With regard to books, 500 copies of the book What does dialysis mean? were given out in the region; this book was validated in 22 patients on peritoneal dialysis (PD) and 18 on hemodialysis (HD). It helped patients to accept dialysis in 65% of cases and to comprehend it in 90%. Four thousand copies of the book Stories, containing 18 interviews on transplantation, were printed, and this book was validated in 21 patients on self-care and 35 on hospital dialysis (potential candidates for graft). Of 56 patients, 53 asked for further material; 19 changed their initial opinion (10 choose transplantation, despite initial skepticism; 9 put off transplantation, despite initial acceptance). On a local scale, the program led 12 of 18 new patients, who followed at least part of the program, to choose self-dialysis (PD, home, and self-care dialysis).

Adult↗
PubMed2000

A two-year experience teaching computer literacy to first-year medical students using skill-based cohorts.

Because it is widely accepted that providing information online will play a major role in both the teaching and practice of medicine in the near future, a short formal course of instruction in computer skills was proposed for the incoming class of students entering medical school at the State University of New York at Stony Brook. The syllabus was developed on the basis of a set of expected outcomes, which was accepted by the dean of medicine and the curriculum committee for classes beginning in the fall of 1997. Prior to their arrival, students were asked to complete a self-assessment survey designed to elucidate their initial skill base; the returned surveys showed students to have computer skills ranging from complete novice to that of a systems engineer. The classes were taught during the first three weeks of the semester to groups of students separated on the basis of their knowledge of and comfort with computers. Areas covered included computer basics, e-mail management, MEDLINE, and Internet search tools. Each student received seven hours of hands-on training followed by a test. The syllabus and emphasis of the classes were tailored to the initial skill base but the final test was given at the same level to all students. Student participation, test scores, and course evaluations indicated that this noncredit program was successful in achieving an acceptable level of comfort in using a computer for almost all of the student body.

Computer Communication Networks↗
PubMed2002

Compliance of primary care doctors with asthma guidelines and related education programs: the employment factor.

BACKGROUND: Primary care physicians' adherence to accepted asthma guidelines is necessary for the proper care of asthma patients. OBJECTIVES: To investigate the compliance of primary care physicians with clinical guidelines for asthma treatment and their participation in related educational programs, and to evaluate the influence of their employment status. METHODS: A questionnaire was administered to a random sample of 1,000 primary care practitioners (pediatricians and family physicians) in Israel. RESULTS: The response rate was 64%. Of the physicians who participated, 473 (75%) had read and consulted the guidelines but only 192 (29%) had participated in an educational program on asthma management in the last 12 months. The younger the responding physician (fewer years in practice), the more likely his/her attendance in such a program (p < 0.0001). After consulting the guidelines 189 physicians (40%) had modified their treatment strategies. Significantly more self-employed than salaried physicians had read the guidelines and participated in educational programs; physicians who were both self-employed and salaried fell somewhere between these groups. This trend was not influenced by the number of years in practice. CONCLUSIONS: All primary care physicians should update their knowledge more often. The publication of guidelines on asthma must be followed by their proper dissemination and utilization. Our study suggests that major efforts should be directed at the population of employed physicians.

Analysis of Variance↗
PubMed2001

Selection and Evaluation Guidelines for Clinical Education Settings in Athletic Training.

OBJECTIVE: To develop and test standards and associated criteria for the selection and evaluation of a clinical education setting in athletic training. DESIGN AND SETTING: A previously validated set of 20 standards for physical therapy clinical education settings, the associated criteria, and 2 related evaluation forms were systematically judged, revised, and adapted through a survey process. SUBJECTS: Program directors, clinical instructors, and students involved with athletic training clinical education from 28 athletic training education programs approved by the National Athletic Trainers' Association or accredited by the Commission on Accreditation of Allied Health Education Programs. MEASUREMENTS: We tabulated respondents' critiques and ratings by type of respondent. Items were judged as to whether they were relevant, practical, and suggestive of high-quality clinical education settings. RESULTS: We accepted a final set of 12 standards and 31 associated criteria to measure these standards. The student form lists 23 criteria relevant to these accepted standards. The accepted standards include the following: learning environment, program planning, ethical standards, administrative support, and Setting Coordinator of Clinical Education. CONCLUSIONS: The 12 standards, criteria, and related forms developed in this research project should be used as guidelines rather than as minimal requirements. They could be helpful in forming an impression not only about a particular clinical setting but also about the requirements of clinical education in general. Further research should include evaluating and comparing perceptions between sexes and among ethnic groups concerning their clinical education experiences. Also, standards and criteria for clinical instruction in athletic training should be systematically developed.

Journal Article↗
PubMedDate not supplied

[Geriatric assessment: possibilities and limits].

A recent meta-analysis has shown that comprehensive geriatric assessment can reduce mortality, increase survival at home, and improve functional status in elderly patients. Despite their high effectiveness, geriatric assessment programs have not yet been widely introduced into clinical practice. This review discusses the following four factors potentially explaining the limited spread of geriatric assessment programs. 1) There is a lack of accepted targeting criteria to select patients who need evaluation and management in costly in patient geriatric units. 2) There are effectiveness gaps in current knowledge on modifiable disability risk factors. 3) Geriatric assessment programs have been insufficiently integrated into the continuity of primary care. 4) More data are needed for evaluating the cost of geriatric assessment. Interdisciplinary research might help to optimize geriatric assessment programs and, at the same time, might ensure access of elderly patients to appropriate geriatric assessment programs despite current restraints in health care costs.

Activities of Daily Living↗
PubMed2004

Improving the physical status and quality of life of women treated for breast cancer: a pilot study of a structured exercise intervention.

BACKGROUND AND OBJECTIVES: This pilot project assessed the acceptability of a mixed-type, moderate-intensity exercise programme following breast cancer treatment, and the impact on presence of lymphoedema, fitness, body composition, fatigue, mood and quality of life. METHODS: Ten women completed the programme and measures of fitness (sub-maximal ergometer test), body composition (bio-electrical impedance), lympoedema (bio-electrical impedance and arm circumferences), fatigue (revised Piper Fatigue Scale), mood (Hospital Anxiety and Depression Scale), quality of life (FACT-B) and general well-being, at baseline, completion of the programme, and 6-week and 3-month follow-up. RESULTS: Participation in the programme caused no adverse effect on the presence of lymphoedema. There was a trend towards reduction in fatigue and improved quality of life across the testing phases. Women rated the programme extremely favourably, citing benefits of the support of other women, trained guidance, and the opportunity to experience different types of exercise. CONCLUSIONS: A mixed-type, moderate-intensity exercise program in a group format is acceptable to women following breast cancer treatment, with the potential to reduce fatigue and improve quality of life, without exacerbating or precipitating lymphoedema. This pilot work needs to be confirmed in larger randomised studies.

Adult↗
PubMed2000

Infant mortality review as a vehicle for quality improvement in a local health department.

BACKGROUND: Many communities across the United States have established fetal and infant mortality review (FIMR) programs as a way of gaining insight into the causes of such deaths and of devising and implementing ways to improve the health of pregnant women and their infants. IMR PROCESS: The IMR process in the Jefferson County Department of Health in Birmingham, Alabama, evolved in a somewhat different fashion than that in other communities. A technical review team reviews all the infant deaths in the county, with particular attention to each woman's pregnancy history. A community review team reviews composite cases that illustrate some particular problem that might lead to infant mortality, such as teenage pregnancy or short intervals between pregnancies. This team provides insights into cultural patterns and a community perspective on the problems. Recommendations from the two teams are acted on by the health department, with the assistance of other agencies as needed. IMPACT OF THE IMR PROCESS: The IMR process has been used to increase community agency participation in health department activities, improve health department procedures, increase health department staff acceptance of a new and controversial program (Healthy Start), and offer services to women who need them. CONCLUSIONS: IMR has become a mechanism for CQI in the health department, embodying many of the principles of CQI, including the use of teams, focus on a team mission, and examination of processes, not individuals. The program offers a model of how to reduce rates of fetal and infant mortality.

Adult↗
PubMed1992

Patient-based health status measures in outpatient dialysis. Early experiences in developing an outcomes assessment program.

This paper describes the initial development of a patient-based outcomes assessment program in an outpatient dialysis unit. This project presented four logistical and practical issues that are discussed in this paper: patient acceptance of quarterly administrations of a generic health status survey (the SF-36); timing of administration during dialysis session; respondent burden; and staff burden. Also discussed are three issues related to the clinical use of these assessments: medical record status of SF-36 data; use in clinical decisionmaking; and clinicians' responses to aggregate data from patient-based health status assessments. The investigation reported presents strong evidence of patient acceptance of the SF-36. Data collection problems reflected the nature of a busy dialysis unit, and most have been corrected. Considering functional status, the role functioning of dialysis patients is most adversely affected; among well-being measures, patients are most compromised by pain and lack of energy. Clinicians' reviews of these results point to the need for normative data, information about severity of primary and comorbid diseases, and knowledge of relationships between SF-36 scores and physiologic parameters to make clinical use of generic health outcome assessments.

Activities of Daily Living↗