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Medicaid agencies use both second surgical opinion programs (SSOP's) and inpatient hospital preadmission review programs to control utilization of services and thus program expenditures. This article reports on the 13 mandatory and 7 voluntary SSOP's and the 21 inpatient preadmission review programs, based on responses from 44 State Medicaid agencies.
OBJECTIVE: This study examined the differential effectiveness and costs of three weeks of treatment for patients with moderately severe substance dependence assigned to inpatient treatment or to a supportive housing setting. Supportive housing is temporary housing that allows a patient to participate in an intensive hospital-based treatment program. Type and intensity of treatment were generally equivalent for the two groups. METHODS: Patients were consecutive voluntary admissions to the substance abuse treatment program of a large metropolitan Veterans Affairs medical center. Patients with serious medical conditions or highly unstable psychiatric disorders were excluded. Patients in supportive housing attended the inpatient program on weekdays from 7:30 a.m. to 5 p.m. They were assessed at baseline and at two-month follow-up. RESULTS: Baseline analyses of clinical, personality, and demographic characteristics revealed no substantive differences between the 62 patients assigned to inpatient treatment and the 36 assigned to supportive housing. The degree of treatment involvement and dropout rates did not differ between groups. Of the 55 inpatients completing treatment, 29 were known to be abstinent at follow-up, and of the 35 supportive housing patients completing treatment, 22 were abstinent. The proportion was similar for both groups, about 70 percent. The cost of a successful treatment for the inpatient group was $9,524. For the supportive housing group, it was $4,291. CONCLUSIONS: Given the absence of differential treatment effects between inpatient and supportive housing settings, the use of supportive housing alternatives appears to provide an opportunity for substantial cost savings for VA patients with substance dependence disorders.
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BACKGROUND: Advances in medical and public health practice have led to many changes in patterns of prostate cancer care. Data from several studies of prostate cancer by the Commission on Cancer of the American College of Surgeons provide information on the directions, magnitudes, and consequences of these changes. METHODS: The Commission on Cancer conducts patient care evaluation (PCE) studies based on the voluntary participation of hospital cancer programs and their tumor registries. PCE studies have been conducted repeatedly for prostate cancer covering patients diagnosed as early as 1974 and as recently as 1990. In addition, the National Cancer Data Base of the Commission on Cancer collects data for all forms of cancer from throughout the country. The Commission on Cancer, the American Cancer Society, and the American Urologic Association also has conducted a focused survey of radical prostatectomy outcomes. In aggregate, these multiple studies have accrued 179,366 reports on treatment of prostate cancer patients. RESULTS: Predominant among practice changes are new techniques of prostate cancer detection and initial evaluation which have led to shifts in disease stage at the time of initial therapy. The proportion of prostate cancer that is localized at the time of detection has increased. Use of radiation therapy and radical prostatectomy has increased as the selection of hormone treatment and no cancer-directed treatment have decreased. Five-year prostate cancer survival has improved for every stage of disease. CONCLUSIONS: The multiple studies by the Commission on Cancer provide data that are not available from other sources. Continued monitoring of prostate cancer patterns of care may be useful in measuring progress in control of this common disease.
An EPA Voluntary Aluminum Industrial Partnership (VAIP) program has been formed to help US primary producers focus on reducing the emissions of two perfluorocarbons (PFCs), tetrafluoromethane (CF4) and hexafluoroethane (C2F6), during the production of aluminum. To ensure comparability of measurements over space and time, traceability to national sources was desirable. Hence, the EPA approached the NIST to develop a suite of primary standards to cover a mole fraction (concentration) range of 0.1 to 1400 micromol mol(-1) for CF4 and 0.01 to 150 micromol mol(-1) of C2F6. A total of eight gravimetric PFC gas standards were prepared with relative expanded uncertainties of < or = 0.52% (approximately 95% confidence level). These primary standards were ultimately used to assign values to a series of secondary gas standards at three mole-fraction levels with relative expanded uncertainties ranging from +/- 0.7% to 5.3% (approximately 95% confidence level). This series of secondary standards was used within the aluminum industry to calibrate instruments used to make emission measurements. Assignment of values to the secondary standards was performed by use of gas chromatography with flame-ionization detection (GC-FID) and Fourier transform infrared spectrometry (FTIR). Real time pot-line and stack samples from a local aluminum plant were also obtained and sub-samples sent to each participating facility for analysis. The data generated from each facility were sent to NIST for analysis. The maximum difference between the NIST and individual facilities' values for the same sub-sample was +/- 26%.
Emissions trading will not be able to become the single instrument of a national climate policy because of costs for monitoring of greenhouse gases and transfers of allowances. Thus, it is important to assess optimal ways of integrating emissions trading into national climate policy mixes, thus leading to a more efficient policy, especially by allowing the use of transboundary transactions. The implemented trading systems of the UK and Denmark, the agreed EU one, and the planned ones of Norway are used as case studies. In the UK, the introduction of an energy tax on industry was the catalyst that led to the development of emissions trading, voluntary agreements, and two subsidy programs. However, in Denmark trading was limited in scope and not integrated with the successful emission tax. The EU and Norwegian trading schemes both have a large scope and integrate international transfers; the former is integrated with other instruments to avoid free riding. Policy integration will thus enhance the efficiency improvements that emissions trading can introduce.
154 Ss were tested using penile plethysmography as part of intake into a voluntary inpatient sex offender treatment program. The testing protocol included slide stimuli of nude males and females in four age categories ranging from age 1 to adult; audiotaped descriptions of sexual activity with children of both genders which included fondling, sexual contact with no resistance, coercive sexual contact, sexual assault, nonsexual assault, and consensual sexual contact with an adult; videotaped depictions of rape of an adult woman, nonsexual assault of an adult woman and consensual sexual involvement with an adult woman, and audiotaped descriptions that paralleled the videotapes. The results indicated that child molesters (male victim) show a decidedly more offense related arousal profile than either child molesters (female victim) or rapists, and that the profiles of child molesters (female victim) and rapists are remarkably similar, although statistically significantly different from each other. Rapists respond significantly more to rape and nonsexual assault than either of the two child molester groups, with child molesters with female victims responding more than those with male victims. In all three groups, the highest level of noncoercive adult responding was to women, with differences among offense groups present for visual stimuli, but not in response to auditory stimuli. Overall, the patterns of results are similar whether they are based on composites across stimulus modality or on the individual stimuli.
OBJECTIVE: To determine the prevalence of recent rape, the characteristics or recent rape survivors, and the seroprevalence of human immunodeficiency virus (HIV), syphilis, and genital herpes (HSV-2) among recent rape survivors. METHODS: We surveyed women 18-29 years old who were recruited from places unassociated with medical or drug treatment or the criminal justice system in three urban communities where illicit drug use is common. We compared characteristics and HIV, syphilis, and HSV-2 seroprevalence of women who reported recent rape with those of women who denied recent rape. RESULTS: One hundred fifty-one of 1104 (13.7%) women reported having been raped in the year before our interview. Rape survivors were more likely than women who denied recent rape to smoke crack cocaine (86.8 versus 56.7%; odds ratio [OR] 5.0, 95% confidence interval [CI] 3.2-7.8), to be homeless (17.2 versus 6.1%; OR 3.2, CI 2.0-5.2), to report a recent sexually transmitted disease (38.7 versus 18.7%; OR 2.7, CI 1.9-3.9), and to be infected with syphilis (42.4 versus 28.4%; OR 1.9, CI 1.3-2.6) and HSV-2 (71.9 versus 57.5%; OR 1.9, CI 1.3-2.8). Survivors were more likely to acknowledge any HIV risk behavior (including sex work) (85.4 versus 49.5%; OR 5.9, CI 3.9-9.0) and to be HIV-infected (23.3 versus 13.4%; OR 1.9, CI 1.3-2.9). Rape was not independently associated with HIV (OR 0.8, 95% CI 0.4-1.3), syphilis (OR 0.9, 95% CI 0.6-1.3), or HSV-2 (OR 1.3, 95% CI 0.9-2.0) infections after adjustment for confounding factors. CONCLUSION: One in seven women reported being raped recently. Rape was most common among sex workers, crack smokers, and the homeless. Most survivors reported HIV risk behaviors, and many were HIV-infected. Programs to prevent repeated rape, voluntary HIV counseling and testing, and other medical and social services may benefit survivors in these and similar communities.
Since dialysis was introduced 30 years ago, constant progress in technology permitted shortening the length of hemodialysis (HD) sessions. Through growing concerns about the inadequacy of tap water for dialysate production, hospitals soon opted for water treatment systems dedicated to HD. Nonetheless, persistent bacterial contamination and the occurrence of pyrogenic reactions were reported in some HD centers. Several factors contributing to this situation were identified. After the introduction of highly permeable synthetic membranes in the late 1970s, microbiologic problems reappeared. Thus, in 1977, the Centers for Disease Control and Prevention (CDC) issued proposed guidelines for HD water quality, followed in 1981 by an American National Standard for HD water, issued by the Association for the Advancement of Medical Instrumentation (AAMI). This Standard was also followed in Canada up to 1986, at which time a National Standard for Canada was released by the Canadian Standards Association (CSA). This prompted the Laboratoire de santé publique du Québec (LSPQ) to implement in the Province of Québec a voluntary HD water quality monitoring program. All 36 HD centers in the Province agreed to participate. The program was launched in February 1987. Water was sampled monthly for bacteria over a 7-year period (February 1987 to January 1994), and every 3 months for pyrogen and chemicals. Participation was more than 95%. Bacteriologic samples were processed in duplicate on heterotrophic plate count agar by the pour plate technique. Incubation was for 48 +/- 3 hours at 35 +/- 0.5 degrees C, and the colonies were counted on a Quebec colony counter (New Brunswick Scientific Co, New Brunswick, NJ). Pyrogen determinations were made using the limulus amebocyte lysate (LAL) test on 1:20 sample dilution by the gel-clot method. Chemical elements were measured by inductively coupled plasma emission, graphite furnace absorption, conductivity, ultraviolet light absorption, or colorimetry. Only fully treated HD water samples were selected from the 11,000 water samples received. Of the 5,820 samples retained for this study, 3,547 were for bacterial, 1,112 for pyrogen, and 1,161 for chemical analyses. Overall compliance to the CSA Standard was 70% for bacteria, 56% for pyrogen, and 86% for chemistry. The performance of different types of water treatments were compared and discussed; the best overall compliance was obtained by reverse osmosis combined with deionization (RO + DI). The type of water treatment that proved most popular was RO alone, which was used by 22 HD centers (61%).(ABSTRACT TRUNCATED AT 400 WORDS)
OBJECTIVE: With prevalence of HIV rising in pregnant women in India, pediatric HIV/AIDS is emerging as a public health problem. We evaluated the additional costs to the health care system and the additional health outcomes of introducing a voluntary primary care HIV screening program for pregnant women in India. METHODS: The analysis was conducted from the government perspective. We analyzed two scenarios: a programme of universal screening nation-wide and a programme of screening restricted to high prevalence states. Health benefits were measured by the number of perinatal HIV cases prevented and the reduction in the potential years of life lost (PYLL). FINDINGS: Nation-wide screening would cost the government Rs. 254.78 million and would prevent 9880 cases of perinatal HIV resulting in savings of 131,700 life years (average cost per HIV case prevented Rs. 25,787; per year reduction in PYLLs Rs. 1935). Implementing the program in only the high prevalence states would achieve 45% of these reductions in cases and life years lost at only 20% of this cost, at an average of Rs. 12,091 per HIV case prevented or Rs. 907 per year reduction in PYLLs (44 Indian rupees = 1 US dollar). In sensitivity analysis, the cost of the program was influenced mainly by antenatal coverage, the cost of the HIV test, the lifetime costs of treatment of a HIV infected child and the overhead costs. CONCLUSIONS: We provide an estimate of the additional costs and health effects of two approaches to introducing HIV screening among pregnant women in India. Decision-makers would have to demonstrate that the resources used for its implementation would result in more health benefits than from the alternative uses of those resources.
From a public health view, there are many important issues to improving children's and adolescent's health, for example, prenatal and childhood nutrition, immunizations, infectious disease control, and drug/alcohol/tobacco control. There has been increasing emphasis worldwide on protecting children from adverse health effects due to environmental factors, including chemicals. For well-studied contaminants (e.g. lead) the risks to children are reasonably known and appropriate risk management actions, in a public health context, can be undertaken. For a number of other chemicals, hazard and exposure data are less complete, and risk-based priorities are consequently less substantive. The US EPA's Voluntary Children's Chemical Evaluation Program proposal prompted additional efforts to develop and improve methods and data for assessing children's exposure. The goal is to efficiently identify the substances and conditions that present the highest potential risks to children, so that resources can be applied efficiently to assure their health improvement. The methods we illustrate use an iterative (tiered) approach for (a) screening level and (b) more detailed exposure assessments relevant to children. We also review and reference the key information sources available for such assessments and analyze the information and method's strengths and limitations.
Previous research has shown that when searching for a color singleton, top-down control cannot prevent attentional capture by an abrupt visual onset. The present research addressed whether a task-irrelevant abrupt onset would affect eye movement behavior when searching for a color singleton. Results show that in many instances the eye moved in the direction of the task-irrelevant abrupt onset. There was evidence that top-down control could neither entirely prevent attentional capture by visual onsets nor prevent the eye from starting to move in the direction of the onset. Results suggest parallel programming of 2 saccades: 1 voluntary goal-directed eye movement toward the color singleton target and 1 stimulus-driven eye movement reflexively elicited by the abrupt onset. A neurophysiologically plausible model that can account for the current findings is discussed.
BACKGROUND: Since 1989, the CDC's Model Performance Evaluation Program has shipped samples to voluntary participant laboratories that test for HTLV antibodies. Each laboratory tests the well-characterized samples, reports the results, and provides information about its testing practices. The data from 15 performance survey periods are reported here. STUDY DESIGN AND METHODS: Multiple logistic regression was used to analyze all data from 15 survey periods from 1989 through 1996. RESULTS: The mean analytic sensitivity for EIA was 99.2 percent per survey period (range, 96-100%), the mean analytic specificity was 97.8 percent (75.6-100%), and the overall accuracy was 88.8 percent (63.8-100%). The mean analytic sensitivity for Western blot was 88.8 percent (75.6-100%); the mean analytic specificity was 95.7 percent (86.7-100%), and the overall accuracy was 91.1 percent (78.1-100%). CONCLUSIONS: Statistical analyses suggested associations between performance and both the retroviral serologic status of the sample and the analytical testing method. Western blot accuracy was associated with weekly testing volume. In early survey periods, performance problems were noted in the analysis of samples from donors with concomitant HTLV and HIV infections and those from donors who were positive for HTLV-II. Technological developments in test methods, such as the addition of recombinant antigens, appeared to have improved the laboratory performance of specific testing methods.
A comprehensive health screening program consisting of standardized health and occupational history questionnaire, blood chemistry profile, complete blood count, urinalysis, chest radiograph, and pulmonary function testing was organized for the Asbestos Workers Union Local Number 1 in St. Louis, Missouri. The program was available on a voluntary basis to all the workers in the Union. One hundred and thirty-five male caucasian workers or 44% of the membership volunteered to participate and all the data were used in this study. All blood chemistry profiles and urinalysis results were within normal limits. Twenty-two of the asbestos workers had radiologic pulmonary abnormalities as well as severe pulmonary function impairment. The remaining 113 workers were divided into subgroups based on the number of years of exposure to asbestos and their smoking history. Although asymptomatic, workers with more than 20 years exposure to asbestos had significantly decreased pulmonary functions compared to those with less than 20 years exposure. When smokers and nonsmokers were compared, an additive effect between smoking and asbestosis was observed. This study also discovered that significant decreases in pulmonary functions occur early in the exposure to asbestos.
The prevalence of HIV infection in correctional settings is several-fold higher than found in community settings. New approaches to identifying HIV infection among prisoners are urgently needed. In order to determine the HIV seroprevalence and to identify the correlates of HIV infection among female prisoners, an anonymous, but linked HIV serosurvey was conducted at Connecticut's sole correctional facility for women (census=1,100). After removing all individual identifiers for inmates' standardized clinical and risk behavior information, data are linked by a third source to blinded HIV-testing information by a third party. This three-step sequential process allows for anonymous HIV testing that can still be linked with deidentified clinical and behavioral data. Of the 3,315 subjects with complete information, 250 (7.5%) were HIV+. Of these, 157 (63%) self-reported being HIV+. Using multiple logistic regression analysis, having sex with a known HIV+ person [adjusted odds ratio (AOR)=9.1] and injection drug use (AOR=6.1) were the most highly correlated risk factors for HIV, whereas leukopenia (AOR=9.4) and hypoalbuminemia (AOR=7.2) were the most significant laboratory markers. Other independent correlates of HIV included self-report of syphilis (AOR=1.9) or genital herpes infection (AOR=2.7) and being Black (AOR=2.1) or Hispanic (AOR=2.2). The prevalence of HIV and HIV-risk behaviors is high among incarcerated women. Existing voluntary HIV counseling and testing programs do not completely target high-risk groups who remain part of the evolving epidemic. Defined demographic, behavioral, and clinical assessments may provide useful information for encouraging targeted counseling and testing. Newer targeted approaches merit further study to determine the effectiveness of this approach. Alternative methods of facilitating more widespread HIV testing, such as saliva tests, rapid serologic tests, and more routine testing in high HIV-prevalence areas should be considered both for clinical and for public health benefits.
ETS contains numerous toxins. Robust epidemiologic evidence implicates ETS as a cause of lung cancer and as a primary cause and source of exacerbation of excess respiratory disease. There is also increasing evidence that ETS may be associated with other outcomes, including heart disease. There is currently little doubt that ETS is an important and avoidable health hazard. Unfortunately, ETS is frequently encountered in the workplace--where it is no safer than in other environments and where it presents hazards to exposed workers and to others. A unique aspect of workplace ETS is that exposure is rarely an outcome of essential manufacturing, extraction, or service delivery processes. Moreover, ETS exposure, with its growing list of known hazards, is preventable by engineering or policy means. Implementation of policies to prevent workplace ETS can be highly effective while entailing low costs and yielding primary and secondary benefits to employers and employees. ACOEM strongly supports an increase in the scope and effectiveness of policies and efforts that protect against exposure to ETS in the workplace and elsewhere. To that end, ACOEM supports voluntary, regulatory, and legislative initiatives to eliminate ETS from the workplace, including public spaces such as bars, casinos, restaurants, schools, day-care centers, and public transportation. ACOEM also encourages employers to provide employee training concerning the health hazards of ETS and voluntary personal smoking-cessation programs.
In December 2000 the EPA initiated the Voluntary Children's Chemical Evaluation Program (VCCEP) by asking manufacturers to voluntarily sponsor toxicological testing in a tiered process for 23 chemicals selected for the pilot phase. The tiered nature of the VCCEP pilot program creates the need for clearly defined criteria for determining when information is sufficient to assess the potential risks to children. This raises questions about how to determine the "adequacy" of the existing information and assess the need to undertake efforts to reduce uncertainty (through further testing). This article applies a value of information analysis approach to determine adequacy by modeling how toxicological and exposure data collected through the VCCEP may be used to inform risk management decisions. The analysis demonstrates the importance of information about the exposure level and control costs in making decisions regarding further toxicological testing. This article accounts for the cost of delaying control action and identifies the optimal testing strategy for a constrained decisionmaker who, absent applicable human data, cannot regulate without bioassay data on a specific chemical. It also quantifies the differences in optimal testing strategy for three decision criteria: maximizing societal net benefits, ensuring maximum exposure control while net benefits are positive (i.e., benefits outweigh costs), and controlling to the maximum extent technologically feasible while the lifetime risk of cancer exceeds a specific level of risk. Finally, this article shows the large differences that exist in net benefits between the three criteria for the range of exposure levels where the optimal actions differ.
The Voluntary Children's Chemical Evaluation Program (VCCEP) is designed to provide information to the public on children's potential health risks associated with chemical exposures. The key question of the VCCEP is whether the potential hazards, exposures, and risks to children have been adequately characterized, and, if not, what additional data are necessary. To answer this question, manufacturers or importers of 23 chemicals were asked by the U. S. Environmental Protection Agency (U.S. EPA) to sponsor their chemicals in the first tier of a pilot program. These chemicals were selected for evaluation because they have been found as contaminants in human tissue or fluids (adipose tissue, blood, breath, breast milk, or urine); food and water children may eat and drink; or air children may breathe (including residential or school air). Under the VCCEP framework, sponsoring companies agree to prepare Tier 1 hazard, exposure, and risk assessments on the individual chemicals, and identify the need for additional data. These assessment documents are submitted to the U.S. EPA and subsequently undergo review by experts in an independent peer consultation meeting that is open to the public. Following this peer consultation process, the U.S. EPA reviews each submission and makes a data-needs determination, which may include requesting further data collection or generation by the sponsor. Sponsoring companies then decide whether to volunteer for the next tier and collect or generate the requested data. The purpose of this article is to describe the VCCEP process and to review and present the key findings from the first set of chemicals that have been fully or partially evaluated under the pilot program (vinylidene chloride, decabromodiphenyl ether, pentabromodiphenyl ether, octabromodiphenyl ether, acetone, methyl ethyl ketone, decane, undecane, and dodecane). Specifically, we provide a brief summary of the sponsors' submissions, the peer consultation panels' discussions, and the U.S. EPA's data-needs decisions. Although we do not attempt to conduct independent analyses of the underlying data, we do identify a number of common themes that have emerged during implementation of the pilot program and discuss several key issues that could become important in the future. The information presented here should be useful for various parties interested in the progress of the VCCEP and the results of the initial (Tier 1) children's assessments.