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PubMed2005

Costs of scaling up health interventions: a systematic review.

National governments and international agencies, including programmes like the Global Alliance for Vaccines and Immunizations and the Global Fund to Fight AIDS, Tuberculosis and Malaria, have committed to scaling up health interventions and to meeting the Millennium Development Goals (MDGs), and need information on costs of scaling up these interventions. However, there has been no systematic attempt across health interventions to determine the impact of scaling up on the costs of programmes. This paper presents a systematic review of the literature on the costs of scaling up health interventions. The objectives of this review are to identify factors affecting costs as coverage increases and to describe typical cost curves for different kinds of interventions. Thirty-seven studies were found, three containing cost data from programmes that had already been scaled up. The other studies provide either quantitative cost projections or qualitative descriptions of factors affecting costs when interventions are scaled up, and are used to determine important factors to consider when scaling up. Cost curves for the scaling up of different health interventions could not be derived with the available data. This review demonstrates that the costs of scaling up an intervention are specific to both the type of intervention and its particular setting. However, the literature indicates general principles that can guide the process: (1) calculate separate unit costs for urban and rural populations; (2) identify economies and diseconomies of scale, and separate the fixed and variable components of the costs; (3) assess availability and capacity of health human resources; and (4) include administrative costs, which can constitute a significant proportion of scale-up costs in the short run. This study is limited by the scarcity of real data reported in the public domain that address costs when scaling up health interventions. As coverage of health interventions increases in the process of meeting the MDGs and other health goals, it is recommended that costs of scaling up are reported alongside the impact on health of the scaled-up interventions.

Geography↗

PubMed2005

Adding insight: a qualitative cross-site study of physician order entry.

The research questions, strategies, and results of a 7-year qualitative study of computerized physician order entry implementation (CPOE) at successful sites are reviewed over time. The iterative nature of qualitative inquiry stimulates a consecutive stream of research foci, which, with each iteration, add further insight into the overarching research question. A multidisciplinary team of researchers studied CPOE implementation in four organizations using a multi-method approach to address the question "what are the success factors for implementing CPOE?" Four major themes emerged after studying three sites; ten themes resulted from blending the first results with those from a fourth site; and twelve principles were generated when results of a qualitative analysis of consensus conference transcripts were combined with the field data. The study has produced detailed descriptions of factors related to CPOE success and insight into the implementation process.

Attitude to Computers↗

PubMed2004

Adding insight: a qualitative cross-site study of physician order entry.

The research questions, strategies, and results of a six-year qualitative study of computerized physician order entry implementation (CPOE) at successful sites are reviewed over time. The iterative nature of qualitative inquiry stimulates a consecutive stream of research foci which, with each iteration, add further insight into the overarching research question. A multidisciplinary team of researchers studied CPOE implementation in four organizations using a multi-method approach to address the question "what are the success factors for implementing CPOE?" Four major themes emerged after studying three sites; ten themes resulted from blending the first results with those from a fourth site; and twelve principles were generated when results of a qualitative analysis of consensus conference transcripts were combined with the field data. The study has produced detailed descriptions of factors related to CPOE success and insight into the implementation process.

Data Collection↗

PubMed1993

[Risk factors for the health of adolescent students].

OBJECTIVE: To profile COU and 5th-year FP students for the theoretical importance they give to health and their self-perception of the same. To measure their level of knowledge, activities and conduct regarding health risk factors. DESIGN: Descriptive crossover study. SETTING: Primary Care district of the Alpujarra, Granada. PARTICIPANTS: 190 COU and 5th-year FP students from schools in the Alpujarra (95% of the total). MEASUREMENTS AND MAIN RESULTS: The majority of these young people cites health as among the three most important elements in their life, yet lived alongside important risk factors. Although 69% defined their health as good or very good, 64% got drunk at least once a year. Although they all accepted the harmfulness of tobacco, 54.1% (with no difference between the sexes) smoked to some degree. Only 2.6% identified the days of greatest risk of pregnancy in a supposed cycle, although 19% stated that they had heterosexual relations. AIDS was considered the illness most to be feared. 13% had had a motor-bike accident in recent years. CONCLUSIONS: There is a contradiction between the high theoretical importance given to health, the self-definition of good health and cohabitation with important risk factors. The inefficacy of the Primary Care and Education systems in the primary prevention of important risk factors affecting adolescents' health was also demonstrated.

Adolescent↗

PubMed1998

[The screening for asymptomatic vascular disease and risk factors in high risk patients: current practice].

OBJECTIVE: To assess current practice in screening for asymptomatic vascular disease and risk factors in patients referred with vascular disease or cardiovascular risk factors. DESIGN: Descriptive, retrospective. SETTING: University Hospital Utrecht, Utrecht, the Netherlands. METHOD: By means of the computerized hospital registration system all patients who were referred to the outpatient clinic with carotid stenosis, peripheral artery disease, abdominal aortic aneurysm, diabetes mellitus, hyperlipidaemia or hypertension during one year were identified. By means of the same hospital registration system the frequency of diagnostic tests performed to detect atherosclerosis or risk factors in these patients within a period of 5 months round the first attendance was determined. RESULTS: 372 Patients with a vascular disease and 317 patients with a risk factor were identified. Tests to detect carotid stenosis, peripheral artery disease or an abdominal aortic aneurysm were each performed in less then 6% of all patients except the test for abdominal aortic aneurysm. Tests to detect coronary artery disease were performed in about 50% of all patients. Tests to detect diabetes mellitus were performed in 35% of the patients with vascular disease and in 81% of the patients presenting with hyperlipidaemia or hypertension. Tests to detect hyperlipidaemia were performed in 18% of the patients with a vascular disease and in 76% of the patients with diabetes or hypertension. CONCLUSION: The results of this study suggest that in current practice patients referred for vascular disease or cardiovascular risk factors are infrequently screened for asymptomatic macrovascular disease and risk factors.

Adult↗

PubMed2004

Adolescents in mid-sized and rural communities: foregone care, perceived barriers, and risk factors.

PURPOSE: To investigate the perceived health care needs, foregone care, barriers to care, and associated risk factors in a non-urban population of adolescents. METHODS: Tenth-grade students attending school and 15-17-year-old youth not attending school in a Midwestern county were surveyed or interviewed. Eighty-six percent provided usable data (n = 1948, 134 of whom were not in school). Nine focus groups (71 participants; 28 were not in school) were conducted in follow-up. Quantitative analysis included descriptive statistics, factor analysis, and logistic regression. Qualitative analysis of taped focus groups identified themes and interpreted findings. RESULTS: Although 91% had seen a physician in the past 2 years, 44% reported foregoing needed care in the last year. Barriers for specific health needs were: cost of care and lack of insurance coverage for injuries and illnesses; lack of knowledge, distrust, and stigma for depression; embarrassment and transportation for birth control and sexually transmitted infections (STIs); and not knowing where or how to access care for drug and alcohol use. Youth most likely to have foregone care included those involved with dangerous activities under peer pressure (1.8, CI: 1.44-2.13), sexual intercourse (1.4, CI: 1.25-1.67), marijuana use (1.4, CI: 1.17-1.67), anticipating parenthood before age 20 years (1.2, CI: 1.04-1.33), male gender (2.5, CI: 1.89-2.86) and perceiving good health (1.7, CI: 1.45-1.85). CONCLUSIONS: Nearly half of this non-urban population (both in and out of school) reported foregoing needed care in the last year. The barriers to care include lack of information, lack of access, poor insurance coverage, parenting issues, and concern about confidentiality.

Adolescent↗

PubMed2004

[Malnutrition of home care patients].

OBJECTIVES: To find the nutritional status of people >65 years old included in a Home Care programme, using the Mini Nutritional Assessment (MNA), to describe the parameters discovered and to identify their relationship with risk factors. DESIGN: Descriptive, cross-sectional study. SETTING: Primary care centre. PARTICIPANTS: 104 patients, who were over 65 and at the time of the study within the centre's home care programme, were included. INTERVENTIONS: The assessment was conducted by nursing staff in patients' homes. MAIN MEASUREMENTS: To assess the scores on the MNA, to describe the social and demographic variables of patients and carers, and to determine the medical, social and pathological factors of risk of malnutrition. RESULTS: Patients' mean age was 84.04 (SD, 8.76). 72.1% of carers were close relatives, with an average age of 61.88 (SD, 13.53). 20.2% of patients suffered from malnutrition and 51.9% were at risk of malnutrition. In both groups there was a low level of autonomy, significantly below that of well-nourished patients. No significant differences were found for the presence of more chronic illnesses, or social or psychological risk factors between these 2 groups and well-nourished patients. CONCLUSIONS: There is an extensive risk of malnutrition and actual malnutrition in the home care population.

Age Factors↗

PubMed2004

Constructing an integrated model of the antecedents of adolescent smoking.

OBJECTIVE: Reviews have called for integrative, theoretically informed models of the 'hundreds of associations' (Miller & Slap, 1989, p. 131) between psychosocial measures and adolescent smoking (e. g. Tyas & Pederson, 1998). Such a model was tested. METHOD: A prospective, classroom-based survey measuring previously identified correlates of smoking allowed comparison of the strength of relationships between antecedents and smoking status six months later. The prospective sample included 225 13 to 14-year-olds. Measures of behaviour-specific cognitions derived from the Theory of Planned Behaviour (TPB)-as well as personality, self-esteem, parental support and parental control, sociodemographic factors, and descriptive norms-were included. Relationships between antecedents were explored using path analyses. RESULTS: High initial rates of smoking were observed. Of the variance in smoking six months later, 56% was explained by seven direct predictors: intention, perceived ease of smoking, estimated number of friends smoking, percentage of older brothers smoking, self-esteem, extraversion and car access. DISCUSSION: Results emphasize the importance of behaviour-specific cognitions specified by the TPB but suggest that other factors, including extraversion and self-esteem, need to be included in models of the antecedents of smoking. The findings also imply that some antecedents, such as parental support, may indirectly influence adolescent smoking through their effect on other variables.

Adolescent↗

PubMedDate not supplied

Sleep disorders in childhood: a review.

Several studies in the last ten years have been directed towards a better understanding of sleep disorders in childhood. Defining sleep disorders in this age is difficult in dependence of relevant differences in sleep patterns at subsequent developmental stages. In new-borns total sleep time is fairly equal during night and day. Normally, day-time sleep gradually decreases over the first three years of life, such that night-time sleep progressively increases till the age of four, and similar to adult sleep-time by adolescence. The most frequent sleep disorders observed in childhood are parasomnias, that, thought to be a CNS sign of immaturity, tend to be quite predictable, recurring in the same families and not even influenced by environmental stimuli. These disorders included: a) arousal disorders, that generally emerge from delta sleep or relate to arousals occurring during NREM sleep, very common in childhood and fairly common in adulthood either; b) somnambulism and somniloquy, that have many common characteristics: first of all, they have the potential to generate a great sense of discomfort and fear in parents watching a child who suddenly sits up in bed eyes-opened but 'unseeing'; c) nocturnal enuresis, that is substantially not a problem of depth of sleep, despite many parents believe. Although narcolepsy is more common in adolescence, many studies have demonstrated that narcoleptic symptoms may begin in childhood. Narcoleptic symptoms in children are similar in their appearance to those predominant in adults, but their expression may be different because of CNS maturational factors. Historical descriptions of the OSAS evidenced since the beginning the importance of neurobehavioral complications associated with the cessation of airflow at the nose and mouth accompanied by respiratory effort, deriving from upper airway obstruction which occurs during sleep.

Adolescent↗

PubMed2005

Trends, risk factors, and prevention of falls in older adults in Wisconsin.

Wisconsin's death rate due to falls among adults 65 years and older is more than twice the national average. The hospitalization rate due to falls-related injuries in Wisconsin increased slightly from 1995 to 2002, with an injury rate of 2159 per 100,000 in 1995, and 2263 per 100,000 in 2002. Emergency department (ED) utilization and hospitalization rates for falls-related injury are higher for women than for men in Wisconsin. In 2002, the total statewide charges for hospitalizations and ED visits for falls-related injuries were more than $96 million. Two thirds of those admitted to the hospital for a falls-related injury were discharged to a nursing home or rehabilitation facility. Multifactorial intervention strategies have been shown to decrease the rate of falls in randomized, controlled trials. The purpose of this paper is to describe trends in falls-related injury fatalities, hospitalizations, and ED visits in Wisconsin. Also included are cost data related to falls, identification of risk factors, and descriptions of the possible role of physicians and other health care professionals in interdisciplinary, multifocal programs to prevent falls-related injuries in high-risk older adults.

Accident Prevention↗

PubMed2006

Predicting the toxicity of weekly docetaxel in advanced cancer.

OBJECTIVES: To determine the safety profile of 40 mg/m(2) docetaxel administered weekly to a mixed population of advanced cancer patients and identify predictors of toxicity and survival following treatment with weekly docetaxel in this population. PATIENTS AND METHODS: 68 patients with advanced cancer were enrolled into the study. Various patient characteristics, including inflammatory and nutritional status, docetaxel pharmacokinetics and liver function were investigated. Predictors of treatment-related toxicity and survival were analysed using multivariate logistic regression and Cox proportional hazards analysis, respectively. RESULTS: 27 patients (40%) experienced grade 3 or 4 toxicity, mainly gastrointestinal toxicities (20%), leukopenia (16%) and neutropenia (12%), during the first 8 weeks of docetaxel treatment. Docetaxel pharmacokinetics were the only predictive factor for haematological toxicity. The odds of severe haematological toxicity were approximately 9-fold higher for patients with reduced docetaxel clearance (e.g. <30 L/h). The odds of non-haematological toxicity were about 3-fold higher for patients with elevated levels of inflammatory markers: alpha(1)-acid glycoprotein (AAGP) >1.5 g/L or C-reactive protein >10 mg/L). Multivariate analysis indicated that weight loss, liver dysfunction and elevated levels of AAGP were independently significant predictors of survival. CONCLUSION: This is the first description of factors predictive of the toxicity and survival following weekly administration of docetaxel. Patients with reduced clearance of docetaxel and elevated markers of inflammation experienced worse adverse effects, while patients with weight loss, liver dysfunction and elevated markers of inflammation had worse survival.

Adult↗

PubMed2003

The Metropolitan Atlanta Congenital Defects Program: 35 years of birth defects surveillance at the Centers for Disease Control and Prevention.

BACKGROUND: The Metropolitan Atlanta Congenital Defects Program (MACDP) is a population-based birth defects surveillance program administered by the Centers for Disease Control and Prevention (CDC) that has been collecting, analyzing, and interpreting birth defects surveillance data since 1967. This paper presents an overview of MACDP current methods and accomplishments over the past 35 years. METHODS: MACDP actively monitors major birth defects among infants born to residents of five counties of metropolitan Atlanta, an area with approximately 50,000 annual births. Cases are ascertained from multiple sources, coded using a modified British Pediatric Association six-digit code, and reviewed and classified by clinical geneticists. RESULTS: MACDP has monitored trends in birth defects rates and has served as a case registry for descriptive, risk factor, and prognostic studies of birth defects, including studies of Agent Orange exposure among Vietnam War veterans, maternal use of multivitamins, diabetes, febrile illnesses, and survival of children with neural tube defects. MACDP has served as a data source for one of the centers participating in the National Birth Defects Prevention Study, and for developing and evaluating neural tube defects prevention strategies related to the periconceptional use of folic acid supplements. CONCLUSIONS: Since its inception, MACDP has served as a resource for the development of uniform methods and approaches to birth defect surveillance across the United States and in many other countries, monitoring birth defects rates, and as a case registry for various descriptive, etiologic, and survival studies of birth defects. MACDP has also served as a training ground for a large number of professionals active in birth defects epidemiology.

2,4,5-Trichlorophenoxyacetic Acid↗

PubMed2005

An interpreter's interpretation: sign language interpreters' view of musculoskeletal disorders.

INTRODUCTION: Sign language interpreters are at increased risk for musculoskeletal disorders associated with work. Previous studies have used survey techniques to identify potential risk factors and approaches to their medical management. Little is known about risk factors and management of symptoms in this group from the perspective of the interpreter. Such qualitative information should help inform future research related to this professional group. METHOD: One thousand ninety-two sign language interpreters recruited from the Registry of Interpreters for the Deaf completed an open-ended question that was a component of a national prevalence survey. Responses were evaluated using content analysis. Inter and intra rater reliability were high (.88 and .92, respectively). RESULTS: Risk factors for initiation and/or exacerbation of symptoms included: difficult job, interpreting setting (educational), interpreting style (e.g., posture, self generated force), and emotional and physical stressors. Exercise (e.g., stretching, aerobics) was a common prevention strategy. Conventional medical treatment was used as the first line approach to symptom control. Self-care methods such as exercise, diet and warm up prior to interpreting were also reported. While massage and chiropractic care was used as commonly as in the general population, acupuncture was found to be used more often. Coping strategies that were more active (e.g. exercise, diet, more control over work schedule) were also reported as useful. CONCLUSIONS: These findings provide a description of factors that interpreters view as important in the development and exacerbation of hand and wrist pain. The results also indicate that interpreters used many self-management approaches. Future research should carefully investigate the utility of such approaches using well-controlled designs. Also, because of its widespread use in this group the evaluation of acupuncture in the management of these symptoms appears warranted. The qualitative approach used in the present study permitted an analysis of the worker perspectives regarding risk and management of these work related symptoms. This information can be used to further inform future research.

Adult↗

PubMed2003

[Relationship between ignorance of own weight and cardiovascular risk in primary care].

OBJECTIVES: To evaluate what health-care users know about their own weight, the distribution of body fat and the relationship of their level of knowledge with cardiovascular risk factors. DESIGN: Descriptive cross-sectional study.Setting. Urban health centre. PARTICIPANTS: 240 patients between 15 and 69, chosen by consecutive sampling. MAIN MEASUREMENTS: Survey, analysis (n=100), body measurements and sphygmomanometry were done. RESULTS: 80.8% of users knew their weight to over-95% accuracy. The biggest errors were found in older patients and in women. There was great prevalence of male-style obesity (71.3%), even among women. The population with greatest errors in knowing their own weight were at greater cardiovascular risk. CONCLUSIONS: In elderly people, age and sex condition the Body Mass Index and their ignorance of their own weight. There is a relationship between this variable and cardiovascular risk factors. This relationship supports the taking of individual-specific health education measures on obesity in primary care.

Adult↗

PubMed2005

Trigeminal neuralgia in a patient with Dandy-Walker malformation.

BACKGROUND: Trigeminal neuralgia may be idiopathic or secondary to a number of cranial pathologies. We report a novel case of trigeminal neuralgia associated with Dandy-Walker malformation, which may be an etiologic factor. CASE DESCRIPTION: A 32-year-old male presented with shock-like pain in the somatosensory distribution of the right trigeminal nerve, which was refractory to all medication. MRI revealed a cystic lesion in the posterior fossa and a hypoplastic vermis. The pain was diagnosed as trigeminal neuralgia and was thought to be secondary to the Dandy-Walker malformation. The trigeminal neuralgia was treated successfully with radiofrequency thermocoagulation rhizotomy (RF-TR). CONCLUSION: Trigeminal neuralgia may be associated with Dandy-Walker malformation, however an etiological relationship is not proven. We suggest that traction on the trigeminal nerve may be significant. The posterior fossa cyst of Dandy-Walker malformation may be a complicating factor when considering microvascular decompression to treat the trigeminal neuralgia. Collapse of the cyst at surgery may destabilize the posterior fossa and further deform the trigeminal nerve. We suggest that RF-TR, which is minimally invasive and reliable, may be preferable.

Adult↗

PubMed1993

Spatio-temporal characteristics of human motion perception.

A bi-local detector array model was assumed to describe the functional performance of monocular motion perception. Distributions of model parameters were measured in human vision at several positions in the visual field. The stimulus paradigm was designed to measure directional motion perception thresholds for individual combinations of spatial displacement and temporal delay in random dot apparent motion stimuli. The resulting data support previous results on perceivable spatial displacement limits in human vision but also indicate that both minimum and maximum perceivable spatial displacement thresholds in human observers have a similar dependence on temporal delay. This dependence changes with eccentricity in the visual field in a qualitatively similar manner but by quantitatively different factors. A description of possible biological properties of the bi-local detector population is presented that may explain how detection of spatio-temporal pattern displacements can be performed by a single system. Such a system also predicts that minimum and maximum perceivable spatial displacement thresholds should scale with visual field eccentricity in a manner consistent with our results.

Humans↗

PubMed2003

Prolonged candidemia in infants following surgery for congenital heart disease.

OBJECTIVES: To describe a group of infants with complex congenital heart disease (CCHD) who had candidemia postoperatively and to perform a case-control study of risk factors. DESIGN: Descriptive and case-control study. SETTING: Tertiary-care medical centers. PATIENTS: Infants with CCHD who underwent cardiac surgery and developed candidemia. Controls were matched for congenital heart disease lesions, age, and postoperative hospital stay. RESULTS: Of 95 infants younger than 6 months with CCHD who underwent cardiac surgery between January 1999 and April 2001, 6 (6.3%) developed candidemia with 5 different species. The candidemia was prolonged (range, 12 to 32 days; median, 17 days). The interval between cardiac surgery and onset of candidemia was 12 to 57 days (median, 24 days). All had a central venous catheter inserted 8 to 50 days prior to the onset of candidemia. The mortality rate was 83%, compared with 13% for the group without candidemia. A univariate analysis of the potential risk factors revealed that duration of total parenteral nutrition (TPN), duration of antibiotics, intraoperative cardiopulmonary bypass time, and documentation of an intravascular thrombus were associated with candidemia. In multivariate analysis, long duration of TPN and documentation of a thrombus were associated with candidemia. CONCLUSIONS: Candidemia following cardiac surgery for infants with CCHD was persistent and associated with high mortality. The variety of species indicates that this was not a common-source outbreak. Risk factors associated with candidemia were duration of TPN and documentation of an intravascular thrombus.

Candida↗

PubMed2000

Identification of neonatal hearing impairment: a multicenter investigation.

OBJECTIVES: This article describes the design of a multicenter study sponsored by the National Institutes of Health. The purpose of this study was to determine the accuracy of three measures of peripheral auditory system status (transient evoked otoacoustic emissions, distortion product otoacoustic emissions, and auditory brain stem responses) applied in the perinatal period for predicting behavioral hearing status at 8 to 12 mo corrected age. The influences of the infant's medical status, the test environment, and test and response parameters on test performance were examined. DESIGN: Seven institutions participated in this study. There were 7179 infants evaluated in the perinatal period. All graduates of the neonatal intensive care unit (4478) and well babies with one or more risk factor for hearing loss (353) were targeted for follow-up testing using visual reinforcement audiometry (VRA) at 8 to 12 mo corrected age. Well babies without any risk indicators (N = 2348) were not targeted for follow-up VRA testing. However, 80 of these well babies did not pass the screening protocol and thus were targeted for follow-up VRA testing as well. Perinatal test performance was evaluated using the VRA data as the "gold standard." RESULTS: The results of this study are described in a series of 11 articles following this introductory article. CONCLUSIONS: The evaluation of newborn hearing tests required a longitudinal study in which newborn test results were compared with a gold standard based on behavioral audiometric assessment. Such an evaluation was possible because all newborns, passes as well as refers, were followed up long enough to permit reliable behavioral measurements. In addition, prenatal, perinatal, and maternal history information, test environment, and test parameter information were collected to provide data that led to a complete description of factors affecting test outcomes. All of these data were obtained in a sample of sufficient ethnic, medical, and geographic diversity in efforts to increase the generalizability of the results. Finally, the data were combined in a relational data base to examine the factors that influence test performance. Specific information related to these issues is presented in the articles that follow.

Evoked Potentials, Auditory, Brain Stem↗