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PubMed1982

High rate of tuberculin conversion in Indochinese refugees.

From January 1979 through December 1980, a total of 664 Indochinese refugees were screened for tuberculosis in Monroe County, New York; 307 (46%) had positive 5-tuberculin unit PPD Mantoux tests. When 217 refugees with initially negative tests were retested at 60 days, 94 (43%) had converted from a negative to a positive test. Although none of the converters had evidence of active tuberculosis disease, 90 (96%) were given isoniazid preventive therapy. This conversion phenomenon has continued over time, discounting an effect of local, national, or international policy changes. The conversions do not seem to be a function of antigen, tester, or reader; criteria for testing, retesting, or reading; home country, camp country, or length of time in camp; or history of prior BCG vaccination, tuberculosis, or immunization exposure, current illness, or testing intervals since arrival in the United States and subsequent testing. Further studies to evaluate boosting or anergy are in progress to assess this potential public health problem.

Adolescent↗

PubMedDate not supplied

Changing health policy in the post-Mao era.

A shift away from Mao Zedong's concept of equality in the delivery of medical care is now taking place in The People's Republic of China. This change is evident in the emphasis now placed upon high technology, basic research, and hospital care. All of these changes are occurring against the backdrop of extremely scarce medical resources. Medicine seemingly is viewed as one of many material incentives to be provided high productivity and leadership groups; the "modernization" of medicine is seen as one visible manifestation of the success of the broader modernization effort itself. As well, population policy has become more stringent, with rewards being given to one-child families and sanctions being applied against couples having three or more children. Although these policy changes offer bright prospects for Sino-American cooperation in the biomedical field, foreigners must remain sensitive to the controversial nature of these alterations in the Chinese political setting.

China↗

PubMed1995

Dying of non-malignant diseases in general practice.

Recent policy changes within the British National Health Service have encouraged the provision of care within the community. The objective of this study was to explore the needs of informal caregivers of people with non-malignant diseases who wished to remain in their own homes until death. Semi-structured interviews with a non-random sample of 20 bereaved carers from 14 surgeries, their general practitioners, and district nurses were analyzed to discover the extent and quality of the care provided by the primary care team. One quarter of the doctors considered that palliative care applied exclusively to people with cancer. One half of the doctors felt that palliative care was primarily concerned with pain relief. Both doctors and nurses believed that their role was that of coordinating care for the patient. Carers were reluctant to criticize professional caregivers, but the results of this study suggest that carers need help with the burden of caring, including emotional support, advice and information regarding social services and financial benefits, and recognition of their caring role. Palliative care is not exclusive to people with cancer but should be extended to people with non-malignant diseases, encompassing not only symptom relief but also explicitly including emotional or spiritual support, care of the family, and support in preparing for the end of life.

Adult↗

PubMed1995

Vision impairment and corrective considerations of civil airmen.

BACKGROUND: Civil aviation is a major commercial and technological industry in the United States. The Federal Aviation Administration (FAA) is responsible for the regulation and promotion of aviation safety in the National Airspace System. To guide FAA policy changes and educational programs for aviation personnel about vision impairment and the use of corrective ophthalmic devices, the demographics of the civil airman population were reviewed. METHODS: Demographic data from 1971-1991 were extracted from FAA publications and databases. RESULTS: Approximately 48 percent of the civil airman population is equal to or older than 40 years of age (average age = 39.8 years). Many of these aviators are becoming presbyopic and will need corrective devices for near and intermediate vision. In fact, there has been approximately a 12 percent increase in the number of aviators with near vision restrictions during the past decade. Ophthalmic considerations for prescribing and dispensing eyewear for civil aviators are discussed. CONCLUSIONS: The correction of near and intermediate vision conditions for older pilots will be a major challenge for eye care practitioners in the next decade. Knowledge of the unique vision and environmental requirements of the civilian airman can assist clinicians in suggesting alternative vision corrective devices better suited for a particular aviation activity.

Adult↗

PubMed1995

Nurse practitioners in a teaching hospital.

The development of a model of care using acute care nurse practitioners in a teaching hospital and the integration of the nurse practitioner into an alternative model of care delivery are discussed. Issues in implementation include lack of understanding about the nurse practitioner role on the part of other members of the health care team, legislative constraints, and the administrative restrictions of teaching hospitals. Education of nurses and physicians regarding the scope of practice of the nurse practitioner role, departmental policy changes, and the development of protocols facilitate the efficiency and utilization of the nurse practitioner in this setting. Specific concerns surrounding costs of a nurse practitioner service and practice differences between the clinical nurse specialist and the acute care nurse practitioner are addressed. Nurse practitioner models of care delivery, which address quality, cost-effective care are on the forefront of tomorrow's health care.

Cost-Benefit Analysis↗

PubMed1995

Women's health as a priority.

Funding for the NIH Women's Health Initiative is allocated by Congress on an annual basis. Since the 1994 elections, which dramatically changed the balance of power and priorities in the U.S. Congress, some individuals have voiced concern over the future of this project. Pharmacists can ensure that funding for this research continues by contacting their congressional representative to express their views directly. They can also join forces with other pharmacists through their national and state pharmacy associations. Law makers and persons responsible for funding decisions are interested in and responsive to the positions taken by professional groups. Pharmacists can improve the health of their female patients by encouraging them to make healthy lifestyle changes (e.g., stop smoking, exercise regularly, reduce fat intake, maintain recommended body weight, obtain a Pap test annually, have mammograms at recommended intervals, and perform monthly breast self-examinations). Pharmacists should urge women who might benefit from HRT to talk about it with their physicians. Pharmacists are a valuable source of information about the advantages and disadvantages of HRT. The exclusion of women from clinical and epidemiologic studies has left clinicians with inadequate information about the best approach to preventing and treating many women's health problems. During the past decade, the efforts of various individuals, government agencies, and professional organizations have brought about policy changes that broaden opportunities for inclusion of women in clinical trials as well as increased funding for women's health research. The Women's Health Initiative and other research currently being conducted will yield valuable information that can be used to improve the health of women.

Cause of Death↗

PubMed1995

Emergency cardiac care. Moral, legal, and ethical considerations.

According to the American Heart Association, "Successful completion of an ACLS course means in accordance with the cognitive and performance standards of the American Heart Association. It does not warrant performance, nor does it, per se, qualify or authorize a person to perform any procedure. It in no way related to licensure, which is a function of the appropriate legislative, health or educational authority." The same can be said for BLS; however, with the recent revisions in ECC programs, even this disclaimer has been eliminated from the most recent textbooks in BLS and ACLS. This is in keeping with "...the American Heart Association's reaffirmation of its role as an educational resource rather than as a certifying agency." Lay public course participants in BLS (which technically includes dentists) will now receive course participation cards. Health care provider course participants will continue to receive "course completion cards" if all criteria have been satisfied by the student. The trend is to categorize what was previously termed testing as evaluation. Certification has become a thing of the past. It is unclear at this time what the impact this policy change will have on agencies who rely upon documentation from the American Heart Association to satisfy requirements that have been imposed upon dentists and other health professionals for initial licensure and relicensure. Semantics aside, one thing that remains clear is the expectation of the dentist with regards to emergency management. Expertise (for lack of a better term) in specific aspects of ECC remains a standard. For all dentists, expertise in BLS is that standard. For dentists administering deep sedation and general anesthesia, expertise in ACLS is the community standard. Although there is some ambiguity for those dentists administering conscious sedation, at the very least, they should have expertise in BLS. In addition, they are strongly encouraged to have expertise in ACLS, particularly because the limited hours of training in conscious sedation provide less medical background than is acquired during training in deep sedation and general anesthesia. In addition, the dentist is ultimately responsible for the demeanor of his or her office and staff. In the prehospital dental office setting, the matter of converting a dental office team geared to efficient delivery of dental procedures, into a team primed to perform emergency cardiac care seems daunting. This is especially so if the dentist has little undergraduate or clinical preparation for managing life-threatening emergencies. Therefore, an emergency management plan (with oversight for its implementation by the dentist) is of paramount importance.

Anesthesia, Dental↗

PubMed1995

Research in adolescent suicide: implications for training, service delivery, and public policy.

Four domains of research in adolescent suicide are reviewed: (1) the role of psychopathology, (2) family history of psychopathology, (3) mental health treatments, and (4) firearms in the home. Based on the extant literature, recommendations are made for changes in training, service delivery, and public policy. Among the recommendations for training professionals are: an emphasis on diagnostic proficiency, skill and attentiveness in the assessment of the entire family unit, and assessment of the availability of firearms in the home. With respect to changes in service delivery, we recommend treatment of the entire family system, and treatment of psychiatric and substance abuse problems in the same setting, and we show the need for a continuum of intensity of care from inpatient to outpatient. With respect to policy changes, we recommended parity of mental and physical health insurance coverage, screening for psychiatrically at-risk youngsters in schools and physicians' offices, providing funding to support a continuum of care between inpatient and outpatient, and gun control laws to restrict access to handguns. We believe that these changes can result in a substantial reduction in the adolescent suicide rate.

Adolescent↗

PubMedDate not supplied

MADD rates the states: a media advocacy event to advance the agenda against alcohol-impaired driving.

The "Rating the States" (RTS) Program of Mothers Against Drunk Driving (MADD) is designed to bring public attention to the status of State government efforts to combat alcohol-impaired driving. MADD's 1993 report, which evaluated each State with a grade from A to D, brought renewed visibility to MADD's fight for new prevention policies and helped to advance key State legislation. Because of MADD's national press conference and other media activities, more than 60 million Americans saw or heard a news story related to the program. This article outlines the program's objectives and methodology, efforts to publicize the results, and what was achieved in terms of news media coverage and in advancing public policy change. The RTS Program is a proven media advocacy strategy for prompting State legislatures and Governors to enact new policies. The article concludes with guidelines for other public health advocacy groups that may want to emulate this strategy.

Accidents, Traffic↗

PubMed1975

Equal treatment and unequal benefits: the Medicare program.

This paper analyzes the distribution of Medicare benefits among elderly persons on the basis of income, race, and geographical location. It first presents available statistical evidence from Medicare on the distribution of benefits and the magnitude of differentials among these elderly. It then sorts out the contribution to differentials arising from differences in the availability of medical resources. prices of medical services, and other demographic factors. The importance of various Medicare program features on remaining differentials--such as the cost-sharing provisions of Medicare, reimbursement policies, and nondiscrimination enforcement procedures--are then investigated. The effect of health status on utilization of medical services by the elderly is also analyzed, and the distribution of Medicare benefits by income for elderly persons of similar health status is presented. The paper concludes with recommendations for reducing differentials in Medicare benefits and indicates those policy changes which would result in a distribution of benefits more closely related to health care needs of the elderly.

Aged↗

PubMed1994

After epidemiological research: what next? Community action for health promotion.

The underlying purpose of all epidemiological research is ultimately to use inferences in order to prevent disease and promote health and well-being. Effective skills in translating results into appropriate policy, programs, and interventions are inherently tricky, and often politically controversial. Generally they are not taught to epidemiologists formally, even though they are a traditionally part of public health practice. To move from findings to policy change requires that the informed and committed epidemiologist should known how to: (1) organize affected parties to negotiate successfully with government and industry; (2) activate populations at risk to protect their health (3) communicate responsibly with lay persons about their health risks so as to encourage effective activism; (4) collaborate with other professionals to achieve disease prevention and health promotion goals. The paper presents and discusses four case studies to illustrate these strategies: (1) the grass-roots social action that was the response of the community to the environmental contamination at Love Canal, New York; (2) mobilization of recognized leaders within the gay community to disseminate HIV risk reduction techniques; (3) collaboration with an existing voluntary organization interested in community empowerment through health promotion in a Chicago slum by using existing hospital, emergency room admissions, and local motor vehicle accident data; (4) a self-help group, MADD (mothers against drunk driving) which fought to change public policy to limit and decrease drunk driving. In addition, the importance of multidisciplinary collaboration and responsible communication with the public is emphasized. Factors that limit the ability of the epidemiologist to move into public health action are discussed, including who owns the research findings, what is the degree of scientific uncertainty, and the cost-benefit balance of taking affirmative public action. Putting epidemiological knowledge to good use should be an integral part of an epidemiologist's repertoire.

Community Health Planning↗

PubMed1995

California physicians' willingness to care for the poor.

Although generalist physicians appear to be more likely than specialists to provide care for poor adult patients, they may still perceive financial and nonfinancial barriers to caring for these patients. We studied generalist physicians' attitudes toward caring for poor patients using focus groups and used the results to design a survey that tested the generalizability of the focus group findings. The focus groups included a total of 24 physicians in 4 California communities; the survey was administered to a random sample of 177 California general internists, family physicians, and general practitioners. The response rate was 70%. Of respondents, 77% accepted new patients with private insurance; 31% accepted new Medicaid patients, and 43% accepted new uninsured patients. Nonwhite physicians were more likely to care for uninsured and Medicaid patients than were white physicians. In addition to reimbursement, nonfinancial factors played an important role in physicians' decisions not to care for Medicaid or uninsured patients. The perception of an increased risk of being sued was cited by 57% of physicians as important in the decision not to care for Medicaid patients and by 49% for uninsured patients. Patient characteristics such as psychosocial problems, being ungrateful for care, and noncompliance were also important. Poor reimbursement was cited by 88% of physicians as an important reason not to care for Medicaid patients and by 77% for uninsured patients. Policy changes such as universal health insurance coverage and increasing the supply of generalist physicians may not adequately improve access to care unless accompanied by changes that address generalist physicians' financial and nonfinancial concerns about providing care for poor patients.

Adult↗

PubMed1995

No breathing room in the anesthesia turf battle.

Anesthesiologists and nurse anesthetists have always jostled each other for work, but managed care and policy changes have brought tensions to a boil. Is the anesthesia battle a harbinger of the future?

Anesthesia Department, Hospital↗

PubMedDate not supplied

Family nursing in community-oriented primary health care.

Renowned for its innovative approach to community health promotion and the key role of the nurse in treatment, prevention, teaching and research, the Philip and Sally Lown Hadassah Community Health Centre in Jerusalem is a model where the nurse is a member of a comprehensive multidisciplinary team that comprises family and paediatric physicians, epidemiologists, psychologist, statistician, social worker, health educator, health recorder, dietician and other public health specialists. As such, the nurse actively participates in the planning, implementation and evaluation of all new programmes, improvements and policy changes. Below, how the nurse works as a team member in the community centre.

Community Health Centers↗

PubMed1994

Morphine use and adverse effects in a neonatal intensive care unit.

Prescribing patterns and appropriateness of morphine use in a neonatal intensive care unit (NICU) were evaluated in a concurrent drug-use evaluation (DUE). Data were collected for 99 infants who received morphine over a six-month period. Patient charts were reviewed to collect the following data: patient's age, weight, dosage schedule, concurrent sedatives, ventilatory status, whether adequacy of analgesia was documented, and descriptions of adverse drug reactions (ADRs). The physicians' orders were reviewed to determine whether NICU morphine dosage guidelines were followed and whether the indication for use was noted. Seven ADRs occurred in six of the patients; three of the ADRs occurred after ophthalmic cryosurgery. Indications for use were noted in 79 of 285 physician orders (27.7%). The adequacy of sedation or analgesia was documented on 60 of the 360 patient days (16.7%). The DUE results prompted several changes: physicians were asked to select indications from a list in the computerized order-entry system, an analgesia or sedation assessment scale was added to nursing flow sheets, and endotracheal intubation became a requirement before ophthalmic cryosurgery. A follow-up DUE showed nearly complete compliance with the new guidelines for morphine use and a reduction in the number of adverse reactions to morphine. A DUE prompted policy changes that improved documentation of indications for and efficacy of morphine use and reduced adverse reactions to the drug in an NICU.

Analgesia↗

PubMed1994

The role of human rights and personal dignity in the rehabilitation of chronic psychiatric patients. A rural therapeutic community in Yanbian, Jilin.

In 1983 the branch hospital of the Yanbian Community Psychiatric Hospital, a rural residential centre for 120 chronic psychiatric patients who have no means of financial support, adopted a new treatment philosophy that emphasised psychosocial rehabilitation and made the protection of patients' human rights and respect for their personal dignity the central organising principles for the hospital's treatment programme. From being a boarding facility for chronic psychiatric patients, the hospital became a thriving community. Comparison of the status of the 81 continuously resident schizophrenic patients before and after the policy change showed that (a) the proportion who actively participated in agricultural labour increased from 10% in 1982 to 38% in 1990; (b) the proportion who worked at non-agricultural jobs increased from 7% in 1982 to 22% in 1990; and (c) their mean yearly income increased from 1.67 Rmb in 1982 to 246.70 Rmb in 1990. Moreover, the number of successful suicides among all the patients in the hospital dropped from 13 in 1975-1982 to 1 in 1983-1990. We conclude that the success of psychiatric rehabilitation programmes depends on the extent to which they address the core issues of personal dignity and basic human rights.

China↗

PubMedDate not supplied

The economic impact of AIDS: a challenge for nursing.

Estimates to determine the cost of financing AIDS care have been uncertain. Current policies governing private insurance as well as Medicaid/Medicare eligibility have created a number of barriers for people with AIDS (PWA). As the number of AIDS cases increase, nursing will play a crucial role in developing necessary policy changes to improve access to care, contain costs, and continue to provide much needed care to PWA.

Acquired Immunodeficiency Syndrome↗

PubMed1994

Using Medicaid claims data to evaluate a large physician fee increase.

OBJECTIVE: This study demonstrates the use of Medicaid claims data in order to evaluate a threefold fee increase in physician fees for deliveries ($265 to $795), which the Maryland Medicaid program implemented in 1986. DATA SOURCES AND STUDY SETTING: The study used Maryland Medicaid claims data for years of service 1985-1988, and was done at the Maryland Department of Health and Mental Hygiene with the help of a Robert Wood Johnson, Health Care Financing and Organization (HCFO) grant. STUDY DESIGN: Overall, our design is that of a pre-test, post-test with multiple observation points both before and after the fee increase. We measured participation in three ways, corresponding to three different units of analysis. With the county-quarter year as unit of analysis, we followed a panel of providers over 16 quarters for each county in the state to determine changes in the number of delivering providers. With the individual provider as the unit of analysis, we identified effects on their Medicaid caseload between years that may have been influenced by the fee increase. Finally, we looked at continuously enrolled Medicaid women who delivered to determine the effects of the fee increase on site and volume of prenatal care. DATA COLLECTION/EXTRACTION METHODS: Analytic files for each unit of analysis were compiled from previously extracted Medicaid claims files using standard statistical software packages. PRINCIPAL FINDINGS: Using techniques described, we were able to get an in-depth picture of overall responsiveness to the intervention. We found a moderate influence of the fee increase on overall participation, less than what we would have predicted. CONCLUSIONS: Administrative data can be used to construct efficient, yet sophisticated evaluations of major policy changes. Findings from our evaluation suggest a moderate effect of the fee increase on overall participation. However, raising fees to the level of private third party payers does not in itself guarantee equal access to private physician health care for Medicaid mothers.

Adolescent↗