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PubMed2003

Recruitment of rural health care providers: a regional recruiter strategy.

CONTEXT: Access to care in rural areas is a major problem. Despite more than 20% of the US population residing in these areas, only 9% of physicians practice there. Extensive research has documented multiple issues that affect where physicians decide to locate and maintain practices. Creative strategies have been used to influence these recruitment and retention decisions. An emerging strategy, borne out of the Robert Wood Johnson Foundation's Southern Rural Access Program (SRAP), effectively uses a targeted regional approach to assist rural communities and health care facilities in assessing health care needs and recruiting primary care providers. PURPOSE: This article examines the issues surrounding recruitment and retention of primary care providers to rural areas and describes the experiences of the regional recruitment strategy in several states and in particular in the Mississippi Delta region of Arkansas. METHODS: A case study approach is used to examine the targeted regional recruiter strategy in the Mississippi Delta region of Arkansas. FINDINGS: The regional recruiter strategy, which combines traditional recruitment efforts with community development activities, has been successful in recruiting health care providers to rural communities. The cost-effective strategy can be easily replicated in other rural states. CONCLUSIONS: Community factors affect provider decisions on practice locations. Addressing community factors in recruitment efforts through community development activities may increase their success.

Arkansas↗
PubMed2003

Suicidal ideation and suicide attempts in a sample of homeless people with mental illness.

This study utilized data from the national ACCESS program (N = 7224) to investigate the prevalence of suicidal ideation and suicide attempts in a sample of homeless people with mental illness. The prevalence of suicidal ideation in this sample was high (66.2% lifetime prevalence). In addition, 51.3% of the sample reported that they had ever attempted suicide, 26.9% reported an attempt that resulted in a nonpsychiatric hospitalization, and 8% reported an attempt in the previous 30 days. Youth, substance abuse, and psychiatric symptoms were all significantly associated with suicide attempts. Those who reported a recent attempt also reported higher rates of mental health care utilization, particularly inpatient care. The authors conclude that homeless people with mental illness are at particularly high risk for suicidal behavior, however, only in part because of the high prevalence of traditional risk factors.

Adolescent↗
PubMed2006

A participatory program evaluation of a systems change program to improve access to information technology by people with disabilities.

PURPOSE: To pilot-test and evaluate an innovative program providing information technology (IT) access to people with disabilities transitioning out of nursing homes into the community using a participatory approach. METHODS: Pre- and post-training data was collected on the 61 program participants to reflect three broad areas related to the IT training experience: performance; self-efficacy; importance, satisfaction and control. Additionally, semi-structured interviews were conducted with seven participants and five members of the program staff to explore environmental barriers to IT access for this group and the efficacy of the program in addressing these barriers. Data analyses followed a mixed methods approach incorporating both qualitative and quantitative techniques. RESULTS: Participants showed substantive changes in different spheres of IT use after completion of training. Post-training changes were significant particularly in areas related to self-efficacy, importance and satisfaction pertaining to use of IT. Qualitative findings substantiated the quantitative results and also revealed the numerous barriers to IT access that persons with disabilities continue to face within their communities. CONCLUSION: Results indicate the feasibility, effectiveness and value of IT access to people with disabilities particularly those transitioning from institutional life to community living. Further action research aimed at increasing IT access for this group within local communities and neighborhoods is needed to address this issue at a broader societal level.

Access to Information↗
PubMed2002

Outcomes and service use among homeless persons with serious mental illness and substance abuse.

OBJECTIVE: This study compared baseline characteristics and clinical improvement after 12 months among homeless persons with a diagnosis of serious mental illness with and without a comorbid substance use disorder. METHODS: The study subjects were 5,432 homeless persons with mental illness who were participating in the Center for Mental Health Services' Access to Community Care and Effective Services and Supports (ACCESS) program. Analysis of covariance was used to compare clients who had dual diagnoses and those who did not and to identify any association between service use and clinical improvement. RESULTS: Follow-up data were available for 4,415 clients (81 percent). At baseline, clients with dual diagnoses were worse off than those without dual diagnoses on most clinical and social adjustment measures. Clients with dual diagnoses also had poorer outcomes at follow-up on 15 (62 percent) of 24 outcome measures. However, among clients with dual diagnoses, those who reported extensive participation in substance abuse treatment showed clinical improvement comparable to or better than that of clients without dual diagnoses. On measures of alcohol problems, clients with dual diagnoses who had a high rate of participation in self-help groups had outcomes superior to those of other clients with dual diagnoses. Clients with dual diagnoses who received high levels of professional services also had superior outcomes in terms of social support and involvement in the criminal justice system. CONCLUSIONS: Homeless persons with dual diagnoses had poorer adjustment on most baseline measures and experienced significantly less clinical improvement than those without dual diagnoses. However, those with dual diagnoses who received extensive substance abuse treatment showed improvement similar to those without at 12 months.

Adult↗
PubMed2004

Pilot study of ER utilization at Tulsa hospitals.

CONTEXT: The Tulsa Community Access Program (TCAP) project has been developed to address the health care needs of the uninsured and underinsured population in the Tulsa MSA. One of the objectives is the development of a 24/7 Care Center. OBJECTIVE: To complete a pilot study on patient demographics and utilization patterns in the Emergency Room (ER) to determine if a 24/7 clinic is needed or would be used as an alternative site for treatment. DESIGN: A survey was randomly administered to ER clients from March 2003 to April 2003 and included 45 open-ended, closed-ended, and Likert scale questions. Acuity level of care was verified by a hospital professional. SETTING: Hillcrest Medical Center, Tulsa, provides a significant amount of indigent care; four time periods were picked for peak and varied ER usage. PARTICIPANTS: 200 ER clients, 50 per time period; survey administration and data analysis were done by University of Oklahoma-Tulsa graduate students. MAIN OUTCOME MEASURE(S): Prior assumptions: uninsured/underinsured use the ER for primary care; demographics of the ER client are low income/unemployed, low education; majority of ER clients are non-urgent/non-emergency and would use a 24/7 clinic. RESULTS: 56% have used ER 1-2 times in past year; 89% of cases were non-urgent/non-emergency; 46% graduated high school; 48% work full-time; 42% have family income 15,000 dollars or less; 76.5% favor an after hours primary care clinic. CONCLUSIONS: This survey is an important tool to determine the needs and patterns of ER utilization; there is a need for a 24/7 clinic and it would be used by the target population.

Adult↗
PubMed2001

Time-limited assertive community treatment for homeless persons with severe mental illness.

BACKGROUND: The assertive community treatment (ACT) model for people with severe mental illness was originally designed to be provided continuously without termination. This study evaluated postdischarge changes in health status and service use associated with the time-limited provision of ACT to homeless people with severe mental illness. METHODS: Clients in the fourth annual cohort of the Access to Community Care and Effective Services and Supports (ACCESS) program (N = 1617) were assessed at entry into ACT and 3, 12, and 18 months later. Random effects models were used to compare outcomes and service use among clients who terminated ACT and clients who remained in ACT, controlling for potentially confounding factors. RESULTS: Altogether, of clients who participated in follow-up, 8.7% participated for less than 3 months; 40.6%, for 3 to 10 months; 15.3%, for 11-13 months; and 35.3%, for 14 months or more. Controlling for potentially confounding factors, mental health, substance abuse, and housing outcomes did not significantly differ between clients who had been discharged at the time of follow-up as compared with those who had not. Those who had been discharged had worked significantly more days than those who had not (t(1794) = 3.24, P<.001), and they reported significantly less outpatient health service use though there was no decline in hospital days or receipt of public support payments. CONCLUSION: Homeless clients who have severe mental illness can be selectively discharged or transferred from ACT to other services without subsequent loss of gains in mental health status, substance abuse, housing, or employment.

Adult↗
PubMed2006

Recombinant therapeutics: from bench to bedside (if your health plan concurs).

A talented medical student at our institution was recently diagnosed with multiple sclerosis (MS). beta interferon was prescribed; however, her annual cap from student health insurance coverage for outpatient drug expenses is only Dollars 3000, a sum that would be exceeded within 3 months and leave her without coverage for symptomatic medications also required for her care. Unable to pay for the treatment from personal resources, she qualified to receive beta interferon without cost from a universal access program established by the manufacturer. Unfortunately, it was evident within a few months that she had a poor therapeutic response, so her physician prescribed natalizumab. Her health care plan requires that infusion therapy be given at the hospital's infusion center, yet for various reasons, the drug was not yet approved by the formulary. She remains unable to receive the drug.

Antibodies, Monoclonal↗
PubMedDate not supplied

Socio-biological factors in underfive deaths in a rural area.

In 1985-86, 286 underfive deaths occurred among a population of 30,000 in a rural area of Haryana. Two hundred and eighty one were analysed for socio-biological factors related to under five mortality. Females had a higher mortality. About 2/3 of the deaths were in infants, and 90% in first 3 years. Most of the deaths (94%) occurred in the village itself, 58.4% did not seek any medical care during the terminal illness, 80-90% did not receive even a single dose of BCG, DPT or O.P.V., and 36.7% died in the first attack of illness. Though 68% had at least one episode earlier, 31.0% had been admitted in hospitals for an earlier episode of illness. In 42.8% of deaths, the birth order was IV or above. Deaths in socially and economically disadvantaged cases constituted 77.6%. The triad of diarrhea, ARI and malnutrition claimed 56% deaths. In 93% of the deaths, the mothers were illiterate and 96.4% were house wives. There was a sibling death earlier in the family in 78.3%, and 60.1% deaths were of those living in poor housing conditions. About 50% had radio for communication, 85.8% had bicycle for conveyance, and in 66.9% the family had piped water supply. All these findings have been discussed in the study.

Age Factors↗
PubMed1997

The Riluzole Early Access Programme: descriptive analysis of 844 patients in France. ALS/Riluzole Study Group III.

Recent controlled trials in outpatients with amyotrophic lateral sclerosis (ALS) indicate that riluzole prolongs tracheostomy-free survival. After 12 months' treatment, riluzole 50 mg, 100 mg and 200 mg daily reduced the risk of death or tracheostomy (relative to placebo) by 24%, 34% and 31%, respectively (by 28%, 43% and 43%, respectively, after adjustment for known prognostic factors). This survival advantage (6-9 patients require treatment with riluzole to avoid 1 death/tracheostomy annually) compares favourably with that achieved therapeutically in breast cancer and coronary artery disease. Some 6000 ALS patients are currently receiving riluzole 50 mg twice daily within the Riluzole Early Access Program. In France, this programme is being implemented as an open-label multicentre trial to assess patients' functional status and quality of life. To date, 844 patients have been enrolled, and they will be followed up for 12 months on riluzole. Baseline demographic and clinical characteristics of this study population are presented here.

Aged↗
PubMed2003

Suicidal ideation and suicide attempts in homeless mentally ill persons: age-specific risks of substance abuse.

BACKGROUND: Despite reports of high rates of suicidal behavior among mentally ill homeless persons, it remains unknown whether the well-established suicide risks of increased age and comorbid psychiatric and substance abuse disorders ("dual diagnosis") documented in the general population are also markers for increased suicide risk among homeless persons. METHODS: Data from a multi-site outreach program (ACCESS) (N = 7,224) were used to investigate whether rates of serious suicidal ideation and recent suicide attempts varied with the age and substance abuse diagnosis(es) (drug abuse and/or alcohol abuse disorders) among homeless mentally ill clients. RESULTS: The prevalence of 30-day suicidal ideation and suicide attempts (37.5 % and 7.9 %, respectively) was extremely high. Although the risk of serious suicidal ideation and suicide attempts was greater among the younger compared with the older homeless mentally ill clients, risks were not significantly increased by co-morbid alcohol and/or drug abuse. However, a significant interaction between age and co-morbid substance abuse was observed showing that among older clients but not younger clients, those with drug and alcohol abuse were at significantly greater risk of suicidal ideation than those without substance use problems, controlling for confounding factors. CONCLUSION: Efforts to prevent suicide should recognize that among homeless people with mental illness, young-middle-aged (30- to 39-year-old) clients are at greatest risk of suicidal behavior. Among older clients the presence of both drug and alcohol abuse significantly increases suicide risk. These patterns are of special importance because they are quite different from those that are well documented in non-homeless populations.

Adolescent↗
PubMed2005

Steady-state pharmacokinetics of atazanavir given alone or in combination with saquinavir hard-gel capsules or amprenavir in HIV-1-infected patients.

OBJECTIVE: The aim of this pilot study was to examine the pharmacokinetics of atazanavir (ATV) when given in combination with amprenavir (APV) or saquinavir hard-gel capsules (SQV) to human immunodeficiency virus (HIV)-positive patients. METHODS: Included in the study were 34 HIV-infected patients enrolled in the ATV Early Access Program, who were treated with unboosted ATV alone (group 1) or with the double protease inhibitor combinations, ATV plus APV (group 2) or ATV plus SQV (group 3). ATV was given at a daily dose of 400 mg q.d. with the morning meal with SQV 1200 mg per day or APV 1200 mg per day. Serial blood samples for steady-state ATV pharmacokinetics were collected before the morning dose and at 1, 2, 3, 6, 8 and 24 h post-dosing. ATV plasma concentrations were measured using a high-performance liquid chromatography method with ultraviolet detection. RESULTS: Of the patients, 12 received ATV as a single protease inhibitor; 12 received ATV in combination with APV; and 10 in combination with SQV. Geometric mean (coefficient of variation) ATV C(trough) was 110 ng/ml (2.38), 86 ng/ml (0.84) and 149 ng/ml (2.01) in groups 1, 2 and 3, respectively. ATV C(trough) in both double protease inhibitor combination regimens was not significantly different from that as a single protease inhibitor [geometric mean ratio (GMR): 0.77; 95% confidence interval (CI): 0.38-1.58, P=not significant for group 2 versus group 1 and 1.34, 0.40-4.49, P=not significant, for group 3 versus group 1). Patients treated with ATV plus APV had a 40.2% lower ATV C(max) and a 30.8% smaller ATV AUC than the reference group treated with unboosted ATV alone: both these differences were statistically significant (GMR, 95% CI: 0.59, 0.41-0.85, P=0.005 and 0.69, 0.48-0.99, P=0.056, respectively). No difference was observed for either C(max) or AUC between the group treated with ATV plus SQV and the reference group (GMR, 95% CI: 0.78, 0.47-1.30, P=not significant and 1.24, 0.73-2.10, P=not significant, respectively). CONCLUSION: ATV pharmacokinetics does not seem to be influenced by the concomitant administration of SQV, whereas APV significantly lowers plasma ATV levels.

Adult↗
PubMed2006

Assessing delayed effects of a multi-site system intervention for homeless persons with serious mental illness.

ACCESS demonstration sites were followed for an additional two years beyond the scheduled four-year evaluation to assess whether any delayed effects had occurred in system and project integration. For system integration, findings indicate that there was a sharp increase between Wave 3 (1998) and Wave 4 (2000), but experimental and comparison sites had identical trends. For project integration, experimental sites at Wave 4 sustained the high level of integration achieved at Wave 3, but the comparison sites achieved the same level as the experimental sites at Wave 4, through an abrupt increase in their scores. The absence of delayed effects is likely due to diffusion of the interventions to comparison sites both in the latter stages of the demonstration and immediately afterwards. Further, aggressive lobbying on the part of ACCESS program managers to generate local and state support to sustain their services following the termination of federal funding, had an integrating effect thereby creating linkages among comparison site agencies. Implications of these findings for policy and further research are highlighted.

Efficiency, Organizational↗
PubMed2005

Gefitinib therapy for non-small cell lung cancer.

Gefitinib is a small molecule that specifically inhibits the tyrosine kinase activity of the epidermal growth factor receptor (EGFR) type 1 by interfering with the adenosine triphosphate (ATP) binding site. At doses that maximally inhibit EGFR tyrosine kinase activity chosen for phase II trials, the most common side effects of gefitinib are low-grade rash or diarrhea. An infrequent but serious side effect of gefitinib is interstitial lung disease (ILD). The Iressa dose evaluation for advanced lung cancer phase II trials (IDEAL 1 and IDEAL 2) of single agent gefitinib, 250 or 500 mg orally per day in pretreated patients with non-small cell lung cancer (NSCLC), found about 20% of patients on IDEAL-1 and 10% of patients on IDEAL-2 had major objective responses and improvement of symptoms. The data from the IDEAL trials and the extensive experience from the 21,000 patients treated on the expanded access program, suggests that the patients who have a major objective response probably have a significant survival benefit in addition to palliative benefit. In addition, approximately 40% of patients on the IDEAL trials experienced improvement in symptoms. Gefitinib was approved for third line treatment of NSCLC. Gefitinib is effective, safe, and well-tolerated single-agent therapy in previously treated NSCLC. Although there have been no direct comparisons, the small molecule inhibitors of EGFR gefitinib and erlotinib appear to have similar efficacy. Erlotinib has been shown to produce a survival advantage compared to best supportive care in an unselected group of previously treated patients with NSCLC. Until similar trials are completed comparing gefitinib to best supportive care, there is a similar survival advantage for gefitinib. Nonsmokers, women, and patients with adenocarcinoma, are more likely to have major objective responses than other patients. Bronchioalveolar lung cancer is a subtype of NSCLC that is more likely to respond to gefitinib. Several groups have now reported that most, but not all, tumors experiencing a major objective response to gefitinib have mutations associated with the ATP-binding site of EGFR. It is reasonable to move gefitinib in to second-line therapy for patients who are known to have a tumor that is more likely to respond to gefitinib. Also, I would treat such patients with gefitinib as first-line therapy on an appropriate clinical trial approved by the Institutional Review Board (IRB). Outside of a clinical trial, patients with advanced disease should initially be treated with a combination of doublet chemotherapy. There is strong evidence that there is no benefit to concurrent chemotherapy and gefitinib. Gefitinib should not be given concurrently with cytotoxic chemotherapy as initial treatment for NSCLC. Sequential therapy combining chemotherapy and gefitinib in advanced disease or as adjuvant therapy should only be done in the context of a clinical trial approved by the IRB. There is preclinical evidence suggesting that gefitinib is a radiosensitizer. Early results from trials combining radiation, or chemoradiotherapy with gefitinib have shown that these combinations are without excessive additive toxicity. There is no proven clinical benefit for concurrent Gefitinib and radiation. Gefitinib should only be given with radiation as part of an appropriate clinical trial approved by the IRB.

Antineoplastic Agents↗
PubMed1976

A DATA MANAGER for the health information system Berlin.

The needs for permanently changing the logical and physical structure of a medical datebase during the development of a health information system have initiated the project of implementing a DATA MANAGER. The concept of the DATA MANAGER covers facilities for the development of the logical data structure model including documentation of the model and programming support for application programs accessing the health information system (HIS) database. The outstanding facilities of the INTERLISP system have been found to be appropriate for writing the DATA MANAGER. A first data structure model, on which the DATA MANAGER will operate, is roughly outlined.

Berlin↗
PubMed1990

Characteristics of condom use and associated problems: experience in Bangladesh.

Data from the 1983 Bangladesh Condom User Survey (BCUS) are analyzed for patterns of condom use and various problems directly influencing their effectiveness. The survey was undertaken to explain an apparent gap between reports of the number of condoms distributed in certain areas compared with prevalence of users as reported in contraceptive prevalence surveys. These data are analyzed from behavioral and management perspectives to identify various factors influencing utilization, with potential implications for understanding and improving family planning and AIDS/STD prevention service systems. Patterns of use are related to differences in source of supply through public, free or private-priced systems, differences in urban or semi-rural place of residence, and differences in perceptions of men or women. The problem with condom use most often identified by the respondents was breakage.

Adult↗
PubMed1995

Decision support in healthcare.

To address the recognized problems associated with information overload and limited human memory, computer-based systems which help healthcare providers use information to make better decisions have been developed and implemented. These decision aids are designed to improve the quality and reduce the cost of healthcare. Currently, the most widely used computer application is to simply provide needed facts about the patient in an organized and timely fashion. Additionally, healthcare workers can access literature, ask questions of aggregates of patient data for clinical or administrative decisions, receive warnings or suggestions when the patient's data satisfy certain logical rules receive critiques when proposing therapies or ordering diagnostic tests, receive guidelines for standards of care, access programs which analyze tradeoffs and likelihoods of alternative outcomes (decision analysis) and receive lists of differential diagnoses. Given this wonderful panoply of capabilities, the question becomes 'why aren't more people using these aids and what are the demonstrated benefits of such capabilities?' In this paper we review the types of decision aids which have been successfully implemented and the challenges to implementation (knowledge representation, connections to databases, need for comprehensive, coded databases and evaluation of benefits).

Decision Making, Computer-Assisted↗