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A framework and case study for exposure assessment in the Voluntary Children's Chemical Evaluation Program.

A conceptual framework is presented for conducting exposure assessments under the U.S. EPA's Voluntary Children's Chemical Evaluation Program (VCCEP). The VCCEP is a voluntary program whereby companies that manufacture chemicals of potential concern are asked to conduct hazard, exposure, and risk assessments for the chemicals. The VCCEP is unique in its risk-based, tiered approach, and because it focuses on children and requires a comprehensive consideration of all reasonably foreseeable exposure pathways for a particular chemical. The consideration of all potential exposure pathways for some commonly used chemicals presents a daunting challenge for the exposure assessor. This article presents a framework for managing this complicated process, and illustrates the application of the framework with a hypothetical case study. The framework provides guidance for interpreting multiple sources of exposure information and developing a plausible list of exposure pathways for a chemical. Furthermore, the framework provides a means to process all the available information to eliminate pathways of negligible concern from consideration. Finally, the framework provides guidance for utilizing the tiered approach of VCCEP to efficiently conduct an assessment by first using simple, screening-level approaches and then, if necessary, using more complex, refined exposure assessment methods. The case study provides an illustration of the major concepts.

Adolescent↗

The challenges of educational program evaluation.

The demand for fiscal restraint and accountability has forced health care facilities to carefully evaluate the benefits of new programs. Some time ago, the Long Term Care Nursing Department of Sunnybrook Health Science Centre in Toronto, Ontario, collaborated with Centennial College to provide a Gerontology Certificate Program to registered nurses. While originally conceived as a retention and recruitment strategy, it became obvious that such a program could and should have additional benefits to staff and long term care residents alike. This article describes the changes as indicated by three scales, and the benefits described by the registered nurses. It also illustrates, rather humorously, that even the more educated and experienced among us can make mistakes and learn from them!

Aged↗

Gynecologic evaluation of the first female soldiers enrolled in the Gulf War Comprehensive Clinical Evaluation Program at Tripler Army Medical Center.

Tripler Army Medical Center initiated the Department of Defense's Persian Gulf Illness Comprehensive Clinical Evaluation Program (CCEP) on June 15, 1994. In the first 5 months, 100 patients enrolled in this program. Sixteen (16%) were women who served in the Persian Gulf during Desert Shield/ Desert Storm, and 1 (1%) was the dependent wife of a Gulf War veteran who is experiencing illness that may be related to the Persian Gulf War. All 17 women enrolled in the CCEP were evaluated in the Tripler Army Medical Center Obstetrics and Gynecology Clinic between June 17 and November 10, 1994. Each patient underwent gynecologic history, pelvic exam, Pap smear, and screen for fecal occult blood. Ten patients underwent baseline mammograms and 13 patients underwent urogenital and cervical cultures for aerobic bacteria, chlamydia and herpes simplex. The 1 patient with an abnormal Pap smear underwent cervical and endocervical biopsies and colposcopy (histology demonstrated no dysplasia or neoplasia). Half of the 16 Gulf War veterans experienced gynecologic problems while serving in the Gulf and 43% admitted gynecologic problems since returning in 1991. Of 6 patients who became pregnant after returning, 5 had normal pregnancies and 1 suffered four miscarriages.

Adult↗

Brief child assessment battery to assist with treatment planning and program evaluation.

A brief battery of self-report measures was constructed to discriminate effectively 45 matched clinic versus nonclinic subjects, ages 8 to 15. The battery consisted of measures from six domains, including externalizing problems, child and parent report of internalizing problems, peer relations, school functioning, and family relationships. Data on subjects and their families were provided by various sources, including parents, teachers, and the children. In an effort to facilitate interpretation and use of this information by unsophisticated staff, within domain scores were converted to bivariate risk scores. Results indicated effective classification (82%) of groups using the bivariate risk scores alone. This constituted only a small loss of information when the risk scores replaced t-scores. Implications for the use of the risk scores to facilitate treatment planning and program evaluation are discussed.

Adolescent↗

[Curriculum evaluation program of the University of São Paulo Medical School--results for 1993 and a 5-year analysis].

The following report contains the results of the "Curricular Evaluation Program" of University of São Paulo Medical School pertaining to the year of 1993 and to the five-year period between 1989 and 1993. This evaluation of all undergraduate courses was made by students, responding to questionnaires supplied at the end of each program. In 1993, 60.6% of programs were considered as very good programs. In relation to 1989-1993 period, are presented the results of a disciplines group of the 4th year and a internship stages of the 5th year.

Brazil↗

Policy-relevant program evaluation in a national substance abuse treatment system.

This article discusses recent trends in public and private substance abuse services and offers suggestions on how the evaluation of such services can inform clinical practice and policy making. This analysis focuses particularly on the Department of Veterans Affairs (VA), which operates the largest substance abuse treatment system in the United States. In recent years, there has been an erosion of services for substance abuse outside the VA. In contrast, due to increased funding from the U.S. Congress, the VA significantly expanded substance abuse treatment from 1990 to 1994. However, efforts to "reinvent" and downsize government initiated a reversal of this growth trend in 1994, and VA services may shrink further as the system becomes more decentralized and adopts managed care strategies from the private sector. Drawing from the VA Program Evaluation and Resource Center's (PERC) experience of evaluating the VA system and working with federal policy makers, this article presents examples and suggestions for making evaluations of substance abuse treatment systems more useful in policy discussions and in day-to-day clinical practice.

Forecasting↗

The Medical Education Evaluation Program of the state of Ohio.

In October 1988, seven foreign medical graduates participated in the first administration of the examination devised by the Medical Education Evaluation Program (MEEP) mandated by the State Medical Board of Ohio. The MEEP was established to provide an objective evaluation of an applicant's clinical competencies; passing the MEEP examination was intended to certify that the applicant's clinical skills were comparable to those of a medical student graduating from a school accredited by the Liaison Committee on Medical Education. An applicant who successfully passed the MEEP examination and fulfilled the other Ohio licensure requirements would be eligible to take the Federation Licensing Examination (FLEX) and apply for an unrestricted license to practice medicine in Ohio. The paper describes the origin and development of the MEEP examination and the testing modalities selected (multiple-choice examinations and the use of standardized patients). Four fundamental areas were tested; these are named and described, along with the method for calculating scores for each area and the criteria for passing the different components of the examination. Although the small sample size prohibited meaningful data analysis for the performance of the first group of MEEP candidates, the MEEP examination appears to meet psychometric standards of certifying and licensing examinations, based on data from comparable tests taken by beginning fourth-year medical students in New England and NBME Part III examination examinees. Some potential pitfalls of the MEEP examination are mentioned, as well as the fact that it presents a challenge to boards of medical examiners of other states to implement performance-based assessments of physicians who graduate from non-accredited medical schools.

Clinical Competence↗

Plasma glucose levels: long-term effect of diet in the Chicago Coronary Prevention Evaluation Program.

In 150 middle-aged men prone to coronary disease, long-term data based on the Chicago Coronary Prevention Evaluation Program's diet showed that there was a favorable effect on fasting glycemia level and glucose tolerance. This diet for reducing obesity and hypercholesterolemia was low in cholesterol and saturated fat and moderate in polyunsaturated and total fat, with replacement of some fat by carbohydrate. At 2 years, decreased weight and serum cholesterol values of normoglycemic men were accompanied by a modest but significant fall in fasting and postload glycemia; at 4 years. fasting glycemia levels remained slightly below baseline. For men with suspect fasting hyperglycemia at baseline, sustained fall in weight and serum cholesterol value was associated with sizeable long-term reductions in fasting glycemia and improvement of glucose tolerance. Decrease in plasma glucose was significantly related to decrease in weight. No evidence of impairment of glucose tolerance with years-long consumption of this diet was recorded.

Blood Glucose↗

Family medicine residency programs. Evaluating the need for different third-year programs.

We asked hospital chief executive officers (CEOs) and District Health Council executive directors (DHCs) to compare third-year family medicine residency programs and judge which are more needed in their communities. Care for the elderly and emergency medicine ranked highest among CEOs, while DHCs ranked care for the elderly and mental health highest. Academic family medicine and northern programs ranked lowest for both groups.

Attitude of Health Personnel↗

Program evaluation in a rural community mental health center.

Can a rural community mental health center with limited resources meet the federal guidelines for program evaluation? This case example shows that a rural center can comply with the guidelines through evaluation activities tailored to its special needs and small size.

Colorado↗

Centers for Disease Control performance evaluation program in bacteriology: 1980 to 1985 review.

This report presents a summary and analysis of data from the Centers for Disease Control performance evaluation program in bacteriology for the 6-year period 1980 to 1985. During this period, the number of laboratories enrolled in the program ranged from about 750 to 1,000. Identification results reported by participating laboratories for representative species of six major groups of bacteria were placed into five response categories that were based on the level and accuracy of the identifications. Data on the performance of participants with bacterial groups and performance with selected species within each major group were analyzed. Overall, participants experienced the least difficulty in identifying species or serogroups of members of the gram-positive and gram-negative cocci. Participants encountered greater difficulties with anaerobes, gram-positive bacilli, and miscellaneous gram-negative bacteria. Identification of members of the family Enterobacteriaceae was of moderate difficulty. Problems in identifying certain bacterial species were probably related to a number of factors such as the characteristics of the species, its frequency of occurrence, the state of technology available for identification, and the state of proficiency and quality control in individual laboratories at the time of testing. Examples are given of improvements over time in the identification of certain bacterial species. Laboratories participating in an external proficiency testing program should take full advantage of the benefits of participation by instituting measures to correct testing deficiencies identified by the program.

Bacteria↗

Rehabilitation program evaluation using a revised level of rehabilitation scale (LORS-II).

The Level of Rehabilitation Scale (LORS) was prepared to aid in meeting program evaluation needs of rehabilitation facilities. Advantages of the original LORS-I, including economy of administration, behaviorally defined levels of function, multiple points of view, and concise presentation of findings were retained. Normative information concerning improvement levels for the activities of daily living subscale was developed for cerebrovascular accident inpatients. Data showed that expected improvement varies according to functional level at admission and patient age.

Activities of Daily Living↗

Economic aspects of clinical decision making: evaluating clinical programs.

The importance of program evaluation is discussed, and issues to consider when designing and conducting program evaluations in the restructuring health-care environment are identified. Program evaluation is carried out for the purpose of supporting specific decisions for individual organizations. Unlike scientific research, program evaluation accepts time as a constraint, and its audience is composed of managers. Considering the likelihood of being fixed-dollar contractors or employees in an era of managed care, professionals must try to understand the cost objectives of management; similarly, managers must understand the patient-care objectives of professionals. Program evaluation can help provide the necessary documentation of a program's impact on the outcome of health care, which influences the total cost of care. Successful program evaluation requires careful planning, and issues related to six steps in the planning process are described: defining the objective of the evaluation, choosing and defining the program to be evaluated, choosing indicator variables, designing the evaluation, presenting the results, and planning follow-through. While program evaluation is too often understood in negative terms, particularly as something done because of external pressure, it is as much a part of management as is directing day-to-day operations or developing a long-range plan.

Decision Making↗

[Evaluating programs for preparation to old age: some theoretical thoughts and a practical example (author's transl)].

In the first part methodically satisfactory experimental designs for evaluating programs for preparation to old age on the basis of Cambell & Stanely (1963) are sketched including conditions which hinder the realization of the ideal notions. In the second part an experiment for comparing two preparatory courses to old age using different methods of instruction is described. It was observed that the more demanding teaching method resulted in more anxiety for old age. This led to the conclusion, that programs for preparation to old age should be planned as a sequence of several units in which the mastering of the new ideas may be learned and in which this learning process may be supervised.

Age Factors↗

Program evaluation in rehabilitation.

Increased accountability and more encompassing accreditation standards have heightened interest in the role that evaluation research plays in improving the quality of life and independence for people with disabilities. The field of Program Evaluation is a valuable resource for conducting studies that meet the standards and information needs in the field of rehabilitation. This article describes the nature of evaluation research and illustrates its contribution to contemporary rehabilitation practice.

Journal Article↗

Comprehensive drug-use evaluation program in a health maintenance organization.

Development and use of a drug-use evaluation (DUE) program for hospital and outpatient facilities of a health-maintenance organization (HMO) are described. A full-time pharmacist coordinates the DUE program. Primary components of the DUE program are (1) establishment and use of drug therapy management protocols, (2) periodic review and evaluation of drug-use statistics by the pharmacy and therapeutics (P&T) committee, (3) monitoring of pharmacist interventions, and (4) evaluation of specific drug use within individual medical staff departments. Information from all DUE activities is channeled through the P&T committee and linked to the HMO's overall quality assurance program. The DUE program has the support of the HMO physicians. It has enhanced the quality of drug use and identified opportunities to further improve the quality of patient care. In surveys by the Joint Commission on Accreditation of Healthcare Organizations, the HMO facilities have received no recommendations. Pharmacists and physicians have cooperated to develop a comprehensive DUE program for an HMO.

California↗