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PubMedDate not supplied

The art and science of the psychopharmacotherapy of African Americans.

Recent research and clinical experience has shown that African Americans may be at greater risk for inappropriate treatment. Such experiences can interact negatively with an existing distrust of the mental health system. Providers may show different prescribing patterns with racial and ethnic minorities: they may overuse antipsychotics, dispense higher dosages, and more commonly give involuntary treatment, which results in more side effects and a poorer outcome. Conversely, they may underuse other psychotropic medications, especially for anxiety and affective disorders, which are underdiagnosed in minorities. Recent research suggests that ethnic differences may exist in pharmacokinetics, and so different dosing strategies may be necessary. Not surprisingly African Americans in distress are more likely to seek initial treatment outside of the mental health system, seek treatment later in the course of the illness, complain more about side effects, and terminate treatment earlier. Cultural as well as socioeconomic factors must be considered. Newer pharmacological agents may be potentially more helpful for minorities because they are better tolerated, have better side effect profiles, and demonstrate better efficacy. However, African Americans have limited access to these agents. Education of providers and patients, policy changes in the public sector, wider implementation of research policies concerning inclusion of minorities, and different marketing strategies by pharmaceutical concerns are probably necessary to maximize pharmacotherapy of minorities.

Black or African American↗

PubMed1996

Media advocacy: lessons from community experiences.

Media advocacy is the strategic use of mass media and community organizing as a resource for advancing a social or public policy initiative. Across the United States, communities are using media advocacy to promote healthier public policies and environments. The U.S. Center for Substance Abuse Prevention commissioned numerous case studies of media advocacy on alcohol and tobacco issues in a diverse array of communities, including efforts in African-American and Latino communities or using computer-based electronic communication systems. The paper describes these efforts briefly, and summarizes lessons learned, including: media advocacy can lead to larger victories when used as a complement to community organizing in the context of a larger strategic vision for policy change; like policy advocacy, media advocacy is best done in the context of clear long-term goals; conscious framing, guiding the choice of spokespeople, visuals, and messages, can alter media coverage and public debate of health policies; advocates need to respect the media but also remember that they have power in relation to the media; and media advocacy is often controversial and not suited to every situation. The case studies show that media advocacy is a potent tool for public health workers, making an important contribution to campaigns to promote healthier public policies.

Alcoholism↗

PubMed1996

Homing in on the homeless: assessing the physical health of homeless adults in Los Angeles County using an original method to obtain physical examination data in a survey.

OBJECTIVE: Public policy that decreases the finding for social services may combine with the ascendancy of corporate managed care to increase the health care deficit. Assessing the health impact of these policy changes on various populations is a fundamental challenge for health services research. Disadvantaged populations, such as the homeless, are likely to be affected disproportionately. Research quality data on the physical health of such populations are difficult and expensive to obtain. In particular, physical examination data have not been available and self-reports are insufficient. Our objective: to develop and utilize a structured physical exam system enabling lay survey researchers to report reliably physical findings related to six tracer conditions in a disadvantaged population. STUDY SETTING: A field survey of homeless adults in Los Angeles County, California. Respondents were 363 homeless adults representing a subsample of a probability sample of the county's homeless adult population. STUDY DESIGN: We integrated existing measures with expert clinical opinion and original means of data collection into a structured physical exam enabling lay interviewers to identify the prevalence of vision problems, significant skin disorders, peripheral vascular disease of the lower extremities, selected podiatric disorders, hypertension, and tuberculosis in a sample of homeless adults. PRINCIPAL MEASURES: We describe lay interviewer performance in terms of mastery of the necessary material based on written and practical exams and in terms of the number of respondents successfully followed. We base our description of the instrument on the time necessary to complete it, and on the proportion of each component successfully completed during the field survey, as well as on interrater reliability. We report the prevalence of the various clinical conditions according to self-report and according to the structured limited physical exam, as well as the marginal proportion of respondents who were identified by the physical exam and not by self-report. PRINCIPAL FINDINGS: Interviewers performed the exam successfully under field conditions. Respondent acceptance of the instrument was high. Interrater agreement was 100 percent regarding the need for referral on the basis of blood pressure and vision. Kappa statistics for skin, foot, and edema findings were .67,.71, and .81, respectively. Adjusted for sampling weights, 60 percent of this population required referral for at least one of the specified conditions. For those portions of the survey for which both self-report and physical exam data were available, lay interviewers made significant percentages of referrals on the basis of physical findings alone. CONCLUSIONS: High blood pressure, poor vision, peripheral vascular diseases of the feet and legs, and significant skin conditions are prevalent among the homeless in Los Angeles County. Without physical exam data, estimates of the prevalence of these conditions will be incorrect. Researchers can use laypersons to collect reliable and valid physical exam data on disadvantaged populations. This represents a new tool for assessing and monitoring the health of these populations.

Adult↗

PubMed1996

A critique of an evaluation of the impact of hospital bed closures in Winnipeg, Canada: lessons to be learned from evaluation research methods.

In the last few years, the continuing increases in health care expenditures have led to a call for greater accountability in health care and have spurred evaluative research into the area of health care policy. Yet the challenge has been to develop health care policy evaluations that maximize the rigor of the evaluation process within the constraints and limitations of evaluation milieus. This paper describes the principles of evaluation research and, using the example of a study evaluating the impact of hospital bed closures on community health status in Winnipeg, Canada, demonstrates the epistemological, methodological and interpretive problems that can occur when these principles are not followed. The conclusions are that studies which fail to outline the causal links between policy actions and outcomes, and use designs and methods which threaten internal and external validity, are limited in their abilities to elucidate the impact of health care policy changes.

Health Expenditures↗

PubMed1997

Where do elderly veterans obtain care for acute myocardial infarction: Department of Veterans Affairs or Medicare?

OBJECTIVE: To examine Department of Veterans Affairs (VA) and Medicare hospitalizations for elderly veterans with acute myocardial infarction (AMI), their use of cardiac procedures in both systems, and patient mortality. DATA SOURCES: Merging of inpatient discharge abstracts obtained from VA Patient Treatment Files (PTF) and Medicare MedPAR Part A files. STUDY DESIGN: A retrospective cohort study of male veterans 65 years or older who were prior users of the VA medical system (veteran-users) and who were initially admitted to a VA or Medicare hospital with a primary diagnosis of AMI at some time from January 1, 1988 through December 31, 1990 (N = 25,312). We examined the use of cardiac catheterization, coronary bypass surgery, and percutaneous transluminal coronary angioplasty in the 90 days after initial admission for AMI in both VA and Medicare systems, and survival at 30 days, 90 days, and one year. Other key measures included patient age, race, marital status, comorbidities, cardiac complications, prior utilization, and the availability of cardiac technology at the admitting hospital. PRINCIPAL FINDINGS: More than half of veteran-users (54 percent) were initially hospitalized in a Medicare hospital when they suffered an AMI. These Medicare index patients were more likely to receive cardiac catheterization (OR 1.24, 95% C.I. 1.17-1.32), coronary bypass surgery (OR 2.01, 95% C.I. 1.83-2.20), and percutaneous transluminal coronary angioplasty (OR 2.56, 95% C.I. 2.30-2.85) than VA index patients. Small proportions of patients crossed over between systems of care for catheterization procedures (VA to Medicare = 3.3%, and Medicare to VA = 5.1%). Many VA index patients crossed over to Medicare hospitals to obtain bypass surgery (27.6 percent) or coronary angioplasty (12.1 percent). Mortality was not significantly different between veteran-users who were initially admitted to VA versus Medicare hospitals. CONCLUSIONS: Dual-system utilization highlights the need to look at both systems of care when evaluating access, costs, and quality either in VA or in Medicare systems. Policy changes that affect access to and utilization of one system may lead to unpredictable results in the other.

Aged↗

PubMed1997

Attitudes about AIDS education and condom availability among parents of high school students in New York City: a focus group approach.

This paper describes parents' views of the New York City Public High School's AIDS Education and Condom Availability Program. It presents findings from 12 focus groups with 81 parents of students at six representative high schools. Focus groups were conducted as part of an independent, comprehensive 3-year evaluation of the program, consisting of both qualitative and quantitative components. Participants were mostly supportive of the program, citing intense concern about AIDS among adolescents, fear that teenagers do not adequately perceive themselves as being vulnerable, and personal experiences with infected relatives and friends. Implications of these findings for program development are discussed and recommendations for social policy changes are presented.

Acquired Immunodeficiency Syndrome↗

PubMed1997

Turning job finders into job keepers.

Most welfare-to-work programs designed to help single mothers leave welfare for employment focus on the challenge of finding a job. This article looks beyond the point of employment to consider the difficulty many former welfare recipients have keeping their jobs. The authors review evidence showing that many families cycle back and forth between welfare and work, losing jobs and returning to public assistance while they seek work again. Factors contributing to high rates of job loss include characteristics of the job and of the worker. Temporary jobs, frequent layoffs, low pay in relation to work expenses, lack of experience meeting employer expectations, and personal or family problems all lead to dismissals and resignations. Drawing from the experience of innovative programs, the authors recommend policy changes and program approaches that can help families overcome setbacks and stabilize their lives as they move from welfare into increasingly stable employment.

Aid to Families with Dependent Children↗

PubMed1997

What should be the elements of any settlement with the tobacco industry?

Litigation and regulatory assaults on the tobacco companies may create a willingness among tobacco manufacturers to bargain resources and acceptance of public policy changes for limitations of liability, as has been seen by the recent settlement with the Liggett Group. Two elements absolutely critical to any plan are the elimination of tobacco advertising and promotion and the removal of addiction as a reason for tobacco use. Minimal components of any settlement should include: (a) acceptance by the tobacco manufacturers of the causal relationship between tobacco use and disease, and the addictive nature of nicotine; (b) a total ban on tobacco advertising and promotion; (c) FDA jurisdiction over tobacco products and their nicotine content, with the intent of removing nicotine as soon as acceptable nicotine substitution products are available; (d) reimbursement to the states for Medicaid and other state expenditures attributable to smoking, to the maximum extent feasible; (e) funding for local, state, and federal programmes and research in tobacco control; (f) acceptance of legislation and regulations protecting the right of non-smokers to breathe air free of tobacco smoke; (g) funding for a large, national, media-led, anti-tobacco campaign; and (h) cessation assistance for addicted smokers. If negotiations toward a settlement proceed, it is essential that the public health community participate in defining the elements of any agreement to ensure that whatever agreement develops is focused on reducing tobacco-related disease rather than continuing the profitability of American tobacco companies. That participation requires articulation of the core elements essential to an acceptable agreement. If resolution of the public health issues surrounding continued sale of tobacco products can be reached in the United States, it may provide a model for similar resolution in other countries.

Adolescent↗

PubMed1997

Community prevention and alcohol retail access.

This paper describes the design, rationale and implementation of the Alcohol Access Component within the Community Trials Project of the Prevention Research Center. The Alcohol Access Component was to reduce the concentration or density of alcohol outlets in each experimental community by a combination of local zoning and land-use planning approaches which was an effect to occur over several years. During the time of this trial, local regulations of alcohol outlets and public sites for drinking were changed in all three experimental communities. The amount of such alcohol policy change exceeded the goals for this component.

Alcohol Drinking↗

PubMedDate not supplied

Effect of Medicaid expansions on preterm birth.

OBJECTIVES: Inadequate prenatal care is thought to be a major modifiable risk factor for preterm birth, the leading cause of neonatal mortality. To improve high-risk women's financial access to prenatal care, the U.S. Medicaid program underwent major expansions during the 1980s. We evaluated these expansions over the nine-year period 1983 to 1991 in Tennessee to determine their effects on Medicaid enrollment, use of prenatal care, and preterm birth. METHODS: We used linked birth certificates, Medicaid data, and U.S. Census files to identify 610,056 singleton births to African-American or Caucasian women in Tennessee whose last menstrual period was between 1983 and 1991. These were classified by maternal characteristics to identify groups with the greatest postexpansion increases in Medicaid enrollment, which should have benefited most from the policy changes. Study outcomes were Medicaid enrollment by delivery, enrollment in the first trimester, inadequate prenatal care (modified Kessner index), and preterm (< 37 weeks) birth. We calculated the changes (delta expressed as births per 100) between 1983 and 1991 in percentages of births with each of these outcomes. RESULTS: The expansions led to pronounced increases in maternal Medicaid enrollment by delivery (21% of births in 1983 to 51% by 1991) and in the first trimester (from 10% to 37%). Married women with < 12 years of education, < 25 years of age, and < $12,500 mean neighborhood incomes (group 1) had the greatest increase, where enrollment and first-trimester enrollment increased from 24% to 86% and 7% to 68%, respectively. In group 1, the percentages of births with inadequate maternal use of prenatal care decreased substantially, from 12.8% in 1983 to 6.4% in 1991, a reduction of 6.4 births per 100 (95% confidence intervals [CI] = -7.6, -5.3). However, the preterm birth rate did not decrease (9.1% in 1983, 9.4% in 1991, change of 0.3[-0.7 to 1.2] births per 100). For other births, there were lesser increases in Medicaid enrollment, correspondingly lesser decreases in inadequate use of prenatal care, but no reductions in preterm birth rates. CONCLUSIONS: In Tennessee, the Medicaid expansions materially increased enrollment and use of prenatal care among high-risk women, but did not reduce the likelihood of preterm birth.

Adult↗

PubMed1997

Health policy and the nursing profession: a deafening silence.

The Australian healthcare system, and those of many other Western countries are experiencing significant shifts in the development of health policy. Many of these shifts are directly related to economic factors that have contributed to the spiralling costs of health care. The trends in health policy appear to be embracing a 'market driven' approach to the distribution of resources and health services. Technology and medical developments have contributed to these current economic trends. Over the past 20 years nurses have been faced with significant shifts in the direction of health policy to the extent that many policies have significantly impacted upon their practice without their apparent contribution. Several theoretical positions exist about nurses' lack of policy participation. This paper examines some of the current health policy changes in Australia that are perceived to have had the greatest impact on the nursing practice, and identifies some of the barriers to the nursing profession's participation in the formulation of health policy.

Australia↗

PubMed1997

Defining 'competency' in nursing (Part I): A policy review.

How the nursing profession in England defines the basic competency of the registered general nurse is crucial for the safety of the patient and the protection of the nurse. It is also essential for determining advanced practice, extended practice and specialist practice in nursing. An historical overview of documentation from the United Kingdom Central Council for Midwifery and Health Visiting, the English National Board for Nursing, Midwifery and Health Visiting and the Royal College of Nursing shows a profound change in educational policy during the 1980s regarding the interpretation of nursing competency. The effects of this policy change on the current methods developed to define, teach and test nursing competency are examined. Preliminary conclusions show shortcomings and uncertainty in the present preparation and evaluation of nursing competency.

Clinical Competence↗

PubMed1997

Impact of banning alcohol on outpatient visits in Barrow, Alaska.

CONTEXT: Community availability of alcohol affects alcohol consumption patterns and alcohol-related health and social problems. In Barrow, Alaska, an isolated community at the northernmost reaches of the United States, during a 33-month period, possession and importation of alcohol were legal, completely banned, made legal again, and then banned again. OBJECTIVE: To determine the impact of these public policy changes on alcohol-related outpatient visits at the area hospital. DESIGN: Retrospective review of outpatient records; time-series analysis of alcohol-related visits with respect to community alcohol policy. MAIN OUTCOME MEASURES: Total monthly outpatient visits for alcohol-related problems. RESULTS: There was a substantial decrease in the number of alcohol-related outpatient visits when the ban on possession and importation was imposed compared with baseline. When the ban was lifted, outpatient visits increased; when the ban was reimposed, the number of outpatient visits again decreased. Interrupted time-series analyses confirm that the alcohol ban, its lifting, and its reimposition had a statistically significant and negative effect on the number of alcohol-related outpatient visits (P<.05). CONCLUSION: In a geographically isolated community, the prohibition of alcohol can be an effective public health intervention, reducing the health problems associated with alcohol use.

Alaska↗

PubMedDate not supplied

The changing requirements for health manpower and the University of Oklahoma College of Medicine.

Sweeping national changes in health care financing and delivery are forcing major modifications in the numbers, types, and distribution of physician manpower thought to be appropriate for the new paradigms. Not surprisingly, these changes are exerting great pressure on medical education institutions to also adapt to the changing requirements. In Oklahoma, these financial and policy changes are accompanied by demands upon the colleges of medicine to increase the numbers of physicians who locate their practices in rural locations. The maintenance of a comprehensive and well balanced basic and advanced medical education effort within these complex and shifting requirements continues to tax the abilities of all faculties, including the Oklahoma University College of Medicine (OUCOM).

Education, Medical↗

PubMed1998

[Changes in homes for the aged and nursing homes: functional impairments and behavioral disorders of residents are increasing].

Residents in homes for the elderly and in nursing homes suffer from physical and mental disorders that are prevalent far above average. In the course of the changes that are presently taking place in the German health care system there is now an increase in the number of mentally ill and severely impaired persons residing in old-age homes. Earlier epidemiological studies do not yield any conclusive predictions of changes in residential structures and hence in nursing care requirements. Two cross-sectional studies are presented on the prevalence of physical and mental diseases, daily and behaviour problems among residents of old-age and nursing homes in Mannheim. There was a distinct increase in average age, functional impairment, depression and disoriented behaviour among residents in 12 homes for the elderly in Mannheim conducted in 1988 (n = 542) and 1992 (n = 497). During the period it was noted that disoriented behaviour significantly increased the mortality risk. In another study the by far larger group of nursing home residents was investigated. So far we have data for 1995 and 1996 on results obtained from 1178 residents of Mannheim homes for the elderly and nursing homes. Among the residents of nursing homes there was a much higher prevalence of functional impairment and behaviour problems than among those of homes for the elderly. Despite a very high prevalence of depression or disorientation, only every third resident was diagnosed as suffering from organic brain disease and only every tenth resident had a depressive disorder. Since a growing proportion of residents will be mentally ill or severely impaired, these institutions will be facing increasing medical and nursing demands. Due to limited resources, the homes cannot meet these demands adequately. Hence, health policy changes are mandatory to improve nursing care and to avoid placing an increasing burden on the nursing staff.

Activities of Daily Living↗

PubMedDate not supplied

Child health, poverty and the environment: the Canadian context.

In Canada, there has been little research exploring the link between child poverty and exposure to environmental contaminants. However, children living in poverty are more likely to grow up in neighbourhoods adjacent to polluting industries and heavily used transportation corridors. They are also more likely to live in improperly designed or maintained buildings where levels of contaminants and toxic residuals may be high, and indoor air quality poor. Risk factors such as exposure to cigarette smoke and poor nutritional status, together with the above living conditions during growth and development, create conditions that make children living in poverty more vulnerable to the effects of environmental contaminants. In Toronto, the South Riverdale Community Health Centre is developing grassroots techniques to build awareness and protect citizens. Given the growing levels of child poverty in Canada and decreasing environmental protection, the author suggests increased community action and health research for use in advocating for appropriate policy changes.

Canada↗

PubMedDate not supplied

Is a routine radiological consultation cost-effective for pediatric orthopedic radiographs?

This investigation was undertaken to determine the value of a routine radiological consultation on all examinations taken during the course of evaluation and treatment of children with elective orthopedic problems. Shriners Hospital in Los Angeles treats children with chronic orthopedic problems. All radiographs are ordered by an orthopedic surgeon. Currently all plain examinations are also read and reported by a pediatric radiologist. The study was a retrospective chart review. Three hundred nineteen radiographic examinations (6.7% of the total performed in calendar year 1995) were reviewed. The orthopedic surgeons documented the results of their readings in 69% of the cases, while the radiology staff documented 92% of the studies. The data do not show evidence of significant misinterpretations in the readings by the orthopedic surgeons. Therefore routine radiological consultation for all examinations is unnecessary in that specific setting. If a policy change were instituted, it would represent a major saving in health-care costs.

Child↗

PubMed1998

Healthcare organizational change: implications for access to care and its measurement.

OBJECTIVES: To summarize evidence from peer-reviewed literature on access to care for vulnerable HMO enrollee populations; to discuss the potential effect of recent HMO and physician organization changes on access to care and its measurement. STUDY DESIGN: Review and summary of peer-reviewed literature for two HMO populations: those with chronic conditions and diseases, and those subject to discrimination due to income, color, or ethnic background. I also reviewed and summarized literature on three major changes in capitated organizations (HMOs and capitated physician organizations) that could affect access to care for vulnerable populations, and summarized findings from healthcare manager interviews conducted for several recent research projects on health system change. PRINCIPAL FINDINGS: Although mixed, there are enough negative results to raise some concerns about access to care for HMO enrollees with chronic conditions and diseases. Several emerging organizational changes have the potential to change access to care for the vulnerable HMO enrollees. The shift in cost-cutting from fragmented clinical management of specific services at a point in time toward more integrated clinical management of all services for specific types of patients across time may improve access to care, as may increased efforts to attract and retain HMO enrollees. The increased importance of capitated provider organizations within the health system may restrict access in some ways, and expand access in others. CONCLUSIONS: Organizational changes can affect both access to care and its measurement. More research is needed on the effects of these changes on access to care and quality of care. For researchers examining access to care for vulnerable HMO enrollee populations, these changes create challenges to determine the most appropriate measures of access to care, and the most appropriate organizations and organizational characteristics to measure. RELEVANCE TO CLINICAL PRACTICE, MANAGEMENT, AND/OR POLICY: Changes in market competition are leading to organizational changes that affect access to care for vulnerable HMO enrollee populations. Public and/or private policies that improve measurement and reporting can affect market competition and improve access to care.

Capitation Fee↗