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PubMed2005

A randomised trial of the cost effectiveness of buprenorphine as an alternative to methadone maintenance treatment for heroin dependence in a primary care setting.

BACKGROUND AND AIM: Buprenorphine offers an alternative to methadone in the treatment of heroin dependence, and has the advantage of allowing alternate-day dosing. This study is the first to examine the cost effectiveness of buprenorphine as maintenance treatment for heroin dependence in a primary care setting using economic and clinical data collected within a randomised trial. STUDY DESIGN AND METHODS: The study was a randomised, open-label, 12-month trial of 139 heroin-dependent patients in a community setting receiving individualised treatment regimens of buprenorphine or methadone. Those who were currently on a methadone program (n = 57; continuing therapy subgroup) were analysed separately from new treatment recipients (n = 82; initial therapy subgroup). The study took a broad societal perspective and included health, crime and personal costs. Data on resource use and outcomes were a combination of clinical records and self report at interview. The main outcomes were incremental cost per additional day free of heroin use and per QALY. An analysis of uncertainty calculated the likelihood of net benefits for a range of acceptable money values of outcomes. All costs were in 1999 Australian dollars (DollarA). RESULTS: The estimated mean number of heroin-free days did not differ significantly between those randomised to methadone (225 [95% CI 91, 266]), or buprenorphine (222 [95% CI 194, 250]) over the year of the trial. Buprenorphine was associated with an average 0.03 greater QALYs over 52 weeks (not significant). The total cost was DollarA 17,736 (95% CI -DollarA 2981, DollarA 38,364) with methadone and DollarA 11,916 (95% CI DollarA 7697, DollarA 16,135) with buprenorphine; costs excluding crime were DollarA 4513 (95% CI DollarA 3495, DollarA 5531) and DollarA 5651 (95% CI DollarA 4202, DollarA 7100). With additional heroin-free days as the outcome, and crime costs included buprenorphine has a lower cost but less heroin-free days. If crime costs are excluded buprenorphine has a higher cost and worse outcome than methadone. With additional QALYs as the outcome, the cost effectiveness of buprenorphine is DollarA 39,404 if crime is excluded, but buprenorphine is dominant if crime is included. CONCLUSIONS: The trial found no significant differences in costs or outcomes between methadone and buprenorphine maintenance in this particular setting. Although some of the results suggest that methadone may have a cost advantage, it is difficult to infer from the trial data that offering buprenorphine as an alternative would have a significant effect on total costs or outcomes. The point estimates of costs and outcomes suggest that buprenorphine may have an advantage in those initiating therapy. The confidence intervals were wide, however, and the likelihood of net benefits from substituting one treatment for another was close to 50%.

Adolescent↗

PubMed2002

Primary health care theory to practice: experience of first-year nursing students in Hong Kong.

In the past, nursing education in Hong Kong has focused on acute illness care, and institutions providing nursing education have been slow to modify the illness-focused curriculum to a health-based curriculum. The nursing curriculum at the University of Hong Kong is unique in that it focuses on primary health care, and these concepts are introduced in both theory and practice in the first year of the baccalaureate program. In the second semester of the first year, students are required to develop and implement a primary health care project in a community setting. This article outlines the process and outcomes of the experience of 8 first-year nursing students who developed and implemented a primary health care project with older adults in a Hong Kong community. The Generalized Model for Program Development (McKenzie & Smeltzer) was used to guide the students in their practicum activities. The students demonstrated a high degree of competency in relation to health assessment skills; analysis of individual and community needs; development of appropriate health promotion sessions in relation to coronary artery disease, diabetes mellitus, and arthritis; and evaluation strategies to demonstrate effectiveness of the intervention. This experience early in the program provided a strong foundation for the students in primary heath care and grounded their nursing practice in scientific-based evidence.

Adult↗

PubMed2004

A case for consideration of cultural diversity in heart failure management--Part 1: Rationale for the DISCOVER Study.

Heart failure is a condition increasing in prevalence and responsible for high health care utilization, morbidity and mortality. Randomised controlled trials of nurse-coordinated interventions have determined self-care and the incorporation of the patient and their family in care planning as critical elements of service delivery. Coping with a chronic illness, such as heart failure, forces the individual to adjust to changed physical, social and emotional functioning and to modify their lifestyle accordingly. Clinicians increasingly use models of care that focus care delivery on the community setting. In order to develop strategies to assist patients and their families with self-care it is important that clinicians understand the health-care seeking behaviours of all individuals targeted in the community. Australia is a culturally diverse nation, yet evaluations of models of care have been undertaken largely in individuals from predominately Anglo-Celtic origins. The end result of this approach is failure to understand the full range of diverse perspectives that individuals hold that can have an impact on self-care behaviours. Consideration of cultural diversity should extend beyond language to a broader appreciation of cultural values, health seeking beliefs and engagement of culturally unique communities. The 'Understanding the cultural experiences of individuals with chronic heart failure (CHF) in South East Health (DISCOVER) Study' seeks to uncover information on the health patterns, information needs and the adjustment process for overseas-born individuals with heart failure. Such information will assist clinicians to tailor health care service delivery and ensure the delivery of appropriate, quality care. This manuscript provides the background, rationale and methods for this study.

Adaptation, Psychological↗

PubMed1991

Antenatal village stay and pregnancy outcome in rural Zimbabwe.

DESIGN: Comparative study of pregnancy outcome for parturients who had stayed in an antenatal village and for those admitted directly from the community. SETTING: A rural hospital in Zimbabwe. OUTCOME MEASURES: Birthweight, perinatal mortality and degree of obstetrical intervention. RESULTS: Women who stayed in the antenatal village experienced better pregnancy outcome than women admitted directly from the community. Birthweight was greater, perinatal mortality lower, and obstetrical intervention less often required in the antenatal village group. CONCLUSIONS: Lack of randomisation, differences between the two groups in antenatal risk factors, and lack of information relating to socio-economic status suggest that generalisations beyond the specific case be made cautiously.

Adult↗

PubMed1993

Measuring the impact of nursing interventions in the community: a selective review of the literature.

In a resource conscious environment, it is imperative that nurses use their skills and knowledge to provide an optimum service. It is suggested that nurses working in the community must measure the impact of their nursing interventions to guide their own role development and to inform the purchasing process. This literature review has revealed, however, that little progress has been made in this area by nurses within the community setting. Indeed, it is suggested that research is needed to test reliable and valid methods of outcome measurement.

Community Health Nursing↗

PubMed2006

The community barometer: a breast health needs assessment tool for community-based organizations.

This article presents findings from the ACCESS Project focusing on the impact of an outreach initiative that used "data sharing" as a mechanism to establish a wide variety of academic-community partnerships for cancer awareness. The Community Barometer, a brief needs assessment tool developed for this purpose, was used to collect data from clients, and sometimes staff members, of a variety of community-based organizations in New York City. Over a 5-year period, Barometer data were collected from 1,001 women who were affiliated with 20 community-based organizations. Analysis of these data supported our hypothesis that community-based organizations are more likely than chance to serve women with similar needs and preferences for breast health education and screening and that customized or tailored programs were warranted. Four case studies are presented. Limitations of the instrument and its administration in community settings as well as future research objectives are discussed.

Adult↗

PubMed2006

Beyond vertical integration--Community based medical education.

The term 'vertical integration' is used broadly in medical education, sometimes when discussing community based medical education (CBME). This article examines the relevance of the term 'vertical integration' and provides an alternative perspective on the complexities of facilitating the CBME process. The principles of learner centredness, patient centredness and flexibility are fundamental to learning in the diverse contexts of 'community'. Vertical integration as a structural concept is helpful for academic organisations but has less application to education in the community setting; a different approach illuminates the strengths and challenges of CBME that need consideration by these organisations.

Australia↗

PubMedDate not supplied

Temporal-spatial characteristics of wheelchair propulsion. Effects of level of spinal cord injury, terrain, and propulsion rate.

The purpose of this investigation was to compare the temporal-spatial characteristics of wheelchair propulsion (velocity, cycle distance, and cadence) of customary wheelchair users in conditions designed to simulate community settings. Seventy adult males with spinal cord injuries (SCI) were grouped by their level of SCI: low paraplegia (n = 17); high paraplegia (n = 19); C-7 tetraplegia (n = 17); C-6 tetraplegia (n = 17). Testing was performed in a wheelchair that had the right pushrim instrumented with force transducers. Participants propelled the test wheelchair at a self-selected, free, and fast pace over tile and carpeted floors. A wheelchair ergometer was designed to simulate loads encountered during propulsion over graded surfaces. Participants propelled the test wheelchair during ergometer simulation of 4% and 8% grades. Mean velocity, cycle distance, and cadence were calculated for each group in all test conditions. A two-way repeated measures analysis of variance and simple main effects testing for comparison across conditions and between groups were performed. For all test conditions, participants with low paraplegia were the fastest and had the longest cycle distance. With successively higher levels of SCI, velocities were slower and cycle distances shorter. During free propulsion on tile, velocities ranged from 95 m/min in low paraplegics to 55 m/min in C-6 tetraplegics. Fast propulsion velocity increased to 141 and 55 m/min, respectively. There was a significant main effect of surface for velocity such that the carpet condition was slower than the tile for all groups. Differences in velocity were most often the result of changes in cycle distance. High and low paraplegic groups were statistically similar for all test conditions. Participants with C-6 tetraplegia were significantly slower than all other groups for most test conditions. Because their fast propulsion velocities were slower than typical community demands, their ability to function independently outside the hospital setting has been further questioned.

Adult↗

PubMed2002

Noncardiovascular disease outcomes during 6.8 years of hormone therapy: Heart and Estrogen/progestin Replacement Study follow-up (HERS II).

CONTEXT: The Heart and Estrogen/progestin Replacement Study (HERS) was a randomized trial of estrogen plus progestin therapy after menopause. OBJECTIVE: To examine the effect of long-term postmenopausal hormone therapy on common noncardiovascular disease outcomes. DESIGN AND SETTING: Randomized, blinded, placebo-controlled trial of 4.1 years' duration (HERS) and subsequent open-label observational follow-up for 2.7 years (HERS II), carried out between 1993 and 2000 in outpatient and community settings at 20 US clinical centers. PARTICIPANTS: A total of 2763 postmenopausal women with coronary disease and average age of 67 years at enrollment in HERS; 2321 women (93% of those surviving) consented to follow-up in HERS II. INTERVENTION: Participants were randomly assigned to receive 0.625 mg/d of conjugated estrogens plus 2.5 mg of medroxyprogesterone acetate (n = 1380) or placebo (n = 1383) during HERS; open-label hormone therapy was prescribed at personal physicians' discretion during HERS II. The proportions with at least 80% adherence to hormones declined from 81% (year 1) to 45% (year 6) in the hormone group and increased from 0% (year 1) to 8% (year 6) in the placebo group. MAIN OUTCOME MEASURES: Thromboembolic events, biliary tract surgery, cancer, fracture, and total mortality. RESULTS: Comparing women assigned to hormone therapy with those assigned to placebo, the unadjusted intention-to-treat relative hazard (RH) for venous thromboembolism declined from 2.66 (95% confidence interval [CI], 1.41-5.04) during HERS to 1.40 (95% CI, 0.64-3.05) during HERS II (P for time trend =.08); it was 2.08 overall for the 6.8 years (95% CI, 1.28-3.40), and 3 of the 73 women with thromboembolism died within 30 days due to pulmonary embolism. The overall RH for biliary tract surgery was 1.48 (95% CI, 1.12-1.95); for any cancer, 1.19 (95% CI, 0.95-1.50); and for any fracture, 1.04 (95% CI, 0.87-1.25). There were 261 deaths among those assigned to hormone therapy and 239 among those assigned to placebo (RH, 1.10; 95% CI, 0.92-1.31). Adjusted and as-treated analyses did not alter our conclusions. CONCLUSIONS: Treatment for 6.8 years with estrogen plus progestin in older women with coronary disease increased the rates of venous thromboembolism and biliary tract surgery. Trends in other disease outcomes were not favorable and should be assessed in larger trials and in broader populations.

Aged↗

PubMed1999

Learning in the city: what is the value added?

As health care services shift to the ambulatory and community setting, health professions educators must consider revamping educational programs to reflect the new venues of care. This transformation extends far beyond the location of services. The dynamic between the health care provider and the patient shifts to provider and customer. Services should be geared to the concerns of the individual and tailored to meet the realities of the person's life. This is true in all settings; and particularly true in the city. This article discusses the unique challenges of the urban environment and the benefits students gain by having clinical experiences based the city and working with members of these communities.

Community Health Nursing↗

PubMed2000

Effects of a multicomponent intervention on functional outcomes and process of care in hospitalized older patients: a randomized controlled trial of Acute Care for Elders (ACE) in a community hospital.

BACKGROUND: Older persons frequently experience a decline in function following an acute medical illness and hospitalization. OBJECTIVE: To test the hypothesis that a multicomponent intervention, called Acute Care for Elders (ACE), will improve functional outcomes and the process of care in hospitalized older patients. DESIGN: Randomized controlled trial. SETTING: Community teaching hospital. PATIENTS: A total of 1,531 community-dwelling patients, aged 70 or older, admitted for an acute medical illness between November 1994 and May 1997. INTERVENTION: ACE includes a specially designed environment (with, for example, carpeting and uncluttered hallways); patient-centered care, including nursing care plans for prevention of disability and rehabilitation; planning for patient discharge to home; and review of medical care to prevent iatrogenic illness. MEASUREMENTS: The main outcome was change in the number of independent activities of daily living (ADL) from 2 weeks before admission (baseline) to discharge. Secondary outcomes included resource use, implementation of orders to promote function, and patient and provider satisfaction. RESULTS: Self-reported measures of function did not differ at discharge between the intervention and usual care groups by intention-to-treat analysis. The composite outcome of ADL decline from baseline or nursing home placement was less frequent in the intervention group at discharge (34% vs 40%; P = .027) and during the year following hospitalization (P = .022). There were no significant group differences in hospital length of stay and costs, home healthcare visits, or readmissions. Nursing care plans to promote independent function were more often implemented in the intervention group (79% vs 50%; P = .001), physical therapy consults were obtained more frequently (42% vs 36%; P = .027), and restraints were applied to fewer patients (2% vs 6%; P = .001). Satisfaction with care was higher for the intervention group than the usual care group among patients, caregivers, physicians, and nurses (P < .05). CONCLUSIONS: ACE in a community hospital improved the process of care and patient and provider satisfaction without increasing hospital length of stay or costs. A lower frequency of the composite outcome ADL decline or nursing home placement may indicate potentially beneficial effects on patient outcomes.

Activities of Daily Living↗

PubMed2004

Resilience of community-dwelling older persons.

OBJECTIVES: To assess resilience of community-dwelling older persons using a new scale based on response to a stressful life event and to identify the demographic, clinical, functional, and psychosocial factors associated with high resilience. DESIGN: Cross-sectional study. SETTING: Community. PARTICIPANTS: Five hundred forty-six nondisabled persons aged 70 and older who had experienced a stressful life event. MEASUREMENTS: Resilience (as assessed using a simple six-item scale), demographic factors, chronic conditions, medications, cognitive status, grip strength, functional status, physical activity, self-efficacy, depressive symptoms, self-rated health, and social support. RESULTS: Participants showed a wide range of resilience in response to a stressful event, with a mean score+/-standard deviation of 8.9+/-4.0 on an 18-point scale. In bivariate analyses, male sex, living with others, high grip strength, independence in instrumental activities of daily living (IADLs), having few depressive symptoms, and having good to excellent self-rated health were associated with high resilience, defined as a score in the best tertile (>10). Independence in IADLs (relative risk (RR)=1.36, 95% confidence interval (CI)=1.05-1.69), having few depressive symptoms (RR=1.59, 95% CI=1.13-2.11), and good to excellent self-rated health (RR=1.38, 95% CI=1.01-1.79) remained independently associated with high resilience in multivariate analysis. Depressive symptoms and self-rated health remained associated with high resilience after controlling for the perceived stressfulness of the event. CONCLUSION: Functional and psychosocial factors are associated with high resilience. Further research is needed to determine the relationship between resilience and future well-being.

Activities of Daily Living↗

PubMed1987

Strategies for community occupational therapy program development.

Occupational therapists who wish to see services expand in community settings must be prepared to take an active role in program development. The article examines 12 program development strategies which are illustrated using the experience of developing a rural program in a social service system. Community occupational therapy services in Prince Edward Island were initially developed, from 1977 to 1979, by a small group of occupational therapists. The group obtained Federal Welfare Demonstration Grant funding for a pilot project which was administered by the provincial Department of Social Services. In 1979, the Prince Edward Island Provincial Government approved on-going funding for an Island-wide community occupational therapy service.

Community Health Services↗

PubMed2006

Community transformation through culturally competent nursing leadership: application of theory of culture care diversity and universality and tri-dimensional leader effectiveness model.

Transcultural knowledge and competency have become a critical need for nurses to accommodate the global trends in cultural diversity and health care disparities. Today, nurses are increasingly taking on leadership roles in community settings. This article addresses the application of Leininger's culture care theory with the sunrise model and Hersey and Blanchard's tri-dimensional leader effectiveness model as potential collaborating theories for capacity building and community transformation from a global, transcultural nursing perspective. The two theories, used in collaboration, view the provision of competent leadership as the delivery of effective, culturally congruent nursing care in promoting health and health equity at the community level.

Community Participation↗

PubMed1997

Demonstrating social accountability in medical education.

The author considers the University of Toronto's Health, illness and the Community course for undergraduate medical students, described in this issue by Wasylenki and associates (see pages 379 to 383). Social accountability in medical education demands a community orientation and hence an emphasis on outreach. Medical schools should expand their clinical service to the community, provide community-based residency placements and offer continuing medical education in rural and regional centres. Accountability also requires community involvement in planning and implementing research projects. Placing students in a community setting as part of the curriculum is praiseworthy, but it is not sufficient to ensure social accountability. What is needed now is a more comprehensive acceptance by faculties of medicine of the mandate of community-centred learning, together with well-targeted funding for education and research initiatives.

Community-Institutional Relations↗

PubMed1995

Food behaviors of southern rural community-living elderly.

OBJECTIVE: To examine how food behaviors and indicators of nutritional status of elderly living in rural communities might relate to age, race, income, medication use, activities of daily living and instrumental activities of daily living, living arrangements, and other lifestyle and health measures. DESIGN: In-home survey administered by trained interviewers. SETTING: Communities in rural North Carolina. PARTICIPANTS: A total of 2178 adults, aged 60 years and older, representing a 2% random stratified example of the region's elderly. MAIN OUTCOME MEASURES: Weight status described by body mass index, functional status as activities of daily living and instrumental activities of daily living, and self-reported food and health behaviors. RESULTS: Substantial diversity exists among households by age, race, residential location, and household size. Almost three fourths of respondents had seen a physician in the last 6 months. More than 33% of women and 28% of men were obese, but none reported having been prescribed a weight-loss diet. About 18% of the respondents were underweight. Weight was not related to income, perceptions of health, chronic disease, medication use, feelings of depression, instrumental activities of daily living, or exercise. Most (65%) ate three meals per day, and almost all were able to eat without assistance. Few drank much liquid or participated in structured exercise programs. Research is needed to determine the impact of weight status on the quality of life of elderly persons living in rural areas. CONCLUSIONS: Current literature descriptions of food behaviors and nutritional status of the elderly may not appropriately describe rural elderly. Attention should be given to the identification and treatment of malnutrition in the elderly.

Activities of Daily Living↗

PubMed2002

Nurses and English primary care groups: their experiences and perceived influence on policy development.

AIMS OF THE STUDY: To investigate the experiences and perceived influence of nurses serving on English primary care group boards. BACKGROUND: The development of the nursing workforce and nursing services in primary care have been piecemeal and nurses have not always contributed to policy development. The recent establishment of primary care groups (PCGs) in the United Kingdom (UK) potentially offers nurses the opportunity to take a concerted and strategic role in developing professional roles and planning service developments. RESEARCH METHODS: As part of a longitudinal study of a 15% random sample of English primary care groups, nurse board members were surveyed in the winter of 1999. One hundred and forty-four nurses were invited to return self-completion questionnaires. RESULTS: Completed questionnaires were returned by 106 of those invited to participate (73%). Respondents reported that combining their usual work with their role in the PCG was frequently difficult. Only 26% perceived that they had been well prepared for their new role. Compared with other board members [for example, general practitioners (GPs)], nurses perceived that their own influence was limited, with only a quarter rating the influence of nurses on decision-making as great. Most of the sample were feeding back information to other primary care and community nurses working in the locality and 52% rated communication with this wider constituency as good or better. Nurse board members were enthusiastic about their role and optimistic about the positive future impact of PCGs on health. CONCLUSIONS: PCGs are still at a relatively early stage in their development. It is still too early to assess their impact on nurses working in primary care and community settings. Board membership offers nurses a voice in local health policy development.

Attitude of Health Personnel↗

PubMed1982

The role of the psychoanalytically oriented psychotherapist within a therapeutic community.

This paper presents a theoretical model for the psychoanalytically oriented psychotherapist working in a therapeutic milieu in which the standard psychoanalytic situation is altered in three respects: (1) the patient is borderline or psychotic and has difficulty participating in a verbal, insight-oriented approach, (2) the therapist is part of a treatment team, and (3) the patient is treated while in a community setting. These three factors can create difficulties in treatment, which will be reviewed with the goal of delineating a model to guide the therapist as he or she responds to the multiple stimuli of a therapeutic community. The role of the therapist will be examined from two broad points of view: the nature of psychotherapy with borderline and psychotic patients within the milieu, and the interaction between therapist, treatment team, and therapeutic community and its effect on the patient. Certain aspects of transference and countertransference in milieu treatment will also be discussed.

Countertransference↗