University of Virginia Telemedicine Program. Improving Access.
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Telemedicine↗
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Primary care case management for Medicaid recipients: evaluation of the Maryland Access to Care program.
A growing number of states are implementing Medicaid managed care programs, and primary care case management (PCCM) is an important component of many of these systems. In this paper, we present results of an evaluation of one such PCCM program--the Maryland Access to Care (MAC) program. The evaluation uses five years of Medicaid claims and eligibility data from the period before and after the program's introduction to determine the program's impact on expenditures and service utilization. Results indicate that the program increased the probability that a Medicaid enrollee would use primary care and preventive services, but had little impact on use of specialty or emergency room services. The gatekeeper program also was successful at controlling expenditures once an enrollee entered the health care system, largely through reductions in the use of ancillary services. The post-MAC increase in the probability of using services was so great, however, that all savings per user were negated, resulting in an estimated increase of about 3.4% in Medicaid expenditures for the MAC-eligible population.
Aged↗
Interventional nephrology in Puerto Rico.
Vascular access is emerging as a critical issue for hemodialysis patients in Puerto Rico. In more than 50% of the hemodialysis patients, tunneled hemodialysis catheters are the sole access for providing dialysis therapy. Most disturbing is the fact that a significant number of these catheters are nontunneled temporary catheters, sometimes placed in the subclavian vein. These facts have contributed significantly to the morbidity and mortality seen in chronic dialysis patients. In addition, many cases of early or late dysfunction of arteriovenous access are not detected and treated in a timely manner due to the lack of a comprehensive vascular access program for end-stage renal disease (ESRD) patients. In fact, monitoring programs to identify and detect vascular access dysfunction are virtually nonexistent in many chronic dialysis units. Even when diagnosed, it is not treated in a timely fashion. Recently literature has shown that procedure-related delays in the treatment of patients with renal disease can be minimized and nephrology care more efficiently delivered by a nephrologist trained in nephrology-related procedures. In an effort to optimize the care of our ESRD patients, we took the initiative to develop an interventional nephrology program that effectively deals with vascular access-related procedures in a timely manner. This approach has minimized delays, decreased hospitalizations and the use of temporary catheters, and improved the medical care of our chronic dialysis patients. So far we have performed more than 400 procedures in the 6 months since the initiation of the program. In this article we describe our initial experience with interventional nephrology in Puerto Rico.
Angioplasty, Balloon↗
Impact of providing a medical home to the uninsured: evaluation of a statewide program.
Lack of health insurance and a regular source of care (RSOC) are associated with suboptimal health care. This study examined the impact of a statewide program called the Community Healthcare Access Program (CHAP), which provided a RSOC for uninsured persons in Delaware. This cohort study used survey data to compare health care utilization from baseline to six months after enrollment in CHAP. The 795 eligible enrollees had significant increases in Pap tests, mammograms, breast exams, cholesterol tests, sigmoid/colonoscopy and influenza immunizations but not stool blood tests or pneumococcal immunizations. There was a significant decrease in the proportion with emergency department visits but not hospitalizations, and there was a significant improvement in satisfaction with care. Delaware's CHAP program is associated with significant improvements across many measures of health care utilization and represents a successful and financially feasible method for states to improve health care for their uninsured populations.
Adolescent↗
Exploring the link between service quality and outcomes. Parents' assessments of family support programs.
Relationships among consumer-generated quality factors, satisfaction, and outcome measures were examined for family support services provided by Michigan's public mental health system. Parents focused on structural and procedural aspects of program accessibility and attended less to program administration issues. Parents who gave the services the highest quality ratings also were the most satisfied with services, saw the services as more effective, had fewer family problems, and rated their time and child-related resources as more adequate. Implications for evaluation practice are discussed.
Adult↗
Access to dental care: the triad of essential factors in access-to-care programs.
BACKGROUND: Solutions to the problem of limited access to dental care for some segments of the population are being sought. Certain factors in access-to-dental-care program design are critical to the success of these programs. OVERVIEW: The author discusses the triad of factors that are essential in the successful design and operation of programs aimed at improving access to dental care for underserved populations. CONCLUSIONS: The author found that attention must be paid to creating an effective demand for dental care, an adequate dental work force to respond to that demand and an economic environment that enables patients and dentists to participate in any programs that are aimed at improving access to care. PRACTICE IMPLICATIONS: Failure to adequately address demand, work force and economic factors will condemn any program designed to increase access to dental care to failure at worst, or to limited success at best.
Cost-Benefit Analysis↗
Developing a partnership model for cancer screening with community-based organizations: the ACCESS breast cancer education and outreach project.
There is growing enthusiasm for community-academic partnerships to promote health in underserved communities. Drawing upon resources available at a comprehensive cancer center, we developed the ACCESS program to guide community based organizations through a flexible program planning process. Over a three-year period, ACCESS partnered with 67 agencies serving various medically underserved populations. Organizations included hospitals, parishes, senior centers, harm reduction programs, and recreational facilities. Program outcomes at the organizational level were quantified in terms of introduction of new cancer information, referral or screening programs, as well as organizational capacity building. ACCESS represents a viable model for promoting partnership to transfer behavioral health programs and adapt interventions for new audiences. Plans to further evaluate and enhance this model to promote cancer screening efforts are discussed. We argue that, ultimately, formation and development of community partnerships need to be understood as a fundamental area of practice that must be systematically integrated into the mission of major academic medical institutions in every area of public health.
Academic Medical Centers↗
Circle of strength.
In 1984, the college of nursing at the University of Saskatchewan (U of S), the First Nations University of Canada and the University of Regina, with funding from Health Canada, established the National Native Access Program to Nursing (NNAPN). This program promoted nursing to aboriginal people, negotiated access seats for aboriginal students at all Canadian universities and offered a nine-week spring orientation program intended to prepare aboriginal students for the demands of campus life and nursing programs. A restructuring of the program in 1997 made it provincial in scope, becoming NAPN, which focuses on the recruitment, support and retention of aboriginal nursing students at the U of S's Nursing Education Program of Saskatchewan (NEPS). Currently, more than 200 self-identified aboriginal students are enrolled in NEPS. All aboriginal students are encouraged to access the NAPN services and to become involved in NAPN activities. NAPN advisers strive for success and excellence for aboriginal nursing students through support and advocacy (personal issues, social services, individual funding, academic assistance, advocacy with faculty), summer employment assistance, recruitment efforts and community partnerships (including community-building activities among the students and building partnerships with outside stakeholders, both First Nations and non-First Nations).
Attitude of Health Personnel↗
Lessons learned. Implementing a vascular access quality improvement program. Part II.
Implementing a CQI program for vascular access can seem an overwhelming task. It encompasses many areas that are not in the nephrologists' or dialysis facilities' control. However, involving the right multidisciplinary team members in the process and aligning the goals and objectives creates an environment conducive to success. Ongoing communication is critical. Everyone needs to be a part of the change process.
Catheters, Indwelling↗
Adverse events associated with lay emergency response programs: the public access defibrillation trial experience.
UNLABELLED: The adverse event (AE) profile of lay volunteer CPR and public access defibrillation (PAD) programs is unknown. We undertook to investigate the frequency, severity, and type of AE's occurring in widespread PAD implementation. DESIGN: A randomized-controlled clinical trial. SETTING: One thousand two hundred and sixty public and residential facilities in the US and Canada. PARTICIPANTS: On-site, volunteer, lay personnel trained in CPR only compared to CPR plus automated external defibrillators (AEDs). INTERVENTION: Persons experiencing possible cardiac arrest receiving lay volunteer first response with CPR+AED compared with CPR alone. MAIN OUTCOME MEASURE: An AE is defined as an event of significance that caused, or had the potential to cause, harm to a patient or volunteer, or a criminal act. AE data were collected prospectively. RESULTS: Twenty thousand three hundred and ninety six lay volunteers were trained in either CPR or CPR+AED. One thousand seven hundred and sixteen AEDs were placed in units randomized to the AED arm. There were 26,389 exposure months. Only 36 AE's were reported. There were two patient-related AEs: both patients experienced rib fractures. There were seven volunteer-related AE's: one had a muscle pull, four experienced significant emotional distress and two reported pressure by their employee to participate. There were 27 AED-related AEs: 17 episodes of theft involving 20 devices, three involved AEDs that were placed in locations inaccessible to the volunteer, four AEDs had mechanical problems not affecting patient safety, and three devices were improperly maintained by the facility. There were no inappropriate shocks and no failures to shock when indicated (95% upper bound for probability of inappropriate shock or failure to shock = 0.0012). CONCLUSIONS: AED use following widespread training of lay-persons in CPR and AED is generally safe for the volunteer and the patient. Lay volunteers may report significant, usually transient, emotional stress following response to a potential cardiac arrest. Within the context of this prospective, randomized multi-center study, AEDs have an exceptionally high safety profile when used by trained lay responders.
Canada↗
Correlates of unsafe syringe acquisition and disposal among injection drug users in Baltimore, Maryland.
Because multi-person syringe use is the most common vehicle for HIV and hepatitis C virus transmission among injection drug users (IDUs), safe sources of sterile syringes and safe methods of disposal are necessary to curb these epidemics. We examined syringe acquisition and disposal in a cohort of IDUs in Baltimore. Between January 1, 1998 and December 31, 2001, 1034 participants reported on syringe acquisition at 3492 visits, and 953 reported on disposal at 2569 visits. Participants were 69.9% male, 93.9% African-American, and median age was 44. Syringes were acquired exclusively from unsafe sources at 32.3% of visits, while exclusively unsafe disposal was reported at 59.3% of visits. Significant correlates of unsafe acquisition were: attending shooting galleries, anonymous sex, sharing needles, smoking crack, and emergency room visits. Significant correlates of unsafe disposal were: injecting speedball, no methadone treatment, acquiring safely, and frequent injection. Having a primary source of medical care was associated with safe acquisition, but unsafe disposal. IDUs continue to acquire safely but dispose unsafely, especially among those with a primary source of care; this suggests that messages about safe disposal are not being disseminated as widely as those about acquisition. These data suggest the need for a more active program involving pharmacists, an expanded syringe access program, and better efforts to enhance safe disposal.
Adolescent↗
Overcoming barriers to arteriovenous fistula creation and use.
National guidelines advocate the placement of arteriovenous fistulas (AVFs) as the preferred vascular access for hemodialysis (HD) patients because of their low complication rate, lower costs, and prolonged patency, once matured. The current Dialysis Outcomes Quality Initiative (DOQI) guidelines aim for an AVF incidence of 50% and a 40% prevalence in the United States. Although patients currently starting dialysis do so at an increasingly older age and with more comorbidity, they should be given every opportunity to receive an AVF. Meeting this challenge is facilitated by a multidisciplinary approach with early referral to the nephrologist in the predialysis period for access planning. Key components of a vascular access program may include the coordination by a dedicated access coordinator and outcome tracking via a prospective database. Preoperative vessel evaluation and careful selection of an appropriate surgical site, along with an experienced surgeon, improve surgical outcomes. Transposed brachiobasilic or other tertiary fistulas should be offered to patients who cannot receive a native radiocephalic or brachiocephalic fistula. The ability to routinely monitor and salvage failing AVFs is important to achieving successful AVF outcomes. Standardized definitions of AVF outcomes are important to allow individual centers and continuous quality assurance (CQA) programs to track and benchmark their outcomes against local and national standards to help them meet recommended targets.
Arteriovenous Shunt, Surgical↗
NOD2/CARD15 does not influence response to infliximab in Crohn's disease.
BACKGROUND & AIMS: NOD2/CARD15 was recently identified as the first gene underlying Crohn's disease (CD) susceptibility. Monoclonal antibodies to tumor necrosis factor (TNF)-alpha (infliximab) are a potent treatment for CD, with about 70% of patients responding. It is not clear which factors influence treatment outcome. We assessed whether variants in NOD2/CARD15 are predictive for differences in clinical response. METHODS: Two hundred forty-five CD patients (86 fistulizing, 159 luminal) receiving infliximab in an expanded access program were genotyped for the 3 main associated variants of NOD2/CARD15, without knowledge of the treatment response. Short-term clinical response was assessed at 4 weeks (refractory) or 10 weeks (fistulizing) after first infliximab infusion, and the mean duration of response was calculated. In a subgroup of patients, production of TNF in response to lipopolysaccharide (LPS) in mucosal biopsy tissue was also determined by means of immunoassay, and results were related to the different NOD2/CARD15 genotypes. RESULTS: In total, 32.6% of patients carried mutations in NOD2/CARD15 (18.8% R702W, 8.6% G908R, and 10.2% 1007fs) compared with 15% in controls (P < 0.001). Despite observed differences in TNF production in mucosal biopsy tissue, there was no relationship between the overall presence of a mutation in NOD2/CARD15 or of any of the mutations separately and short-term infliximab response or response duration. Furthermore, multivariate analysis could not identify clinical characteristics that, in combination with NOD2/CARD15 mutations, were associated with response to infliximab. CONCLUSIONS: In this cohort of CD patients, the frequency of NOD2/CARD15 mutations was significantly greater than that of healthy controls. However, NOD2/CARD15 was not predictive of treatment outcome with infliximab in CD.
Adult↗
Demographic and clinical parameters influencing the short-term outcome of anti-tumor necrosis factor (infliximab) treatment in Crohn's disease.
OBJECTIVE: Infliximab is an effective treatment for refractory or fistulizing Crohn's disease (CD). However, about 30% of patients do not respond to infliximab for unknown reasons. Identifying predictive factors of response is important for optimizing clinical management and for better understanding infliximab's mechanisms of action. The aim of this study was to assess whether demographic or clinical parameters influence short-term response to infliximab. METHODS: The first 240 CD patients of the Belgian Infliximab Expanded Access Program were studied for response to infliximab treatment and assessed at 4 (refractory luminal CD) or 10 wk (fistulizing CD) after the first infusion. Detailed demographic and clinical information on age, sex, type of disease (fistulizing or refractory), Crohn's Disease Activity Index score, C-reactive protein (CRP), smoking habits, disease duration, localization of disease, concomitant medication, and previous surgery were obtained from all patients. Logistic regression and decision tree analysis were performed. RESULTS: There were 73.5% responders and 26.5% nonresponders to treatment. Stepwise logistic regression identified age (OR = 0.971, 95% CI = 0.947-0.995, p = 0.018), isolated ileitis (OR = 0.359, 95% CI = 0.177-0.728, p = 0.004), and previous surgery (OR = 0.429, 95% CI = 0.233-0.787, p = 0.006) as inversely correlated with response, whereas isolated colitis (OR = 1.905, 95% CI = 1.010-3.597, p = 0.046) and concomitant immunosuppressive treatment (OR = 2.670, 95% CI = 1.430-5.016, p = 0.0022) were positively correlated with response to infliximab. Surprisingly, smoking habits were not retained as predictors for response. Decision tree analysis provided a working algorithm based on age and immunosuppressive treatment that warrants further exploration. CONCLUSIONS: In this large cohort of infliximab-treated CD patients, young age, Crohn's colitis, and concomitant immunosuppressive treatment were identified as independent variables favoring short-term response to infliximab.
Adult↗
GAO's role in the evaluation of federal health programs.
The General Accounting Office (GAO) is a legislative branch agency whose mission is to support the oversight role of Congress. Health policy issues have constituted a substantial part of GAO's recent workload. Whereas GAO's work on health has ranged broadly, it has often focused on fraud and abuse in federal programs, particularly Medicare and Medicaid; the lack of meaningful indicators and other information, particularly on outcomes in health programs; access to care, increasingly connected to managed care; quality of care; and issues related to cost control.
Cost Control↗
Decisions without consequences: cost control and access in state Medicaid programs.
States have implemented a number of strategies to provide services, pay providers, and control Medicaid spending. We test the effects of some differences in state Medicaid policies on program enrollees' access to and use of health care services. Logistic and OLS regression analyses of cross-sectional data indicate that these policies exert significant influences on enrollees' access to health services but have a weaker direct effect on their use of them. However, we find evidence that utilization is affected indirectly (through increased access) by state policy decisions. Somewhat surprisingly, Medicaid policies designed to contain costs by limiting utilization appear to affect neither access nor utilization. Medicaid enrollees have greater access to a private physician in states with higher physician reimbursement and additional Medicare insurance for their enrollees. Other nonpolicy variables with pronounced impacts on access to private office physicians include race and the availability of private insurance.
Cost Control↗
Improving patient retention and access to oral health care: the CARES program.
Improving access to dental care for patients experiencing barriers such as financial, transportation, or mental health is a public health concern. Dental schools have an obligation to assist patients experiencing such barriers as well as to educate future dentists and allied professionals on how to assist these patients in overcoming barriers. Once admitted to the dental clinic, retention issues can further complicate the provision of dental care. This article will describe an innovative program designed to address biopsychosocial barriers to dental care. Needs assessments of patients sitting in the waiting room of the dental clinic were conducted by master's of social work (M.S.W.) students. Based on needs assessment results, common dental care barriers were identified and served as the foundation for the establishment of a social work program in the dental clinic. Dental students, faculty, and staff refer patients to the social work program when barriers to care are found. These biopsychosocial barriers are addressed by social workers, uniquely qualified professionals in providing case management, advocacy, referrals, education, and services (CARES). Over the course of three years, 80 percent of patients experiencing an identified barrier to the receipt of dental care were retained through social work intervention. These patients were able to receive dental care within the past year. Dental schools can collaborate with social work schools to establish a protocol and assistance program for dental patients experiencing difficulty accessing care, thereby improving oral health status, retention rates, and dental student education.
Adolescent↗
Getting from here to there: evaluating West Virginia's rural nonemergency medical transportation program.
With funding from the 21st Century Challenge Fund, the West Virginia Rural Health Access Program created Transportation for Health, a demonstration project for rural nonemergency medical transportation. The project was implemented in 3 sites around the state, building on existing transportation systems--specifically, a multicounty transit authority, a joint senior center/transit system, and a senior services center. An evaluation of the project was undertaken to answer 3 major questions: (1) Did the project reach the population of people who need transportation assistance? (2) Are users of the transportation project satisfied with the service? (3) Is the program sustainable? Preliminary results from survey data indicate that the answers to questions 1 and 2 are affirmative. A break-even analysis of all 3 sites begins to identify programmatic and policy issues that challenge the likelihood of financial sustainability, including salary expenses, unreimbursed mileage, and reliance on Medicaid reimbursement.
Adult↗