Quality of care for uninsured type 2 diabetic patients in a financial assistance medical home model

The medically uninsured population in the United States is 16% or 42 million people and consists of a significant number of Type 2 diabetic patients which is the predominant form of diabetes with 798,000 new cases diagnosed each year. There is limited health services research on uninsured populations concerning health system measures or specific disease conditions. ^ The purpose of this investigation was to determine the impact a newly implemented health care program had on the quality of care provided to patients with Type 2 diabetes. The primary study objective was to compare the quality of care while controlling for utilization, and health status of patients in the new program to their status during the previous financial assistance program. The research design was a retrospective matched-pairs design. The study population consisted of 225 patients who received medical care during 1996 and 1997 at the University Health System in San Antonio, Texas. ^ Six quality of care measures individually failed to demonstrate a statistically significant difference when compared between the two periods. However, an index measure reflecting the number of patients who received all six of the quality of care measures demonstrated a statistically significant increase in 1997 (p-value < 0.05). In 1996, 8 patients (2.6%) received all six medical management components. In 1997, 38 patients (16.8%) received all six medical management components. Four regression models were analyzed; two out of the four models demonstrated inconsistent results based on the program membership variable. ^ It is concluded that there has been a small effect of the Carelink program demonstrated by an increase from 8 to 38 patients receiving all quality of care components for Type 2 diabetics at the UHS. It is recommended that additional research be conducted in order to evaluate the quality of care provided to Type 2 diabetic patients. ^

Lessons for emerging state Children's Health Insurance Premium Assistance programs: Case study of the Massachusetts Masshealth Family Assistance Program (MHFAP)

Providing health insurance coverage for vulnerable populations such as low-income high-risk children with limited access to health care is a challenge for many states. Over the past decade, higher private insurance premiums and unpredictable labor markets have increased the number of uninsured and underinsured children nationwide. Due to recent economic downfalls, many states such as Texas, have expressed interest in using premium assistance programs to increase enrollment of low income children and families in private coverage through employer sponsored health insurance. Massachusetts has been especially successful in reducing the number of uninsured children through the implementation of MassHealth Family Assistance Program (MHFAP), an employer based premium assistance program. The purpose of this study is to identify key implementation factors of a fully established premium assistance program which may provide lessons and facilitate implementation of emerging premium assistance programs. ^ The case study of the fully established MassHealth Family Assistance Program (MHFAP) has illustrated the ability of states to expand their Medicaid and SCHIP programs in order to provide affordable health coverage to uninsured and underinsured low income children and their families. As demonstrated by MHFAP, the success of a premium assistance program depends on four key factors: (1) determination of participant and employer eligibility; (2) determination of employer benefits meeting benchmark equivalency (Medicaid or State Children's Health Insurance Program); (3) the use of appropriate marketing and outreach strategies; and (4) establishment of adequate monitoring and reporting techniques. Successful implementation strategies, revealed by the case study of the Massachusetts MassHealth Family Assistance Program, may be used by emerging premium assistance programs, such as Texas Children's Health Insurance Premium Assistance Program (CHIP-PA) toward establishment of an effective, efficient, and equitable employer sponsored health program.^

STUDIES ON CHOLINERGIC FUNCTION AND MEMORY IN MICE (CHOLINOTOXINS, WORKING, REFERENCE MEMORY, RADIAL ARM MAZE)

Considerable evidence suggests that central cholinergic neurons participate in either acquisition, storage or retrieval of information. Experiments were designed to evaluate information processing in mice following either reversible or irreversible impairment in central cholinergic activity. The cholinergic receptor antagonists, atropine and methylatropine were used to reversibly inhibit cholinergic transmission. Irreversible impairment in central cholinergic function was achieved by central administration of the cholinergic-specific neurotoxins, N-ethyl-choline aziridinium (ECA) and N-ethyl-acetylcholine aziridinium (EACA).^ ECA and EACA appear to act by irreversible inhibition of high affinity choline uptake (proposed rate-limiting step in acetylcholine synthesis). Intraventricular administration of ECA or EACA produced persistent reduction in hippocampal choline acetyltransferase activity. Other neuronal systems and brain regions showed no evidence of toxicity.^ Mice treated with either ECA or EACA showed behavioral deficits associated with cholinergic dysfunction. Passive avoidance behavior was significantly impaired by cholinotoxin treatment. Radial arm maze performance was also significantly impaired in cholinotoxin-treated animals. Deficits in radial arm maze performance were transient, however, such that rapid and apparent complete behavioral recovery was seen during retention testing. The centrally active cholinergic receptor antagonist atropine also caused significant impairment in radial arm maze behavior, while equivalent doses of methylatropine were without effect.^ The relative effects of cholinotoxin and receptor antagonist treatment on short-term (working) memory and long-term (reference) memory in radial arm maze behavior were examined. Maze rotation studies indicated that there were at least two different response strategies which could result in accurate maze performance. One strategy involved the use of response algorithms and was considered to be a function of reference memory. Another strategy appeared to be primarily dependent on spatial working memory. However, all behavioral paradigms with multiple trails have reference memory requirements (i.e. information useful over all trials). Performance was similarly affected following either cholinotoxin or anticholinergic treatment, regardless of the response strategy utilized. In addition, rates of behavioral recovery following cholinotoxin treatment were similar between response groups. It was concluded that both cholinotoxin and anticholinergic treatment primarily resulted in impaired reference memory processes. ^

Exploring the use of pharmaceutical patient assistance programs as an option to improve access to and affordability of prescription drugs

Background. Pharmaceutical-sponsored patient assistance programs (PAPs) are charity programs that provide free or reduced-priced medications to eligible patients. PAPs have the potential to improve prescription drug accessibility for patients but currently there is limited information about their use and effectiveness. ^ Objectives and methods. This dissertation described the use of PAPs in the U.S. through the conduct of two studies: (1) a systematic review of primary studies of PAPs from commercially-published and “grey” literature sources; and (2) a retrospective, cross-sectional study of cancer patients' use of PAPs at a tertiary care cancer outpatient center. ^ Results. (1) The systematic review identified 33 studies: 15 evaluated the impact of PAP enrollment assistance programs on patient healthcare outcomes; 7 assessed institutional costs of providing enrollment assistance; 7 surveyed stakeholders; 4 examined other aspects. Standardized mean differences calculated for disease indicator outcomes (most of which were single group, pre-posttest designs) showed significant decreases in glycemic and lipid control, and inconsistent results for blood pressure. Grey literature abstracts reported insufficient statistics for calculations. Study heterogeneity made weighted summary estimates inappropriate. Economic analyses indicated positive financial benefits to institutions providing enrollment assistance (cost) compared to the wholesale value of the medications provided (benefit); analyses did not value health outcomes. Mean quality of reporting scores were higher for observational studies in commercially-published articles versus full text, grey literature reports. (2) The cross-sectional study found that PAP outpatients were significantly more likely to be uninsured, indigent, and < 65 years old than non-PAP patients. Nearly all non-PAP and PAP prescriptions were for non-cancer conditions, either for co-morbidities (e.g., hypertension) or the management of treatment side effects (e.g., pain). Oral chemotherapies from PAPs were significantly more likely to be for breast versus other cancers, and be a newer, targeted versus traditional chemotherapy.^ Conclusions. In outpatient settings, PAP enrollment assistance plus additional medication services (e.g., counseling, reminders, and free samples) is associated with improved disease indicators for patients. Healthcare institutions, including cancer centers, can offset financial losses from uncompensated drug costs and recoup costs invested in enrollment assistance programs by procuring free PAP medications. Cancer patients who are indigent and uninsured may be able to access more outpatient medications for their supportive care needs through PAPs, than for cancer treatment options like oral chemotherapies. Because of the selective availability of drugs through PAPs, there may be more options for newer, oral, targeted chemotherapies for the treatment breast cancer versus other for other cancers.^

A descriptive study on Hurricanes Katrina and Rita evacuees participating in the Harris County Housing Authority Disaster Housing Assistance Program

Natural disasters occur in various forms such as hurricanes, tsunamis, earthquakes, outbreaks, etc. The most unsettling aspect of a natural disaster is that it can strike at any moment. Over the past decade, our society has experienced an alarming increase of natural disasters. How to expeditiously respond and recover from natural disasters has become a precedent question for public health officials. To date, the most recent natural disaster was the January 12, 2010 earthquake in Haiti; however the most memorable was that of Hurricane Katrina (“Haiti Earthquake”, 2010). ^ This study provides insight on the need to develop a National Disaster Response and Recovery Program which effectively responds to natural disasters. The specific aims of this paper were to (1) observe the government’s role on federal, state and local levels in assisting Hurricanes Katrina and Rita evacuees, (2) assess the prevalence of needs among Hurricanes Katrina and Rita families participating in the Disaster Housing Assistance Program (DHAP) and (3) describe the level of progress towards “self sufficiency” for the DHAP families receiving case management social services. ^ Secondary data from a cross-sectional “Needs Assessment” questionnaire were analyzed. The questionnaire was administered initially and again six months later (follow-up) by H.A.U.L. case managers. The “Needs Assessment” questionnaire collected data regarding participants’ education, employment, transportation, child care, health resources, income, permanent housing and disability needs. Case managers determined the appropriate level of social services required for each family based on the data collected from the “Needs Assessment” questionnaire. ^ Secondary data provided by the H.A.U.L. were analyzed to determine the prevalence of needs among the DHAP families. In addition, differences measured between the initial and follow-up (at six months) questionnaires were analyzed to determine statistical significance between case management services provided and prevalence of needs among the DHAP families from initial to 6 months later at follow-up. The data analyzed describe the level of progress made by these families to achieve program “self sufficiency” (see Appendix A). Disaster assistance programs which first address basic human needs; then socioeconomic needs may offer an essential tool in aiding disaster affected communities quickly recover from natural disasters. ^

An evaluation of Employee Assistance Programs: An overview and case study

Methodologies for the analysis and cross-evaluations of Employee Assistance Programs (EAPs) are necessary to indicate program weaknesses and strengths for both present and future EAP services.^ As EAPs have matured from simplistic industrial alcoholism programs to all problem-encompassing, complex programs, an aggressive group of entrepreneurs has developed. Business and industrial managements need established criteria to select the most suitable professional services for their needs, as well as the best investment value for cost containments.^ Four major EAPs were compared to determine critical areas necessary for cross evaluation. Future standardization of terminology and definitions of services will facilitate both the evaluation of a specific program and its comparison to problems or successes of other EAPs.^ Past evaluation difficulties have been caused by the lack of EAP program accreditations and professional personnel licensure requirements. The Association of Labor Management Administrators and Consultants on Alcoholism (ALMACA) has recently set certification criteria for personnel, which will enhance the professional standards for EAPs. ^

INTAKE VARIABLES AS PREDICTORS OF ASSESSMENT AND REFERRAL PROCEDURE OUTCOMES IN EMPLOYEE ASSISTANCE PROGRAMS

While reported prevalence rates of troubled employees vary considerably, even conservative estimates indicate a major public health problem. For example, alcohol and drug related problems alone cost U.S. industry more than 45 billion dollars annually.^ Of the alternatives available to deal with these problems, e.g., dismissal or disciplinary actions, the most viable and cost effective are employee assistance programs (EAP), designed to provide professional assistance to employees experiencing alcohol, drug, emotional or personal crisis.^ The principal component of an EAP is that of assessment and referral, and this study was developed to determine which EAP client intake variables are the most efficacious predictors of assessment and referral procedures.^ Although, specific client intake variables were statistically significant the discriminant classification analysis was demonstrably inadequate. Nevertheless, the identification of A/R procedure phases which were not efficacious, as well as EAP client populations for whom services were not effective, were extremely valuable discernments. Identifying the less efficacious components of the A/R process provided an opportunity to recommend alternatives to current program procedures and practices, which may ameliorate program effectiveness. ^

Understanding the Influence of Photon Energy on 6MV Non Reference Dosimetry and CT Dosimetry using TLD and OSLD

Measurement of the absorbed dose from ionizing radiation in medical applications is an essential component to providing safe and reproducible patient care. There are a wide variety of tools available for measuring radiation dose; this work focuses on the characterization of two common, solid-state dosimeters in medical applications: thermoluminescent dosimeters (TLD) and optically stimulated luminescent dosimeters (OSLD). There were two main objectives to this work. The first objective was to evaluate the energy dependence of TLD and OSLD for non-reference measurement conditions in a radiotherapy environment. The second objective was to fully characterize the OSLD nanoDot in a CT environment, and to provide validated calibration procedures for CT dose measurement using OSLD. Current protocols for dose measurement using TLD and OSLD generally assume a constant photon energy spectrum within a nominal beam energy regardless of measurement location, tissue composition, or changes in beam parameters. Variations in the energy spectrum of therapeutic photon beams may impact the response of TLD and OSLD and could thereby result in an incorrect measure of dose unless these differences are accounted for. In this work, we used a Monte Carlo based model to simulate variations in the photon energy spectra of a Varian 6MV beam; then evaluated the impact of the perturbations in energy spectra on the response of both TLD and OSLD using Burlin Cavity Theory. Energy response correction factors were determined for a range of conditions and compared to measured correction factors with good agreement. When using OSLD for dose measurement in a diagnostic imaging environment, photon energy spectra are often referenced to a therapy-energy or orthovoltage photon beam – commonly 250kVp, Co-60, or even 6MV, where the spectra are substantially different. Appropriate calibration techniques specifically for the OSLD nanoDot in a CT environment have not been presented in the literature; furthermore the dependence of the energy response of the calibration energy has not been emphasized. The results of this work include detailed calibration procedures for CT dosimetry using OSLD, and a full characterization of this dosimetry system in a low-dose, low-energy setting.

Supplemental Nutrition Assistance Program: A policy analysis of restricting foods with minimal nutritional value

In 2011, expenditures for the Supplemental Nutrition Assistance Program (SNAP) reached an all-time high of $72 billion. The goal of SNAP is " to alleviate hunger and malnutrition…by increasing food purchasing power for all eligible households who apply for participation." It has been well established that proper nutrition is essential to good health, making SNAP an important program to public health consumers. Thus, this analysis examined whether SNAP is meeting its stated goal and whether the goal would be reduced if the purchase of foods of minimal nutritional value (FMNV) were restricted. ^ A review of existing literature found that SNAP has been shown to alleviate hunger, but the studies on the nutritional impact of the program were not sufficient to assert whether change is needed. When considering whether limiting FMNV would reduce or improve the effectiveness of SNAP at alleviating hunger and malnutrition, there is very little information on which to base a policy change, particular one that singles out a low income group to restrict purchases. ^ Several states have attempted to restrict the purchase of FMNV but, to date, no such change has been implemented or tested. Conducting pilot studies on the restriction of FMNV, along with better data collection on SNAP purchases, would guide policy changes to the program. Although there are many potential public health benefits to restricting FMNV purchase using SNAP dollars, research is needed to quantify the cost impact of these benefits.^

Information Management and Mediation in a Digital Reference Service Focused in Social Sciences

This paper investigates the current relationship between information management and information mediation along with the digital reference service through a case study which took place in an academic library. The concept of information mediation is herein analyzed, since a conceptual examination provides elements that will help people to comprehend and evaluate the concerned service. The information professional plays a very important role in the mediation aforementioned, which may be directly or indirectly; consciously or unconsciously; by himself/herself or plurally; individually or inserted into a group ? in all such manners that mediator facilitates the acquisition of information, fully or partially satisfying a user?s need of all sorts of knowledge. Meanwhile, we here approach information management from a scope that points out a description over performed activities concerned to policies and procedures put into effect until the service evaluation by proposing a criterion for such point. Finally, we outline a few actions to be implemented in long-term perspective, which goal is to continually ameliorate such assistance, taking in account the human factor