Pediatric obesity: Managed care collaborating with providers to improve diagnosis and treatment

Child overweight and obesity reaches across ethnic, cultural, socioeconomic and regional barriers. It must be assessed, diagnosed and treated to help families make sustainable behavior changes. Treatment recommendations have been made to address pediatric overweight and obesity. They include screening for risk factors, monitoring BMI trends and educating patients and families to make small sustainable changes. Health insurance companies can play a meaningful role in supporting and facilitating provider education and behavior change to diagnose, treat and prevent pediatric overweight and obesity.^ The aims of this thesis were: (1) Describe a disease management program that uses evidence-based practices to create provider behavior change related to pediatric obesity screening, diagnosis and treatment. (2) Identify ways to improve the implementation of the program based on the perceptions of participating clinicians.^ A literature review was completed to evaluate current recommendations for screening and treating pediatric obesity using the Ovid data base. The evidenced-based recommendations were compared against the practices of the Healthy Lifestyles Program (HeLP). The literature confirmed that HeLP is following evidence-based recommendations for assessment, diagnosis and treatment of pediatric obesity.^ A Children’s Mercy Family Health Partners focus group was convened to create a provider survey. The goals of the survey were to assess providers’ perception of the Healthy Lifestyles Program (HeLP). The survey was sent out through email using Survey Monkey. All survey responses were anonymous. The survey was sent to a total of 80 providers who had completed HeLP. Twenty-five percent responded. The survey results were evaluated to make recommendations for HeLP.^ Results of the survey included motivating factors for participation in HeLP. Concern about the increasing prevalence of pediatric obesity was a frequent motivator for participation. Provider barriers to obesity diagnosis were evaluated. Lack of time during clinic visits a frequent barrier to obesity diagnosis. ^ In conclusion several recommendations for the HeLP were made based on survey results. It is recommended that the program evaluate methods and tools for facilitating effective weight management follow up visits. Promotional materials should highlight the increasing prevalence of pediatric obesity when advertising HeLP. These recommendations will be used to refine the current Healthy Lifestyles Program.^

Specialized managed care for children with cystic fibrosis: Resource use patterns and rate design for a high cost Medicaid population

Objective. This research study had two goals: (1) to describe resource consumption patterns for Medi-Cal children with cystic fibrosis, and (2) to explore the feasibility from a rate design perspective of developing specialized managed care plans for such a special needs population.^ Background. Children with special health care needs (CSHN) comprise about 2% of the California Medicaid pediatric population. CSHN have rare but serious health problems, such as cystic fibrosis. Medicaid programs, including Medi-Cal, are enrolling more and more beneficiaries in managed care to control costs. CSHN, however, do not fit the wellness model underlying most managed care plans. Child health advocates believe that both efficiency and quality will suffer if CSHN are removed from regionalized special care centers and scattered among general purpose plans. They believe that CSHN should be "carved out" from enrollment in general plans. One alternative is the Specialized Managed Care Plan, tailored for CSHN.^ Methods. The study population consisted of children under age 21 with CF who were eligible for Medi-Cal and California Children's Services program (CCS) during 1991. Health Care Financing Administration (HCFA) Medicaid Tape-to-Tape data were analyzed as part of a California Children's Hospital Association (CCHA) project.^ Results. Mean Medi-Cal expenditures per month enrolled were $2,302 for 457 CF children, compared to about \$1,270 for all 47,000 CCS special needs children and roughly $60 for almost 2.6 million ``regular needs'' children. For CF children, inpatient care (80\%) and outpatient drugs (9\%) were the major cost drivers, with {\it all\/} outpatient visits comprising only 2\% of expenditures. About one-third of CF children were eligible due to AFDC (Aid to Families with Dependent Children). Age group explained about 17\% of all expenditure variation. Regression analysis was used to select the best capitation rate structure (rate cells by age and eligibility group). Sensitivity analysis estimated moderate financial risk for a statewide plan (360 enrollees), but severe risk for single county implementation due to small numbers of children.^ Conclusions. Study results support the carve out of CSHN due to unique expenditure patterns. The Specialized Managed Care Plan concept appears feasible from a rate design perspective given sufficient enrollees. ^

Cost -effectiveness of services and treatments for ambulatory dually diagnosed CMHC clients: Implications for managed care

This paper reports a cost-effectiveness analysis of standard therapeutic interventions received by ambulatory dually diagnosed clients of a Community Mental Health Center (CMHC). For the purposes of this study dually diagnosed was defined as a DSM-III-R or IV diagnosis of a major mental disorder and a concomitant substance abuse disorder. The prevalence of dually diagnosed people among the mentally ill and their unique and problematic nature continues to challenge and encumber CMHCs and poses grave public health risks. An absence of research on these clients in community-based settings and the cost-effectiveness of their standard CMHC care has hindered the development of effective community-based intervention strategies. This exploratory and descriptive effort is a first step toward providing information on which to base programmatic management decisions.^ Data for this study were derived from electronic client records of a CMHC located in a large Southwestern, Sun-belt metropolitan area. A total of 220 records were collected on clients consecutively admitted during a two-and-one-half year period. Information was gathered profiling the clients' background characteristics, receipt of standard services and treatments, costs of the care they received, and length of CMHC enrollment and subsequent psychiatric hospitalizations. The services and treatments were compared with regard to their costs and predicted contributions toward maintaining clients in the community and out of public psychiatric hospitals.^ This study investigated: (1) the study groups' background, mental illness, and substance abuse characteristics; (2) types, extent, and patterns of their receipt of standard services and treatments; (3) associations between the receipt of services and treatments, community tenure, and risk of psychiatric hospitalization; and, (4) comparisons of average costs for services and treatments in terms of their contributions toward maintaining the clients in the community.^ The results suggest that substance abuse and other lifestyle factors were related to the dually diagnosed clients' admissions to the CMHC. The dually diagnosed clients' receipt of care was associated strongly with their insurability and global functioning. Medication Services were the most expensive yet effective service or treatment. Supported Education was the third most expensive and second most effective. Psychosocial Services, the second most expensive, were only effective in terms of maintaining clients in the community. Group Counseling, the fourth most expensive, had no effect on community maintenance and increased the risk of hospitalization when accompanied by Medication Services. Individual Counseling, the least expensive, had no effect on community maintenance. But it reduced the risk of hospitalization when accompanied by Medication Services. Networking/Referral, the fifth most expensive service or treatment, was ineffective.^ The study compared the results with findings in the literature. Implications are discussed regarding further research, study limitations, practical applications and benefits, and improvements to theoretical understandings, in particular, concepts underscoring Managed Care. ^

Broadcast and Band Phosphorus and Potassium Placement for Corn and Soybean Managed with Till or No Till

No-till minimizes the incorporation of crop residue and fertilizer with soil; resulting in wetter, colder soils and the accumulation of organic matter, phosphorus (P), and potassium (K) near the soil surface. Banding of P and Kcould be more effective than broadcast fertilization by counteracting stratification, applying nutrients in the root zone (starter effect), and minimizing reactions with the soil that may reduce their availability to plants. Therefore, a long-term study was established in 1994 to evaluate P and K fertilizer rates and placement methods for grain yield of corn and soybean managed with no-till and chiselplow/disk tillage.

Biochar and Managed Perennial Ecosystems

Biochar is a carbon-rich material that is similar to charcoal. It is produced when biomass is burned in the absence of oxygen, a process otherwise known as pyrolysis. Pyrolysis and the production of biochar are currently being promoted as a means to both produce domestic fuel (bio-oil) while concurrently producing a co-product that increases crop yield and sequesters carbon in the soil (biochar). While there may be many potential benefits in the application of biochar to agricultural soils, such as enhanced soil fertility and improved soil water status, there are no studies of higher-order ecological and ecosystem effects of biochar and its potential synergistic interactions (either positive or negative) on complex perennial systems. The goal of this field experiment is to determine how biochar and manure addition directly affect ecosystem structure and function in perennial systems, specifically soil nutrients, water, plants, and soil organisms.

Phosphorus and Potassium Rates and Placement Methods for Corn and Soybean Managed with No-till or Tillage

No-till management for corn and soybean results in little or no incorporation of crop residues and fertilizer with soil. Subsurface banding phosphorus (P) and potassium (K) fertilizers with planter attachments could be more effective than broadcast fertilization, because in no-till with broadcast fertilizer, both nutrients accumulate at or near the soil surface. A long-term study was initiated in 1994 at the ISU Northwest Research Farm to evaluate P and K fertilizer placement for corn and soybean managed with no-till and chiselplow tillage.

Placement Methods of Phosphorus and Potassium for Corn and Soybean Managed with No-till and Chisel-plow/Disk Tillage

No-till management limits the incorporation of crop residue and fertilizer with soil resulting in wetter, colder soils and the accumulation of organic matter, phosphorus (P), and potassium (K) near the soil surface. Banding of P and K could be more effective than broadcast fertilization by counteracting stratification, applying nutrients in the root zone (starter effect), and minimizing reactions with the soil that may reduce their availability to plants. Therefore, this long-term study was established in 1994 to evaluate P and K fertilizer placement methods and grain yield of corn-soybean rotations managed with notill and chisel-plow/disk tillage.

Epiphytic orchid diversity and community composition in managed and natural moist evergreen Afromontane forest in SW Ethiopia

In SW Ethiopia, the moist evergreen Afromontane forest has become extremely fragmented and most of the remnants are intensively managed for coffee cultivation (Coffea arabica), with considerable impacts on biodiversity and ecosystem functioning. Because epiphytic orchids are potential indicators for forest quality and a proxy for overall forest biodiversity, we assessed the effect of forest management and forest fragmentation on epiphytic orchid diversity. We selected managed forest sites from both large and small forest remnants and compared their epiphytic orchid diversity with the diversity of natural unfragmented forest. We surveyed 339 canopy trees using rope climbing techniques. Orchid richness decreased and community composition changed, from the natural unfragmented forest, over the large managed forest fragments to the small managed forest fragments. This indicates that both forest management and fragmentation contribute to the loss of epiphytic orchids. Both the removal of large canopy trees typical for coffee management, and the occurrence of edge effects accompanying forest fragmentation are likely responsible for species loss and community composition changes. Even though some endangered orchid species persist even in the smallest fragments, large managed forest fragments are better options for the conservation of epiphytic orchids than small managed forests. Our results ultimately show that even though shade coffee cultivation is considered as a close-to-nature practice and is promoted as biodiversity conservation friendly, it cannot compete with the epiphytic orchid conservation benefit generated by unmanaged moist evergreen Afromontane forests.

Architectures for Video-on-Demand content distribution in managed networks

La demanda de contenidos de vídeo ha aumentado rápidamente en los últimos años como resultado del gran despliegue de la TV sobre IP (IPTV) y la variedad de servicios ofrecidos por los operadores de red. Uno de los servicios que se ha vuelto especialmente atractivo para los clientes es el vídeo bajo demanda (VoD) en tiempo real, ya que ofrece una transmisión (streaming) inmediata de gran variedad de contenidos de vídeo. El precio que los operadores tienen que pagar por este servicio es el aumento del tráfico en las redes, que están cada vez más congestionadas debido a la mayor demanda de contenidos de VoD y al aumento de la calidad de los propios contenidos de vídeo. Así, uno de los principales objetivos de esta tesis es encontrar soluciones que reduzcan el tráfico en el núcleo de la red, manteniendo la calidad del servicio en el nivel adecuado y reduciendo el coste del tráfico. La tesis propone un sistema jerárquico de servidores de streaming en el que se ejecuta un algoritmo para la ubicación óptima de los contenidos de acuerdo con el comportamiento de los usuarios y el estado de la red. Debido a que cualquier algoritmo óptimo de distribución de contenidos alcanza un límite en el que no se puede llegar a nuevas mejoras, la inclusión de los propios clientes del servicio (los peers) en el proceso de streaming puede reducir aún más el tráfico de red. Este proceso se logra aprovechando el control que el operador tiene en las redes de gestión privada sobre los equipos receptores (Set-Top Box) ubicados en las instalaciones de los clientes. El operador se reserva cierta capacidad de almacenamiento y streaming de los peers para almacenar los contenidos de vídeo y para transmitirlos a otros clientes con el fin de aliviar a los servidores de streaming. Debido a la incapacidad de los peers para sustituir completamente a los servidores de streaming, la tesis propone un sistema de streaming asistido por peers. Algunas de las cuestiones importantes que se abordan en la tesis son saber cómo los parámetros del sistema y las distintas distribuciones de los contenidos de vídeo en los peers afectan al rendimiento general del sistema. Para dar respuesta a estas preguntas, la tesis propone un modelo estocástico preciso y flexible que tiene en cuenta parámetros como las capacidades de enlace de subida y de almacenamiento de los peers, el número de peers, el tamaño de la biblioteca de contenidos de vídeo, el tamaño de los contenidos y el esquema de distribución de contenidos para estimar los beneficios del streaming asistido por los peers. El trabajo también propone una versión extendida del modelo matemático mediante la inclusión de la probabilidad de fallo de los peers y su tiempo de recuperación en el conjunto de parámetros del modelo. Estos modelos se utilizan como una herramienta para la realización de exhaustivos análisis del sistema de streaming de VoD asistido por los peers para la amplia gama de parámetros definidos en los modelos. Abstract The demand of video contents has rapidly increased in the past years as a result of the wide deployment of IPTV and the variety of services offered by the network operators. One of the services that has especially become attractive to the customers is real-time Video on Demand (VoD) because it offers an immediate streaming of a large variety of video contents. The price that the operators have to pay for this convenience is the increased traffic in the networks, which are becoming more congested due to the higher demand for VoD contents and the increased quality of the videos. Therefore, one of the main objectives of this thesis is finding solutions that would reduce the traffic in the core of the network, keeping the quality of service on satisfactory level and reducing the traffic cost. The thesis proposes a system of hierarchical structure of streaming servers that runs an algorithm for optimal placement of the contents according to the users’ behavior and the state of the network. Since any algorithm for optimal content distribution reaches a limit upon which no further improvements can be made, including service customers themselves (the peers) in the streaming process can further reduce the network traffic. This process is achieved by taking advantage of the control that the operator has in the privately managed networks over the Set-Top Boxes placed at the clients’ premises. The operator reserves certain storage and streaming capacity on the peers to store the video contents and to stream them to the other clients in order to alleviate the streaming servers. Because of the inability of the peers to completely substitute the streaming servers, the thesis proposes a system for peer-assisted streaming. Some of the important questions addressed in the thesis are how the system parameters and the various distributions of the video contents on the peers would impact the overall system performance. In order to give answers to these questions, the thesis proposes a precise and flexible stochastic model that takes into consideration parameters like uplink and storage capacity of the peers, number of peers, size of the video content library, size of contents and content distribution scheme to estimate the benefits of the peer-assisted streaming. The work also proposes an extended version of the mathematical model by including the failure probability of the peers and their recovery time in the set of parameters. These models are used as tools for conducting thorough analyses of the peer-assisted system for VoD streaming for the wide range of defined parameters.

Formas de mensuração X stewardship: implicações nos ativos biológicos

A aprovação da norma contábil IAS 41- Agriculture em 2001 trouxe uma série de desafios nas práticas contábeis das empresas, sendo a principal delas o reconhecimento de ganhos/perdas durante o crescimento biológico de um ativo e a mensuração destes ganhos/perdas pelo valor justo. Toda forma de reconhecimento e mensuração apresenta relação com o modelo de negócios da empresa e irá afetar o relacionamento entre os envolvidos neste contexto e a forma como os usuários da informação contábil avaliam a gestão dos recursos investidos na entidade, que é o stewardship. Desta forma o objetivo deste trabalho foi discutir quais e como os fatores internos e externos presentes no contexto social das organizações, contribuíram para que a informação contábil a valor justo atingisse o objetivo de stewardship. Para isto foi realizado um estudo etnográfico por meio de entrevistas direcionadas aos responsáveis pela informação contábil em onze empresas de diferentes segmentos do agronegócio. O modelo de analise primeiramente se ateve ao entendimento do Modelo de Mensuração dos ativos biológicos dentro destas empresas, e como esta informação é utilizada para fins de stewardship. Em três empresas, a informação contábil referente ao ativo biológico é utilizada para fins de avaliação de performance global e do gestor e para o relacionamento com o credor, que constituem elementos para a proxy do stewardship. O processo de mudança nestas empresas, analisado conforme modelo desenvolvido por Miller (1991) se deu primeiramente pela Problematização ocorrida no contexto social destas empresas, em que seu modelo de negócios tem a madeira como produto final, bem como no modelo de gestão que visa em primeiro lugar o retorno do capital investido, mensurado pela valorização da floresta ao longo dos anos. Os atores que agem para que isto se torne numa mudança efetiva, denominados de Comunidades Epistêmicas, são os acionistas e os credores destas empresas. Os acionistas que são fundos de investimentos têm que apresentar aos seus cotistas a valorização destes investimentos, e o credor (em uma das empresas) vincula a garantia dos empréstimos ao valor da floresta. Também atua neste processo de uma forma mais distante (Ação à Distância) a cultura dos fundos de investimentos, em que a gestora florestal é responsável pela formação e venda de novas áreas florestais, bem como a legislação específica da constituição destes fundos. Nas outras empresas, além de o ativo biológico ser um insumo de produção no modelo de negócios na maioria dos casos analisados, o modelo de gestão é baseado na eficiência operacional. Desta forma, a mensuração a ser utilizada deve ser relacionada tanto ao modelo de negócios como ao modelo de gestão da empresa, que são fatores que revelam como os ativos estão sendo geridos, e isto influencia na perspectiva de geração de caixa do negócio. Apesar da obrigatoriedade que uma norma contábil impõe, a prática contábil segue suas próprias leis no âmbito social que operam as empresas, e qualquer alteração imposta passa por um extenso processo de problematização antes de esta norma ser socialmente aceita.