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Health Care: for People or for Profit?

Date: 22 Oct 1987 (est.)
Length: 517 pages
TIMN0322275-TIMN0322791
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Rtlomas E. Getzesl, TenQle Dnivcrsity ABILITY CF TH'S EIlE188 TO AFPOHD ISFBZAM Ata) IMSUFiANCE Microdata on 18,599 persons in the 1982 Social Security Administration "Mew Beneficiary Survey' is analyzed to determine the affordability of lifecare as defined by a linear function of i2lmne and wealth. Using 1983 1reaI1 charges of $64,500 and 1,278 nrrlthly for oouples, and $44,000/734 ooflt111y for singles, 31% of all retirees could afford lifecare. This included 35% of married eouples, 32% of single mell, and 24% of single women. Blacks (5a), Iatinos (13E), Southerners (27t), notl-3LSA (26%), large households (22E) and early retirees (29t) are less likely afford lifecare, l.hile Westerners (381) and the college educated (54%) are nore likely. Health is a major predictor of ability to pay. Those uA1o quit working for health reasons (20t), had nore than 21 sick days (19%), six or more specified health problems (17%), or were bedridden (15%) Wxre consistently less able to pay for private long tem care services. Those working wilile retired (33%) or who delayed retireinent past age 69 (49b) had greater financial resources as well as better than average health. ZH_P_ioir_ot+ski, LR LaPalio, EB Prye, L Piccoli c ea sP ta , rq'n, no s CHANGES IN THE EPIDEMIOLOGY OF HOSPITAL CARDIOPULNONARY RESUSCITATION PRACTICES (CPR) AFTER THE INTRt)DUCTION OF A DO-NOT-RESUSCITATE (DNR) POLICY. Medical Technology has provided increasing ability to monitor/treat critically ill patients. When medical intervention only serves to prolong suffering, patients/families consider the option to withhold CPR, a decision termed DNR. Hospital guidelines for DNR orders are increasingly more cosnon. Compliance with a ONR policy will not only ensure that the decision is iade in a medically responsible, ethical and sensitive process that protects the rights of patients and families, but one can expect changes in the practice of CPR. A four-year retrospective study was undertaken of CPR p-atients and all hospital mortalities before and after institution of a hospital-wide DNR policy. Over 2,400 deaths, 1,050 CPR's and 200 DNR orders were examined. Evidence of change was determined by examining: proportion and repeat CPR rate, survival rate per CPR, length of stay, discharge status (nursing home vs own residence). Threats to interpretation in future studies are discussed. 1009 Annrew D. Miller, M.D., M.P.H., New Jersey Departnent of Health, and Robe,tt W. Sherwood, Jr., M.A., H.S., Utah Defaartment of Health A S(IIiVf.Y T'O DEt'FRFffSqg CYMLZq t:OAIla Ab'D AtR•LVIT= GE' STA'1'E Ma'1.LTH D6PARTM€NT [NITS RFSPCfqSIDLE FYR y.rarsCra;qryg LOGIL IE71LTH DEPAFUVINtS In moat States, basic public health services are provided by local health departmefits (LMs) . state health dapartments (SFlae) may relate in a number of different ways with IfDDs, e.g. setting perfor- n>a21ae standards, evaluating IID) perfozaellce, providing training and technical assistgllce, administrsing the distribution of State Aid funds to LEDs, or servillg as a liaison betweea S[D psograsss and LMDS. A survey of the directors of SFfl units responsible for liaison with LH)s was undertaken in order to determifle cam+on rolea of these units. The survey asked aboat the goals, activities, and resources of these SfID units. The .info,m:aticn obtained will be shared amoflg the directors of the State units as well as others interested in the relationship between State and local healt3l depuut nrnts. 1010 N rli ^h 11 g A a i kfn-rr.e-.r se_n_ rinor v nedt a+ Pian, tr.e_ fDDICAID ELIGfatES Ix F81Qs: CLIfXf SATISFACSIqf Although the use of prepald fioancinq by the Medicaid proqrm is no longer a nev coe- cept, little inforaation an the outcors of such daeonstrations has been available. Data on outcome aeasures, such as client satisfactioe with care, have been particularly lackinq. Is this paper, ve exaaine patterns of Medicaid elidibles' experience vith care provision md their satisfaction with health care services under the tee-foz- service systn and tvo years later under the saaaged, prepaid systee of care. In June of 1955, Monroe Cm smty, New York, began to impleeent a federally-sponsored desonstratlon prolect of a sanaged, capitated pre-paid systu of care provision for Medicaid recipients. A pre-earolisent interview vas coeducted to exmine !Sedicaid eligibles' satisfaction vith bealth care reeeived in the fee-for-service systee. After one year's experience vlth a eandatorily enrolled Medicaid population, a follov-up •urvey was conducted and 900 questiovmaires vere coepleted. This paper coeyares data froe both surveys. Dfsenslons of client satisfactioa, such as, huaaneness of doctors, quality of ure, and general satisfactfos vith the sediul carm received, as well as, chanqinq patteras of carm are exmined. In addition, attestios is given to satisfaction with the client-provider relationship under sanaged ure, the extent and re.aons for dissatisfactioo, end ciieots' uoderstandioq of the procedures for obtaining health care is a sanaged delivery systee. 6 ABSTRACTS C. Doberty, MPA, a. Teskla-Grev;.er, r C. Ryan 4uetS.r, YPA nonroe Cuuoty MedlCsp Plan, Inc. MIDICAID IK ,3lDS: nAl1lGED URF RLYISITiD pecent Leqislative chaoges affectiaq the Medicaid progras proepted .any state and local offlcials to look far aiternatives to the fee-for-sarvice systee of financing and care ,rovisioa. treyaid, na.^.aged care, via ENOS, hu become the focus of aany Yedicaid officials atteapting to find sore cost-effective rays of providing care to %ad:cald recipients. The enthusiase for the cnncepts of prepayin¢ and aanaged .are is under- staadmle qlven the preliferaticn of catch-vords msociated vlth it, such m"cost coetrof," "ccmprehensive, continuous, and coordinated ure," ete. Yet, this enthusiase easily aasks the very lisated experiecce of t&Aa with health care provision to the sedicaid population. This pape$ describes and analyzes the ryriad of adainistrative, eesDer, and provider related lssues involved in establishlr.q snd ealntafniog nedicaid-Fpq risk arrangesents. The wncept of aanaged care, to which the success of 19f0s is so frequently attributed, is reexmined since Medicaid prepayaent functions differently in sany important vays froe privately financed prepaysent. Issv:es crucial to the success or failure of nedicaid risk contracting which are e:mined Sn this paper include: ditfennces totveer the Medicaid versus traditioral nD0 benefit paekage, the role of the primary care provider in controllinq utilzzation of services which are not provided (or are Ilslted) uoder the traditional HMD benefit package, coordination of pre-existinq (fe.-for-service patterns of care upon enrollsent of the Medicaid aeebers in the 1ClD, fears and realtties of adverse seleetioo. This preseatatioo is based on tvo years of risk-coatractinq experience betveen the sonroe County nediCan Plan. Incs and tvo ig10s, for the provision of prepafd, sanaged a. Teakin-Greener, Ph.D. aad_ J. a. Jeaser. 7.s. Monroe Countf MediCap Pla_n, Inc. CAPITASIGN AATE SErrIMG: SCIFNCE, Aii1', MAGIC? :his paper describes and analyzes the rate setting experience of the Monroe County MediCap Plan, Inc. Ie 1902, nMediCap beuae one of five natfonwlde Medicaid desonstra- tioes sponsored by DCFA to test a variety of alternative delivery strategies for tkdiui recipients. Prepaid capiutioo hm beea explored by all of the deeenstratfons, with rate setting sethodoloqies and processes proving to be both complex and crontroverilal. Capitation has been a serious alternative to traditional eharge and cost reiaburses.nt since the 1970s. And, aithough a n:osber of states are agressively pursuing enrolleent of aedicaid recipients ln a variety of nM0 eodels, little is knovn today about the swtnodoioqy md the process of estabilshioq adequate and appropriate payment rates. A variety of rate setting aproaches - actuarial, .arket oriented and politlcal - can tv found operating, sosetises all at the saae tiae. . Ia this paper, a risk-adluaied capitaficn ecdel operatlnq in Monroe County alnce August of 1985 ls described and analy:ed in teras of its tapact on the p.yora and the providers. The ettects of annual fluctuations in aorolieent case-s1x are exaalned as are the costs of the eligibility extenders vhlch quarantee a siz eontA enrollsent for any Medicaid eligible entering the pre-pafd proqrm. Furthersore, this paper explons L9e prohlems of data araflabtlity aad quality, rate setting sethodoloqies, and rate negotiations vith payors and providers. Robert E- Hurley, UNC-Chapel Hill, Steven Garfinkel, Research Triangle f - institute A ST&OCfDRAL 1.`IALYSIS OF MEDICAID MAHAGED CARE DEMONSTRATIONS This paper exaaines the inter- and intra-organizational design features of several Medicaid alternativa delivery system plans. The nature of contractual relationships and mnt[wds of payment are used to explore ho risk-sharing is distributed among Medicaid agencies, intermadiary eatities, and health care providers. Though theory-basad, the paper illustrates in non-theoretical language the rationales and relative advantages and disadvantages of different plan struetures. flaas in five states are briefly described and contrasted based on structural cosmanalities and differences. One state which operates a multiple plan program is examined in detail. This state permits hospital out- patient clinics, neighbothood health centers, an IPA, and individual, inaffiliated physicians in the same managed care demonstration. Varia- tions in Medicaid contracting, provider payment, patient management and administrative control methods are examined and linked to the strua- turns of each plan type. The paper coneludes with a diacussion of the prescriptive implications of this analysis for program designers and managers. Mehdi Nassirpour, Ph.D.; Gary J. Giacomel4i, M.P.A.; Oft_rtce of Prozrau Analvsis, Illinois nepartm.nt of Public Aid A cOHOLT dMALYSIg Os' M[DICAID HMD DISEIRdLLEIg I1 ILLIIOIf Disenrollment patterns among Medicaid populations partieipating in BMOs have significant effects upon public policy both t the state and national levels. Limited information exists concerning the dis- enrollment pattern among Medicaid 8M0 enrollees. Usine Life Table Model, this paper examines the longitudinal experience aver four yeare of the AFDC (Aid to Families With Dependent Children) casea who en- rolled in BMOs during July 1982 through June 1996 period. Particular attention was given to the voluntary/undatory disenrollment patterns among the selected cohorts, controlling for socio-demographic char- acteristics and,health-related factors, such as age, sex, family size, duration of enrollment and level of satisfaction vith services. To identify possible deterainants of the disenrollment pattern, soeio- deaographic and health-related factors were tested through logistic regression. Results and policy implication of the findings as well as the lessons learned and generalization to other state Medicaid programs are discussed. TIlVIN 322463 .r
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Hitchell F. Riv. Ph.D. Louisiana State University THE RISE A38) DEt;LINE OF BL1CR HOSPITALS IN THE UNITFD STATES From the late 1800s to the 1980s approximately 400 black hospitals have existed to provide hospital/medical care to the black population. By 1986 only 30 black hospitals remained. Research has pointed out that segregation policies and practices in many states and cosunities led to the rise of black hospitals. This paper examines the origin and development of early black hospitals, the roles and contributions of philanthropy organizations, donors and foundations in the funding and support of blaek hospitals, and the con8itions and circumstances which have led to the virtual demise of black hospitals. The conclusion offers and discusses strategies necessary for the survival of black hospitals. O O Leonard H. Glantz, J.D., Boston University School of Public Health MANDATORY DRUG TESTING: IS IT CONSTITUTIONALLY PERMISSIBLE? During the past two years, the federal government, along with a nua of states and cities, have instituted drug screening programs for a vat of employees. While these policies have been justified on public healt grounds, such as locating and treating drug abusers or protectinq the public from impaired employees in public safety jobs, this paper argue<- that such policies are thinly veiled law enforcement procedures. A nun of courts have addressed the constitutionality of drug screening progra with decisions coming down on both sides of the issue. This paper expl how courts have analyzed the issue, the factors that have led some cou to uphold such programs and other courts to invalidate them, and the danger to individual liberty that these programs engender. This paper also explores when it might be constitutionally permissible to test go mental employees for drug use, and how to approach the issue from a tr public health perspective. Wendy K. Hariner Harvard School of Public Health EQUAL PROTECTION REVIEW OF ACCESS Tn HEALTH CARE AFTER C EBURNE The need to 7imit resources spent on health care has spawned diverse measures to reduce federal and state government benefits under Medicare, Medicaid, and other programs. Such measures may result in excluding some groups of people from access to important health care services in ways that could be considered violations of eeual protectic under the federal or a state constitution. While traditional eousl protection analysis has generally deferred to legislative determination of social welfare benefit levels, several U.S. Supreme Court decisions indicate that differential access to basic health care miqht be scrutin more closely. The author will consider the likelihood that newer rationality review, as exemplified in Cit of Cleburne v. Cieburne Livi Center, can be applied to ensure that ene t deterpiinat ons do not unreasonably prejudice access to basic health care by the medically needy. Aadrea toz ScSuazt:. D.,iavere Di.isioa of Publie 6ealth A EnSM LOOK AT A DYInG ISSUE. This paper presents a unique framework for understanding the Constitutional and Social-Cultural issues surrounding a patient's right to die. Although this issue has been addressed froa a number of different perspectives in the past, a number of critically signifieaqt issues have been uniformly ignored. Legislative developments have not, in general, kept pace with technological development in the Health and Medical arenas. Moreover, the advocacy of patient's rights as recipients of these advanced technologies have frequently been adsrepresented, especially with respect to the right to refuse them. The United Btates Constitution and The Bill of Rights protect the fundamental rights of individuals to choose their own treataent protocol. These issues will be addressed in the contezt of patiant advocacy and proposals for significantly isprovad legislation will be outlined. 1091 Roaer y gg¢Q American Red Cross, Biomedical R & D, Rockville, MD CURRENi RESULTS FROM SCREENING PROGRAMS FOR HIV ANTIBODY IN THE UNITED STATES Routine screening for anti-HIY in the U.S. is confined to blood and plasma donors, military personnel and prospective recruits. These populations are not at increased risk of HIV infection and are screened, or self-selected for absence of risk factors prior to testing. Consequently, screening programs generate information about the spread of HIY infection into the so-called 'normal" population. The results of major national screening programs will be reviewed and contrasted with the epidemiologic pattern for overt AIDS. Overall, the prevalence of confirmed positives in screened populations is much less than 1% and, despite the use of highly sensitive and specific tests, the predictive value of a positive ELISA test may be less than 10%. These data have a critical bearing on the need for confirmatory tests and an laboratory quality control. Charles A. Schable, AIDS Program, Centers for Disease Control, Atlanta, GA HIV ANTIGEN TESTING HIV antigen testing is a new and potentially quite useful tool in the overall analyses of HIV infection. The current tests are entymeissnmoassaya which neasure p24 antigen in serum or cell culture fluids by antigen-capture. For detecting HIV in cell culture, the antigen assay was 2 orders of magnitude more sensitive than the reverse transcriptase assay. No cross-reactivity was noted with HTLV-1, HTLV-2, CMV, Varicella-toster, HSV-1, EBV, Adeno-5 or Polio-1. For detecting HIV antigen in serus there are 2 clear roles: first, detection in very early infection before antibody has developed and second, the~reappearance of antigen combined with a loss of p24 antibody seems to herald i poor prognosis. Brenda McEvoy DeVellis, Ph.D., University of North Carolina at Chapel Hill JA iBIY THEORY AND ATTBIBUTION THEORY First, an argument for the utility of theory-informed interventions to the field of health education will be .ade. Tne re.ainder of the presentation vill foc5&on attribution theory and its relevance to the development of health education interventions. Attribution theory and the assumptions that underlie it will then be briefly described. Cosson aisunderstandings about this and other "cognitive" models will be discussed. Examples of the utility of this theory to understanding health behavior will be presented. These examples will draw on research done by the speaker and by others. Meredith Minkler, jh•.P.H., Associate Professor, School of Public Health, University of California, Berkeley Social Support Theory Revisited While social support theory has become an important part of health education's theoretical base, recent research has raised important questions about how social support actually operates to prevent disease and promote and maintain health. This paper will review current thinking about the "buffering" and the direct or 'main effects' hypotheses as well as new evidence for the notion that social support may work principally by contributing to a broader sense of coherence or control. Finally, ethical issues will be raised concerning the use and misuse of social support theory and research to further public policy objectives. TIMN 322504 ABSTRACTS 47
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/( r n R.va ~ , Dscldra2Caad.c(,tt2, Ca/u.w.6ik (tu,Lerr,~ pE;Ltou~F(.. cAR4 dE~6++a6NCY QV Ttfir otdE+! t~t+th7)oM ? P[Vl-l'I3v/ The aging of the population of the United States has °and will continue to necessitate changes in services designed to meet the needs of older people who are dependent in personal care. An important question for gerontological research is whether the rate of age-specific personal care dependency in the older population has increased, decreased, or remained the sanx over the past two decades. While age-specific mortality has declined, the relationships between mortality, morbidity, disability and dependency are complex and mortality is an insufficient measure for answering the question. This paper presents preliminary findings from research that entails a secondary analysis of national probability sampled data on activities of daily living, the means chosen for operationalizing the construct personal care dependency. The paper examines whether or not there was change in the rate of dependency and discusses the impact of the findings on the health, the quality of life, and on unmet need for health services among the older population of the U.S. 1047 Pattee, Christine, DrPg, CT Dept. of Health Services; Korbin Liu, Ph.D. Urban Institute. TRUE LEtrGTH OF STAY FOR NURSING HQ.E pATIEt.'TS. Knowledge of true length of stay for nursing hone patients is necessary for insurance companies to accurately cost out long term care benefit plans, and for state governments to make policy and budget de- cisions on long term care delivery. The Connecticut Nursing Eome Data Set is being used to make reco®endations on these issues. Eight years of demographic and functioning level information from Connecticut nursing homes was compiled into a longitudinal data set in which individual patient records are traced from date of first adnis- sion to final outcome date, i.e., last discharge, or death, including death in a hospital or other setting after discharge from the nursing home. Patient "institutional histories", i.e., movements among home, hospital and the nursing home during the length of stay period, will be described along with true length of stay. Characteristics of the patient population will be differentiated according to whether they are "short or long stayers", with particular emphasis on mental and rehabilitative patients. Length of stay and pay ment source are analyzed in relation to the time it takes for an indi- LvIdual to seend down private resources and so into Medicaid. Spector W.D., &aDp MC. Centers for Gerontolo and Health Care Research. Brown University, Providence, Rii. 0291 . 1DISCHARGE STATUS AND SUBSEQUENT DESTINATIOND FOR NURSING HOME RESIDENTS Few studies have followed nursing home residents beyond their disposition at discharge. This paper presents results of a follov-up study of two cohorts of nursing home residents, one group admitted in 1982 (ih3,276) and one adnitted in 1984 (N-3,727). All individuals were admitted to the nursing home from an acute care/general hospital, had not been residents of a nursing home in the previous year, were 65 years or older at the time of admission, and were admitted to one of 48 for-profit nursing homes. Post-discharge locations were tracked for three months; individuals who remained in the nursing home or were re-admitted were followed until death or for up to one year. The pattern of first and second locations for these two cohorts are presented. Approximately 95% of this population vas discharged within one year of admission. Of the one-third nho went home, the majority remained there at least three swnths. However for the one-third who were discharged back to the hospital, approximately tuo-thirds returned to the same nursing home, while the majority of the balance died in the hospital. With subsequrnt nursing home stays, discharged residents were more likely to go to the hotpitul and less likely to be discharged home. William Barker, N.D., Peter Nott, M.D., Anne Bryer, i7.0. University of Rochester (New vork) INCIDENCE AND HAhAGEMENT OF AC11TE ILkNESS EPISODES IN LON,-TERfi CARE FACILITIES. A COt!PARISON BETWEEII THE U.S. AND U.K. While functional status of lonq-term care (LTC) patients has been studied extensively in recent years, little is known about the patterns of acute i1lne.s episodes (AIEs) among those highly vulnerable persons. This paper compares and contrasts incidence and types of AIEs and their medical management as measured systematically in two LTC facilities (LTCFs), one in the U.S. and one in the U.K. The two LTCFs were comparable in size (90-100 beds), and residents were similarly very aged with high prevalence of dementia and AL dependency. LongitudinaT record reviews revealed rates of 163 and 157 medically attended urgent AlEs per 1000 patient months in the U.K. and U.S. LTCFs, respectively. Types of AIEs were very similar with infections, druy-related problems, and trauma most conmon. Rates of acute hospitalization differed mark- edly: 4 per 1000 pt. mos. in the U.K. versus 41 per 1000 in the U.S. These rates reflect national differences in rate of hospitalization from LTCFs compiled from data available for the two countries. The lower rates in the U.K. may be attributed to the active role of geriatricians in ongoing medical care in LTCFs as part of canprehen- sive geriatrics services in that country. J. Lian¢ (U. of Michigan), Ed Tu (NYS Dept. of Health), and N. s~hlte-law (U.-o€ Mi.ehigan) THE RISK FOR INSTITUTIONALIZATION AMONG THE AGED In a previous paper(Liang i Tu, 1986), a double-decrement life table was constructed to assess the lifetime risk o€'nursing home residency. One limitation of this approach is the- assumption that once an individual enters an institution, he will be there until his death. This assumption would undoubtedly lead to an ovet'dstiaation of the risk of institutionalization. In the present paper we develop an increment-decrement life table to estimate the lifetime risk of institutionalization for the elderly in the U.S. Using the 1976 National Nursing Home Survey 4 the U.S. Life tibles, we construct 3 tables dealing with noninstitutionalization, institutionalization, and death respectively. The probability of entering a nursing home is derived. We compute tWe proportion of cohort life spent in nursing homes at various ages. The lifetime ri3k of institutionalization is .29r' and the probability of entering a nursing home for an individual 6S years of age is .3S6. The proportion of entire life cohort life spent in nursing homes is 4.6%. The proportion of cohort life over age 6S in nursing homes is 22.9tr ~~~faawaissere Pbb Cvnthia Creadv AB Unwersitv North rolins of ounci,. on ne C HOSPITAL-TO-NURSING-HOHE PLACEMENT DELAYS: A PILOT STUDY Unnecessary hospital stays of patients awaiting transfer to a nursing home has been a major problem for years, now worse with DRGs. Researeh suggests that heavy care needs of the patients and Medicaid coverage are the main causes. But the literature is weak in studies where the patient vat the unit of analysis. Our pilot study of 1019 discharges to nursing homes from 3 large hospitals in a low-nursing-home-bedded city with a moderate Medicaid payment rate produced different results. Rates of placement delay averaged 64% of nursing home transfers for the 3 hospitals. Multiple regression analysis showed that neither Medicaid coverage nor most heavy care problems were a cause of placement delays, ,Huch mora important was the time it took to get Medicaid financial ~eligibility certified. Nursing homea do not want poor patients who may gat turned down by Medicaid for unexpected reasons because the home then gets stuck for the bill. This findfng questions the usefulness of nursing home case mix reimbursement for improving access. Other important causes of placement delay were found to be: discharge prior to DRG enaetment; living with others prior to admission; nonwhite; circulatory or mental disorder; discharge to a nonhospital affiliated facility; tubefeeding; surgery during hospitalization; male; and having a family member involved in the placement process. Eileen J. Tell, Marc A. Cohen, Stanley S. Wallack, Health Policy Centei Heller Graduate School, Bran is University LIFE CARE AT HOMEi A NEW OPT IN THE FINANCE AND DELIVERY OF LONG- TERM CARE. Life Care at Home (LCAH) is a new long-tera care insurance and service delivery model which combines the financial and health securit3 of a lifecare co®unity with the freedom and independeoce of living at hane. LCAH retains riijipooling for long-term care services, plus all the benefits and guarantees of CCRCs, including unlimited nursing home care. By eliminating the requirement that members move from their homet to join the program, as is currently done in lifecare comwnities, program costs are substantially lowered and more individuals can participate. LCAH provides a case-managed delivery system to ensure access to highly-quality service providers. This paper describes the key features of the model including benefit package, tGethods of managing risk, and expected costs and pricing. We discuss the market potential of LCAH, based upon extensive consumer surveys. The paper ,highlights variations on the basic LCAH model which are appropriate ~£or varying market areas and describes a small multi-site demonstra- Ition of LCAH initiated by the Robert Wood Johnson Foundation. Hirsch S Ruchlin Ph.D. Cornell University Medical College CONTINUING CARS RETIREMENT COMMUNITIES: AN ANALYSIS OF FINANCIAL VIABILITY Thirteen financial ratios encompassing liquidity, debt structure, asset productivity, and profitability measures were calculated to assess the financial viability of a sample of 109 life care communities over the 1981-1985 period. Net income and equity positions were also analyzed. Liquidity and debt structure were fairly comparable to those of other health and personal service industries and, over time, moved in the desired direction. Problems emerged, however, for productivity and profitability. For the entire sample, operating expenses exceeded operating income. Over 30% of the sample reported negative net income and equity positions. When analyzed separately, these facilities also displayed locv liquidity and high debt levels. Unless these problems are addressed, some comminities may face difficulties in tho future honoring their implicit guarantee of lifetime care. ABSTRACTS 31 TIMN 322488 I i
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1051 a n ayne, Llnda H. Potts, Edgar D. Charies, Susan 0. Horn, Ilene Baldwin; University of Alabama at Birminghast, Birmingham, Alabama and Johns Hopkins University, Baltimore, Maryland. CODING ERRORS CAN COST HOSPITALS MILLIONS OF DOLLARS The classifying of hospital pts in a manner which predicts their costs has become critical since DRG-based prospective payment was implemented for Medicare pts in Oct. 1983. Data for this study were collected on 6331 burn injury cases discharged in FY 1983-84 from 23 hospitals acress the U.S. (13 with burn centers and 11 without). For 1. 7% of pts the case could not be DRG grouped because the portion of the ICD-9 diagnosis code which specifies the percent of burn and the percent 3rd degree was not coded. This resulted in lost or delayed revenues amounting to $784,041. Pertinent clinical information was also abstracted from the medical record of each pt. In 21.3% of the cases the percent burned and the percent full thickness burn were not clearly delineated. Since this information is required for proper assignment of diagnosis codes which are part of the criteria for payment by all 3rd party reimbursers, an amount in excess of 58,000,000 in revenues could have been lost or delayed. If this pattern holds true for other Major Diagnostic Categories, this amount would exceed $100 million for these 23 hospitals. Thus significant revnues may be lost through factors which the hospital can control. Herbert Traxler, National Center for Health•Services Research and Health Care Technology Assesssent REHABILITATION UNDER MEDICARE PPS AND THE INCREASING NEED FOR TRANSITIONAL CARE SERVICES The continuing increase in sortality rates, especially for the older age groups, and the rise in life expectancy are projected to increase the 65+ population from 25.7 million in 1980 to nearly 35 million in the year 2000. The 85+ age group is expected to more than double in size over those two decades - from 2.2 to 5.1 million. Recently, reports of hospital patients being sent home "quicker and sicker- have been the subject of media reports and Congressional hearings. According to the results of a 1986 urvey, nearly one-half of the respondent physicians felt unduly pressured into presature release of hospital patients, who then often face a vaeuum in post- acute,'or transitional care, er.ices. This author has investigated recent patterns in transitional care, their policy implicatioos and some major researchable issues. The present paper vill explore swre in detail the role of rehabilitation in the transitional care spectrum, especially in light of the expansion of Medicare Part 1 in late 1982 to include services furnished by comprehensive outpatient rehabilitation facilities (COBFs) and the exemption of rehabilitation hospitals and -distinet part' hospital rehabilitation units from the prospective payment system, PPS. Na aprasanna 8anaalore PE DBA, Mt. Sinai Medical Center, Miaui, Flor ida and Thomas H, Dunaye DrPH, Dept. of Health Services Adain., Plori- da International University, Miami, Florida. 1VLW ALLOCATION SYSTEMS FOR HOSPITAL NURSING CAR€ UNDP.R D$G REGULITIONS Prospective payment ur.der Medicare along with numerous other growing external pressures have caused the health care industry to rediscover a production emphasis on cost efficiency and related engineering applica- tions to streamline operations. Nursing services in hospitals, as the largest user of input resources, has become a primary target for pro- ductivity analysis, cost reduction and staff realignments based on the acuity, type and length of patient needs per DRG adaiuion. This paper presents the results of a study of 251 major teaching hospitals through out the U.S. which have attempted specific measures to establish a swre efficient nursing allocation system. Various hypotheses were tested re garding the functional results and general satisfactionAth these .ech- anisms, including the elements of patient clasrification and production features of each approach followed. The findings of this study indi- cate what features were believed to be the most generally productive and desirable within the context of a composite analysis which provides a comprehensive guide for "optimizinge nursing allocation procedures in large hospital settings. Conventional and innovative industrial engi- nering techniouee are described in their aoalication to this oroblem. WPH and Deborah L. tbas AAHSA• Soumeastem F'amela b. Wo sh i 1 ro ram or or n e ea ore = AT1VE UFORT Southeastern Michigan Program for Affordable Health Care's (SEMPAHC) overall objective is to slow the rise of health core expenditures by reducing demond for and utilization of health care services w,thout reductions in access and quolity; redirecting demand and utilization of health core services from inpatient settings to other appropriate and cost-effective settings; and odjusting the supply of facilities ond services to a level consistent with revised patterns of demand ond use. This objective is to be achieved through a series of demonstration projects which were developed through the collaborative efforts of hospitals, physicians, insurers, business, ond labor. The development of an effective forum consisting of these diverse interest groups with a commitment to health core cost containment was itself a goal, as well as a meons to the above stated objective. This forum evolved as SEMPAHC's rrwltifacited governing body, the Committee for Affordable Health Care. This Committee has taken a strong leadership role in demonstrating creative opprooches to health care cost containment by sponsoring five projects which address specific aspects of the health care system: outpatient surgery organization and financing; health care services at the worksite, reduction of use of foot care services, substonce abuse treatment and Older Adults Soeial/HMO. This paper will discuss the major accomplishments of SEMPAHC since Its inception in 1984. )avid E Gagnon MPH Author; Rachel M. Schwartz, MPH, Co-Author• :atherine Rowlande, MBA, Co-Author_ NPIC rRENDS IN HOSPI'LAL DECIS10N-MAKING BASED ON SERVICE'S LOSSES AND GAINS In an increasingly competitive environment in hospital care, it is critical to understand comparative cost and reimbursement (under Medi- care) for services measured against hospitals similar in size and sophistication. Using a data base developed by the National Perinatal Information Center (NPIC) from more than 100 major hospitals in the U.S this study analyzes the major diagnostic categories which are gainers and losers of all these hospitals. Within the top five gainers and top five losers, the study examines the specific DRG categories that relate to the overall loss or gain. The study also examines the impact of outliers on these gains and losses. Increasingly, as hospitals develop product-line management, they will identify and develop those services that generate revenue and eliminate those that generate significant losses. A caamunity'a dependence on a specific service might be placed in jeopardy by this decision. It is important for administrator managers and planners to understand the relationships between case-aix statistics and decision making. Jane Levit}„ Lehman :ollege, CUt/Y THE IMPACT OF PPS/iiRGs ON THE.USE OF DIAGNOSTIC IMAGII7G TECFL*tOLOGY -. This paper focuses bn the im3act of the prospective pay- ment system and diagnosis-reL'ftdd groups on the use of diagnostic imaging technology: It has been projected that hospitals wil2"use less`services including diagnos- tic testing in ord`eu to save money. Preliminary research has shown that while there may be less use of routine testing, there is a shift to the use of higher-level technologiesj for`Example,'Yontine x-rays may decrease, but the' use of CT"8cans and„MRI`are increasing. In addition, the sit:d"of petformir.g tests has shifted to out-patient areas•f.o~.pre-ydmissi.pn screening and ambula- toYy c'a=e. The dps.t of'tests,is being shifted so the hospital can.ge€ reimbursed fXom third-uarty payers separately. Hospital cutbacks do not seem to be coning from the area of.4agnostic imaging technology and it is predicted that thst business" will continue to grow. kGreer CR. Semuel L Seker. and Jennie J, 1Cronenfeld, School of c Health. Uaiverait. of 5auth Carolina. GOING HOttE EARL7: IliPACf OF DRG'SN HOME HEALTH SERVICE REFERRAL Hospital discharges to home health services (HHS) increased dreauti- cally with the iaplementation of DRG-based Medicare reimbursement. A study of discharge abstracts from 68 of the 71 short term acute care hoapitals in South Carolina''tfound that discharges to HHS increased from 1.7% of all Medicare discharges in 1981 to 4.0% in 1984. The average length of hospital stay (ALOS) of patients discharged to HHS fell by 3.8 days, though their age-sex-race-adjusted case mix was unchanged. These changes were encouraged by (1) the DRG incentive for early discharge, (2) the elastic supply of home health services in S.C. during this period, and (3) an inelastic supply of nursing home beds. Small and medium sized hoapitals (<300 beds) responded the .ost. Their ALOS for IiFiS-discharged patients fell by 4.4 days though their case mix for' this cohort was unchanged. The larger, tertiary, hospitals reduced their AIAS for this cohort by les€ than 2 days. The larger hospitals in S.C. benefit from direct medical education reimbursement, an urban wage index that is relatively more favorable, and a smaller relative impact of outlier lengths of stay. M KC. ~P-.~I-~. .~Mdl,i,r~wst. i,R„ J.D. qua~~t , t~$SSa(fiUSet[s bit@7it Of PnbiiC Health. H Since the inception of Medicare reimbursenent based upon diagrosis related groaqs, ne4y states have reported anscdotal evidence of hospital quality problem such as premtu^e discharge or denial of ad+dssion. The Massafiusetts Departnpnt of Public Health has beeoaandated by statute to evaluate the impact of Drs on the quality of mre afforded to the state's Medicare beneficiaries. To evaluate the impact of D2Gs, the Dsparfient has focused on the analysis of claims data fran the state's Rate Setting Cartsdssion. These data -equivalent to patient level data found in the p 6licly available HIM file - include diag+ostic, demgraphic, and charge infcr- nation on all disd>arges from MassaUsnetts acute care hospitals fran 1982 thr'eugh 19®6 - the first post-PPS year. The time series analysis of these data will focus on changes in utilization wfiidl may be most reasonably associated with poor quslity as detenained by expertmedical opinion. These include changes in readnissions due to cmplicattans of su-gery, changes in medical readaissions for certain indicative or "tracw coditiens", evidence for d anges in the sequencing of adnissions, and dlanges in the utilization of IOJ/CCU facilities for certain specified conditions. A unique feature of the Massachusetts analysis is that it allows cawisans between Medicare ani other paj4rs to test the hypothesis that hospitals treat Medicare bene- ficiaries differently fraa payers operating under cost based systems. ABSTRACTS 33
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A_f;lene Rubin Stiffman Ph D fiearae Warren Brorwt `3chool of Social Wark Washinaton Universitv St Louis r70 TFE INFLLIENCE OF MENTAL AND PHYSICAL t€ALTH SERVICES ON THE IMPACT OF ADOLESCENT PREGNANCY The effect of services on physical and mental health is explored in a sample of 477 females (222 of ..hom had been pregnant) from three different midwestern cities (St. Louis, Indianapolis, and Chicago). These youths .rere interviewed in 19BS-1986 and again in 1986-1987. Specifically, this paper presents data on changes in depressive symptoms and diagnoses, conduct disorder symptoms and diagnoses, alcohol and drug use and abuse, somatic syRptoms, and chronic and common physical health problems as influenced by the use of social, mental, and physical health services. The changes experienced by adolescents who have been pregnant are compared to the changes experienced by those who have never been pregnant. Family support; welfare; age at pregnancy; health of infant; and repeat pregnancies are used as mediators. Policy implications for the provision of welfare, mental health/social services in conjunction with health clinic services, and other supportive interventions are discussed. Sheryl Rotl: CSW and Mindy Stern, CSW, ACSW Inwood Rouse John Gibson MSW, Columbia University School of Social Work SHORT-TER.~1 INDIVIDUAL COUNSELING & CASEWORK AS A COMPONENT OF A SCHOOL-BASED PREGRANCT PREVENTION PROGRAH This paper reports on the individual counseling and social casework component of the Inwood House Community outreach Program (Teen Choice), offering school-based pregnancy ~revention services to inner-city ado- lascents in seven public junior and senior high schools in Brooklyn and Manhattan. It describes the incidence of sexual activity and teen- age pregnancy in these counties and our comprehensive preventive ap- proach to addressing these problesuo. The paper explores,the advantages of having a voluntary social service agency on-site in school and focuses on the range of individual counseling issues students present, the clinical interventions required, and the nature of referrals to cosaunity agencies. The following social casework issues are dis- cussed: abstinence counseling, "As I Normal" counseling, birth control counseling, crisis intervention, services to pregnant teens and teen parents, and counseling severe problems of a sexual nature. 1075 Jerald Shapiro, D.S.W., H.P.H. Professor, San Francisco State University DRGs and the Evolving Nature of Medical Social Work Practice: The Impact of Organizational Policy on Client-Worker Relationships This paper reports on the preliminary findings of a studying exanining the impact of DRGs on the nature of social work practice in medical settings. Drawing material from interviews conducted with medical sociaq workers in hospitals located in a large urban population center, it presents the perceptions and experiences of practitioners challenged to balance the hospital's i®plementation of DRG policies with the iamediate and long term needs of patients and their families. Particular attention is given to exploration of the social worker's identity and self-image within the context of changing roles and expectations generated with the introduction of DRGs into hospital systems. The question of worker satisfaction with the daily work experience is also addressed. Lastly, the question of professional boundaries and organizational self-interest is raised as a perspective from which to consider the direction in which social workers might be moving in attempting to deepen their involvement in health care settings. Sheryl C. Goldberg, x.S.w. and Carroll L. Estes, Ph-D. Institute for Health s Aging, University of California, San Francisco THE IMPACT OF MEDICARE'S PAOSPECTIVE PAYMENT POLICY Op ELDERLY CLIEerS Research documentinq the ways in which recent federal and state cost containment policies have affected eo®unity-based health and social service organizations serving the elderly is being conducted at the Institute for Health & Aqing- Using findings from a random sample of service agencies including home health, adult day care, hospitals, nursing homes, senior centers, eomunity mental health centers and hospices in five states in nine SMSAS, this presentation will focus on :the impact of health care cost containment policies on elderly clients as reported by directors of such agencies. Dimensions of client impact will include the patient's condition (health status) at hospital discharqe.au~d during post-hospital care, use of, access to and quality of post-hospital services and out-of-pocket expenditures for those Iservices. Herbert K.-fibbs ACSW CSW New York-Veterane_ Adminiatr t on Med cal enter an Jane ko .D. New York- Veterane dm strat on Me c~Center, MONITORS OF SOCIAL WORK ACTIVITY AND THE PATIENT PROFILE FORM FOR QUALITY ASSURANCE. The current JCAH Standards for Quality Assurance require that health care providers explicate their professional activities. These professional behaviors (monitors) must be measureable (as quantifiable criteria) and tracked con- tinuously and concurrently with patient outcome monitors. This presentation identifies monitors of aocial work acti- vi,ty and patient outcome. Information is presented in a format that, itself, can be used as an instrument to col- lect data for Quality Assurance review. In addition, we suggest the use of a patient profile monitor to be used by social workers to summari~,e and verify patient history in- formation, suggesting that independence of the social wor- ker from circulating hospital records may expedite dis- charge planning, discharge, and follow-up. osterbuscb Ra9 PAYMENT OF KIN IN COMMUNITY CARE: ADMINISTRATORS' ATTITUDES Attitudes & perceptions of 77 administrators of state-contracted home care agen- cies toward hiring of kin to care for their own relatives were assessed via mailed questionnaire. This paper describes responses to Likert scale items describing anticipated problems, & qualitative analysis of two open-ended questions on ad- vantages/disadvantages. Responses were analyzed 1) to determine the extent to which answers reflected a market orientation similar to that of policy makers, i.e., concern about the so-called'woodwork' k•substitution' effects &, 2) to discover what other market & social welfare/justice themes & variations on themes were expressed. 92% responding to the Likert scale items identified exces- sive demand ('woodwork'), 96% identified family feelings of entitlement, & 80% identified families withholding care unless paid ('substitution") as potential prob- loms. 89% saw abuse of the program by families as a potential problem. Qualitative analysis of the open-ended responses showed a4imilar level of concern with market issues & abuse of the program and clients. The level of concern expres- sed about fraud & abuse of the program & potential harm to clients suggests that some of these administrators may view the families of their elderly & indigent ciients as potential'welfare cheats' g likely to be exploitive of their own kin for personal financial gain. A minority expressed the issues in terms of distributive justice or the expansion of choice & opportunity to a disadvantaged group. 1078 Linda T. Bilheimer, Arkansas Department of Health i~ PROBLEMS IN OBTAINING STATISTICS ON AIDS lionitoring the spread of the AIDS epidemic poses complex problems. This paper discusses so/E of the statistical and ethical controver- sies surrounding such issues as: changing the AIDS surveillance definition, estimating the prevalence of HIV infection, evaluating AIDS education prograas, and long-ters projections of mortality, morbidity and costs. Clifford C. Clogg, Penn State University POPUf.ATION UNDERCOU.-r AS AN ISSUb FOi: PUBLIC ilE.1LT-I PROGR.I:IS Population undercount in the decennial census has major implications for analysis of census data and for analysis of data based indirectly on census results. This is the case because differentials in under- count rates are associated with color, age, sex, poverty status, and ecological units. The probable effects of undercount for research on public health are examined together with the implication of adjusted census counts likely to be produced for the 1990,Csnsus. TIMN 322500 i I I ABSTRACTS 43 a- 0 0
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1058 Monica A. StynchulaL MSW brector-Hea th Promot on, Greenfield Area Medical Center ASSESSMENT AND INTERVENTION ISSUES AFFECTING HEALTH EDUCATION IN RURAL POPULATIONS -v Providing health education in rural areas requires strategies tailored to the needs and special problems of these geographically isolated populations. Prevention and health promotion must be translated and delivered within the pre-existing formal and informal social networks. Changing health behaviors and attitudes requires analysis and intervention specific to the cultural, social, medical, educational, political and economic characteristics of the cotrnunity. The resulting effect will be the comiunity's active involvement and ownership of health education activity. riigrant "l CutvemTty Hea:th Centers, i(etworking xTLh uuher eya3:c:e~, local Public Mesith Departments To maximize access to and resources available for health care. trust vs Turf prolams. benefits, barriers. wiii include such areas as IiCH - STD. HospitaltzatTon-Connun:tY Outreach, Urban-Rural differences e 1 1 an an Annette M. Phil ipp. T.nvelace t+ediea Foundation ealth Services Research & Education Division, Albuquerque, 4@[. ~BFECTS OD COtM'JRITY-DAS@D EXERCISE PROGRP2tS 09 CAYDIOVASCULAR DISEASE T ZUUI PULBLO. e study is designed to dateraina the effectiveness of the Zuni Indi- a Health Prosotion Exercise Prograss on prevention of cardiovascular isaase and to assess and quantify the impact on use and eost of ealth services in this rural eosamity. These programs, initially isad at the comeatnity's large diabetic (D) population, now enjoy road cosranity popularity and enroll all segments of the population. Data has been collected on four groups for 6~ years: 1) D partici- pants, 2) D nonparticipants, 3) non-D participants, and 4) aon-D non- 2articipants. Major variables of interest are patient and prograa :haracteristies and health services use. Hultivariate statistical :achniques are being used to analyze these data in order to isolate ~rograe effects and the effects of individual prograa components. If this pro6ran is effective, then cost-affective eoas:nity-based pro- ;rass could be designed and important conuaity-based eodels could be spplied in other rural areas. Donna Clar:ce Bird. i?ealth Systems Acencv of :;E;:Y DEVELOPING CONSORTIA FOR PRIMARY AND PREVENTIVE HEALTH CARE SERVICES IN NORTHEASTERN YEW YORK The cqnso r-iusa model for delivering primary and preventiva health care services is receiving increasing attention and support nationwide. In recent years, a number of consortia have emerged in the largely rural Yortheastera New York region. Many of these programs are foraiag in response to State requests for proposals, alt , aough a few are the result of provider or community initfative. This paper will draw upon the author's extensive field experience and describe a representative cross-sactior. of these groups. The examination viii focus on such factors as number and variety of providers involved, extent of community participation, and degree to which programs contribute to improvements in access to care and ultimately in health status. Special considAr3ticn will be given to the broader community deve'o;.ment and _ social change issucs surrounding this phenomenon. - 36 ABSTRACTS Ray Goldsteen, Dr.P.H., Assistant professor, Department of Health and I Safety Studivs, University of Illinois at Urbana-Champaiqn; Karen Goldsteen, Dcctoral Student, Department of Health and Safety Studies, University of Illinois at Urbana-Champaign. THE UTILITY OF COUNTY PUBLIC HEALTH DEPARTMENTS Four rural counties in East Central Illinois are without public health departments. We have undertaken research to investigate whether or not this lack adversely affects health. Using county level data from 1984 and 1985, we will examine relevant health indicators such as incidence of childhood diseases, infant mortality and neonatal mortal- ity rates, immunization levels, teenage pregnancies, public dental clinics, and incidence of salmonella poisoning. These rates will be compared to those in counties with health departments in the East Central Illinois Health Systems Agency area controllinq for such county characteristics as age, income, education, racial makeup, unemployment, and prosperity. Discussion will address: 1) the role of other institutions in providing tr5ditional public health services; and 2) implications of the findings for rural health policy. GITTENS, EUGENE R., RESEARCH CONSULTANT AND SABRINA MANIGO CHIEF RESEARCH ASSIST. WOMEN'S AFFAIRS DIVISION, MINISTRY OF HEALTH ATTITUDES TOWA[tDNONTRADITZONAL WORX AMONG GRENADIAN WOMEN Social standards that exclude women from certain types and levels of education and employment, together with women's self-imposed exclusion by virtue of their conviction that cer tain jobs are "not suitable for women," determine that Grena= dian women generally have less education and training than men. Low self-esteem, somatic complaints and chronic illneas are,linked to the inelasticity of the supply of female worker Locked into one market, with a steady oversupply of female workers, women continue to experience higher levels of unem- ployment than men and are forcedto accept lower wages, even if the job is the Bame. ' Mildr®d Vera Pafaela es and ita A1 4a School of Public Health, Universitv oFTuerto Riw 9DCIf®0.'I10~ffC, dULTURAL AFD IIIPFRPER9QdAL RISK FACICI7.S AS IINIDICATC[LS OF [gN7AL HFALTH NE'~6 The goal of this is is to examine an ,int®grated model of mental health needs di takes into eonsideration psychiatric symptams and dysfunctions, behavioral dimensions, as c.ell as socio- eoorneic and cultural factors. This nndel presupposes that specific life events and positions of the respax3ent in different dimensions of the social structure qre basic factors for the identification of inental health naeds. The method of data collection was a per- sa:al interview with a sample of two hundred acmunity mambers, 18 to 64 years, selected using a stratified random sampling based on the criteria of sex and age. Also a sample of one hundred recip- ients of services offered by the outpatient clinics of the Cortmmity Mental Health Centers were interviewed. Statistically significant differences were identified between age, sex, education, number of risk factors and levels of mental health need. This evidence suggests that social roles and specific risk factors are basic elanents in detexndniag mental health needs. 'Sepuivede. J.;"thpia. R.;'M4edis, R.;•'draveo. J.;"De la SUmts JR. •WnSahy of Hralth, ;dadoo '•Ikudcan Irstipite of isy[3'nahy FOSDLHMATIC SDES"i SITIIiTE Mi. BFdRtQtS (F E+F70:N C11Y'S FARDqHioi4 'Die strcly ues catzicted d,rl:g OctrRes tlx=4: Detmber, 1995. The eb,iective, wse in detsadne the irrldence and ihe valahles related with fha orrit of Post~tic St[asa 9yn&va (PSS). This infonnat[on a: be uaal iin the develoTymt of Fmmttve`rarrtaI Ixalth prc@re= in nahsal disaete:a. A b+o-stoge cluster emple design "es ueed. Individsls bebwa: 18 and 64 y.av'witRsin selected faulies rQS intraviei.ed. '!he qumttaneirs (K..86) ewSiyw mr{t.lties aoading to D34-III =teria and diatir•uished bsb,©an osees related to tlie eva:t'ad ttcoe ptesmt before the eartikrFdms. A brtaL[g'S7d intavtewo w,ee apa2iaC. D7( qale and 71% facela; avwage age of 35 yeas; 9(X sutffered matarial.IOrss: S(AL lort{ss;tiaLl,y their hnnea and 4(AG with total Icss. 3(S ccported the death of relatives ar7/or iriatlt; Di we:e b.'apped with mild iRt-rira. 'D:e resuits shw tist 32% premmtnd PES alme ad 12% essociatsd with ana4aly#d depresmim. M:lttvariate aal,ysis indicatea that sax, aee, rteci.tal qkbas, sleco at the smsert of tte evert, to hm.e seet hu[ldin@t cc houees ihll, laee of relatives md/ol• iMa,i3, anzng ouiea, are veria6ies tlnt ron be arrelatad with the msdt of PAS ip a pcpu7ation savtvor of a nabasl dimstxs of this Idid. TIMN 322493
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N I Kooert b. Murphy and Catherine E. Woteki. Division of Health Examination Statistics, National Center for Health Statistics. NATIONAL HEALTY AND NUiRITION ERAMINATION SURVEYS (NHANES) - ISSUES RELATED ?0 THE CONTENT DEYELCPFENT, COLLECTION, ANO RELEASE OF._ INFORMATION The process for developing the scope and content of NHANES is described briefly identifying major considerations involved in selecting a research topic for inclusion in this unique study. Since persons will be followed over time, increased scrutiny must be given to the baseline information collected and its interpretation with respect to the longitudinal issues addrdssed. The possible impact of content on the success of the study is explored with the example of different ways to assess exposure of the population to the AIDS virus - blind testing or informing the participants that the test will be done. With broad input and support of Federal health agencies, the issues of who should do data analysis and when to release public use data files are raised as concerns that can affect the content and collection of data through the NHARES mechanism. Owen Tharnberry National Center for Health Statistics NEW APPROACH FOR THE NATIONAL HEALTH INTERVIEW SURVEY This paper will address issues resulting froa new initiatives on the National Health Interview Survey (NHIS). The NHiS has been a continuous national survey since 1957. The objective of the survey is to address major current health issues through the collection and analysis of data on the civilian noninstitutionalized population of the U.S. Each year data are obtained for around 50,000 households and 135,000 persons. Major recent initiatives include redesign of the sample and the basic health and demographic questionnaire, expanded capability to address current health issues, procedures for the timely release of data,'and the development of a targeted follow- up survey capability. 1079 Naihua Duan, Willard G. Maaning, Jr., Joseph P. Newhouse The RAND Corporation • CRFDIBILI'LR METHt1DS IN SETTING PQRE PREMIUM FOR NEDICAHE INSIiRED GROUPS We apply credibility methods to set the capitated rate for a given group of Medicare beneficiaries when the group (former employer or union) assumes risk for their benefits. We propose a multistage credibility method to deal with the hierarchical structure, with individuals nested in groups, and the groups nested in the co®znity. We also propose a correction for survival bias due to the higher level of use of beneficiaries who die in the previous year. Urban, Nicole, Fred Hutchinson Cancer Research Center; Kessler, Larry, National Cancer Institute; Self, Steven, Fred Hutchinson Cancer Research Center RESEARCH COST ANALYSIS OF A RANDOf1IZED CANCER PREVENTION TRIAL The Uomen's Health.Trial (l1HT) is a multi-center, ten-year randomized prevention trial to test the efficacy of a reduction in dietary fat in reducing the risk of breast cancer. The feasibility phase Just completed suggested a full scale design with 32,000 women randomized In approximately 20 clinical units, at a direct cost of about $100 million. To evaluate the effect of design variations in reducing full scale trial costs, a swdel describing the components of cost of the trial was specified. Trial costs were estimated, using data from pilot studies, as functions of 1) eligibility requirements, 2) choice of locations for clinical units, 3) recruitment strategies, and 4) the intervention protocol and its implementation. It is concluded that the lovest-cost choice of trial design, articulariy with respect to eligibility requirements and recruitmeng strategy, depends on the willingness to participate of eligible women, as well as the ratio of recruitment costs to the costs of intervention and follow-up. 44 ABSTRACTS Son a Johansen Ph.D.• Ad unct Assistant Professor Columbia Univeraitv School of Publie eelth STATISTICAL ISSUES IN COMPARING TWD PROSPECTIVE REIMBURSEHENT MODEiS Several methods of predicting length of stay and reimbursement amounts within "similar" groups of hospital patients were studied. Aggregate methods (which assume that every patient within a group should have the same resource utilization) are based on group mean or group median, as the diagnosis-related group (DRG) model is. Individualized methods (which allow for incorporating patient and hospital variables that may legitimately affect patient resource utilization) are based on individualized estimates of mean or median, obtained by the prospective individualized reimbursement (PIR) model. In a study of 23040 patients, errors in predicting length of stay using the DRG and PIR models were reduced from an average of 2.0 to 1.4 days per patient, average prediction errors in dollars of resource use were $692 and $459 per patient respectively, and the numbers of groups required for the two models vere 17 and 11 respectively. The PI:R model was also able to Sncorporate exact patient age, death, and emergency admission (proxy measures for severity) in the formula. 1081 Moderators: Violet P. Chsrry".G.S.~W. MPFJ,_ 6. LewisH. Clarke, M.A. Moderator/Consultations: ~chael A. Jen ns, MPA, H.P.H. ~ - "State of the Art Report on Minority Access Issues" The first part of the Workshop vill address an update on Minority Access to heaith training, health careers and jobs in the health professions and will include the following: 1. Recruitment and access to medical education and to schools of public health. Kathleen A. Torrea, M.P.H. 2. Implementing an effective equal opportunity/affirmative action program in a State Hea th.4ep.artment.._ Ha~i,ne Willi_ams Knox, M.A. 3. Iaplications of P.L..94-437 relating to American Indian/Alaskan Michael E. Bird, M.P.H., David McCoy, J.D.) nat .ealth man ow H. S R c c. Gsrmaine, Ph.d '~---..-_~,__~~,_ .~~~. 4. Upata - nortev M•ewg~valinws}Cip Program - N.Y. State Health Departmen[,CAlfred F. Fiacher. M-- -•--`-`-'-"'^ -~ 5. Minorities in t eTi overn©en~5ector j Kenneth N. Moritsugo,M.D.,MPH 6. Recruitment of MInority High School Students info"th1 hailth ---'-J Professions: Marcellus A. Lewis, M.P.H. Discussant: Edward Salsberg, M.P.A. 6F'CNbR F1e~ It~ /~drn,n S«~~~, P~la~(~ Ca~wE ~'f ~ Hoderafor: Hichael A. Jenkir~ M.P.A., H.P.H•., and Panel of Speakers froa Mir.Srity Access Issues Ao~~rkshop Access to Consultation Participants attending the earlier Workshop on Minority Access to health training, healthsbrears and jobs in the health profassions' will have access to the entire speaker panel. Consultants will provide advice, counselling and guidance on jobs, and job related resources, educational opportunities advancement in the health professions, in small group sessions or individual interviews. The groups will cover specialty areas such as: Government sector (Federal, State, County, Local), international health, public and private sector health delivery systems, research and manage- mena.consultant fields! 1082 Bill Ro ers MSPH Urban A Comaunitv Proarams Universitv of Oklahoma Ran y arnosk z n ea ce, Hoiton, Kansas t rv INTERORGANIZATIONAL NATIVE AMERICAN WELLNESS PROGRAMS This paper describes two aeonraphically separate employee wellness programs that serve multiple Indian organizations. The proorams have similarities and differences that both enhance and hinder their effectiveness. Current health promotion activities, perceived need, employee health habits, prevalence of risk and ethnic concerns wi11 be discussed. In addition, factors that contribute to the interorganizational cooperation and coordination will be examined. TIMN 322501
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Q' P.titc finlth .9-anrh. MEdm- (bdfrev . 701 ai' Hv_ict ±+? ~mtc_„1~1~iti, 2FE EPIIt}Oa.AGY ¢ v'IkLi1Y. A rAiE IXI(fIC(. SItII{ CF taFSIA17L SUiV1VAZ AtD C4ShFi•-AN Ca,1vFRt. Car'en over am :•isa in cman+mf section deliveries hes usuA.l.7„y cm4ed arard thecoat involved ard lncarle,ience to the molixr. 'Dds paper pceamffi rvuits of an Inveatigatim offte relationship babaem aram®a: delivery and early neoratal ecrtsd.ity. 1he resulta are besed on the stu$y of 2&Fi ss•iy nesatal deatis (ceaes) aM 3257 savivors (carttols ban in 25 ho®pital.s in bEnd.co City dring the eumer of 11994. Tne rate of ceservan, delivery was Z776. Veriatim bet4ten health agencies acd diffa:mt social g:IOLPs wes not related to obstetric riak. This suggrata that a siacble p,c.portion of the epereticrs r.ere p[obabiy srt ,)tstified. Babies of nunall birtlaeigtit (2.`00 g or erre) delivered by cesarean section rcre sig:ificartly more liholy to die in the eal,y neareta)l perieid as carmpared with vagirnlly delivered tabias of fhe saa yeight. 'D:e od9 ratio adfiated for otetetric riatc wae 2.51 (L43, 4.41). The e:cess of arsiallta• muld mt be explained by the effect of cate:re7l dmaractaistics or mspiiratiafa wrh as diabetea pr teeed: pres3mtation, ns LBy di1'ferences of birth+eight or gatatlonel agE. Trc excesa of mwtal.ity in uaa:rs: delivered bebiea .aa caneiderably hi*ar ,tim the opecaticn was perfonasd 1n hmpitals with relative scacnity of naeascea and rtrre a higa pccpartion of the otstetric cae was :rnde-taam by residmte. This euggats that it xee the ca-ditiau; in uhid: the cperatirn sas prrfa:ed rhid: pac6eb(y explainned the inaessed risk of eerly neoratal death. VarSatims in tie q.alitay of resusitatim arl n:rsptrabxy care are inplirat.ed in a casal link between ceassemn sactim and sQial.ity. Anthony H Burton Barbara Panter-Connah E1 zabeth E Ruberv Douclas K'Elaucka N.2., Division of Surveillance and Eoidemi Cont ers for Disease Studies Epidemiolozr Proxra. Offiee Cent THE EPIDEHIOLOCIC SURVEILLAECE PROJECT: THREE-YEdR REPORT In 1984 the Epidemiology Prograa office, Centers for Disease Control (CDC), in conjunction with the Conference of State and Territorial Epidemiologists and State Epidesiologists in six States, instituted the Epidesd.ologie Surveillance Project (ESP). Case-speeifie data for 54 notifiable diseases are transsdtted weekly froa State health department computers to CDC via a commercial telecon.mications service. Thirty-one States, the District of Columbia, Yaw York City, and Puerto Rico currently participate, and the ESP data base contains sore than 200,000 records. Future plans include participation of all States by 1990, reporting of disease-specific data, inclusion of non-infectious conditions, and online access to the ESP data base by participating members. Stacey C. FitzSiasaons, National Center for Health Statistics, James E. Everhart, National Institute for Digestive Diseases SELF REPORTED PEPTIC ULCER DISEASE: PREVALENCE AND CORRELATES IN ADULTS FROM THE SECOND NATIONAL HEALTH AND NUTRITION EXAMINATION SURVEY (NHANES II), 1976-80 The most commonly reported chronic digestive condition is ulcer of the stomach and duodenus. Little is known about the national rates of peptic ulcers or of correlates of peptic ulcers. Among interviewed adults from NHANES 11, 1646 (10.7%) report having a peptic, stomach or duodenal ulcer diagnosed by a physician. Significant correlates include: race (11.1% white, 8.5% black), sex (13.2% sale, 8.7% female), age, income (12.1XtS6000, 6.8fJS20,000), geographic region use .(~.5S u yes, 7 6.5% N no), srecrestionaSS physical 0 activit~ (6Y2Zsyes,n 12.7% no). Correlates of peptic ulcer disease in .ultivariate analyses accounting for sampling weights and complex survey design will be presented, including other health status, health condition and treatment variables. Respondents with peptic ulcers who report that their ulcer is still present (N•602, 36%) are more likely to be black, poor, smokers, aspirin users, and females than respondents who report that their ulcer is no longer present. Douglas N. Klaaoke Andrew C. Dean Donna F. Stroup, Epidemiology Program Office Centers For Disease Control, Atlanta, GA )0333 EXPLODED POPULATION-BASED SPOT HAPS: A NEW HETHOD TO SHOW THE GEOGRAPHIC DISTRIBUTION 0€ DISEASES Display of the geographic distribution and variations in the rates of diseases are essential to the analysis of epidemlologic surveillance data. Traditional spot maps are based on land area, do not show rates of disease, and may give misleading information about disease clustering. Shaded maps can show rates of disease, but not numbers of cases at the same time. We propose a new type of population-based map as an alternative way to simultaneously show the actual number of cases, the rates of disease, and the clustering of cases, without using text labels. In these maps the displayed area of each political unit is proportional to its population; therefore the density of spots indicates the rate of disease. in contrast to other population-based maps, our maps retain the normal shape of political units and can be created using proprietary software on a ®icrocomputer. ' Wi11inC Carr, Natan Szapiro, Toni Heisler, United Hospital Fund of New o ANALYSIS OF SENTI-dEL HEALTH EVENTS IN NEW YORK CITY Given the dramatic changes in the health care system, it is vitally important to have ways of determining the impact of the health system on the populations it serves. This study explores whether the senti- nel health events approach can be used as a tool for monitoring health system performance. Sentinel health events are negative health states (deaths, disability, and disease) that might have been avoided given current medical and public health knowledge and technology. The occurrence of the sentinel events, defined by the Working Group on Preventable and Manageable Diseases, is studied in New York State using hospital discharge data. Diffarences among population subgroups in rates of potentially avoidable deathe and disease occurrences are used to asaEss areas of possible unmet needs. The major contributions of potentially avoidable cancera, heart disease, and respiratory conditions to the totality of sentinel events are highlighted. A critique is provided on the applications of the sentinel events approach using hospital data, and method and data-refinements and alternatives are suggested. Gerald A. Faich, N.D., MPH, Food and Drug Administration NATIONAL ADVERSE ~)6 REACTION SURVEILLANCE: 1986 While the Food and Drug Ad.inistration has monitored postmarketing adverse drug reactions (ADRs) for over 20 years, several recent changes have made this surveillance increasingly important and useful. Regulations governing submission of ADRs by pharmaceutical manufacturers were cha:~ed in 1985. Projects to increase physician reporting are underway. Litigation concerns and heightened public awareness have contributed to an over 4 fold increase in the number of reports received by FDA over the past 5 years. The distribution of over 40,000 AOR reports received in 1986 by drug class, type of reaction and patient factors will be presented. Most reactions occur within one week of initial drug exposure. Nearly 30% of reports involve death or hospitalization. Increasing numbers of foreign reports are being submitted. The reporting, collection and analysis of ADR reports represent a crucial public health activity necessary to expand our knowledge about pharmaceutical products to ensure their safe and appropriate use. All care providers should be aware of their resoonsihilities in *h+e •• 1041 Buehler .7W- 1uc Centers for Dises se Control, Atlanta, _ RACIAL AND ETHIC DISPABITIES IY THE OCCUg$HYCE of 1NYLIlIABLE DISEASES Each week, all States report prelisdnary counts of notifiable diseases to the Centen for Disease Control (CDC), and 31 States telecoedni- cata ds®ographic information on individual cases. More co.prehansive data are reported separately to CDC prograu. To assess whether the case-level data can be used to monitor trends in coamunicable diseases by race/ethnicity, we calculated annual morbidity rates for 1984-1986 for 11 diseases (aseptic meningitis; partussisi hepatitis A, B and non-A, non-B; salmonellosis; shigellosis; campylobacteriosis; tuberculosis; seningococcal infections; and asps) that vary in modes of transmission and approaches to prevention. Because many preliminary raports did not specify race, our comparisons ware limited to 2 to 9 States per disease. Morbidity ratas ver* genecally highest for fative Awricans, ranging from 37 times the rate for whites for shigellosis to 1.6 times the rate for whites for aseptic srninsitis, Eates for blacks and Hispanics co.pared with those for whites sbo.wd no consistent pattern of differences. Use of the weekly morbidity reports for monitoring the iapaet of cosunicable diseases on the health of minority groups will require sore eomplete reporting of demwgraphic infor.ation. ti.R- Gold, P, Franks: Family Medicine, University of Rochester FARt1IN8: PRIMARY PREVENTION OF HYPERTENSION? A progran has been-_estab,lished iD a fi~lnci,al-Ly, depressed agricultural area of upstate. New York,.whiCb.S~sgs A g0+jnalaity orlented primary qard approach in defining and attempting to change the high•cardTovasculIIr mortality.ra.tes found.,iD the arla: P,ersqrls aged 16 and over in two contiguous demographically similar,tRYm,s-Yferg gprveyed for,standard sociodemographic'data, information about attlization of and baNrte'rs to iealth care.and preventjve.ser.vices.,cardioXaf.cul~r risk,-factors,.and were screened for blood pressure and.glucose-)eyel ,Farmers„had,sig.. nificantly more low income hooseholds, less education, less preveofJve carer more out of pocket exp)nses„and ate more eggs. After•,a,djustment for other indgpendent variables farming was associated with a 3:24`amHcj lower mean blood pressuri (95 percent confidence interval-.(CIa-1~S.5) comp4red to other acc.pations.. Age was a significar~t;prediotor of ineaa bloo$,pressur,e-,.for non-farmers (.25 nw Hg/yr., CI~.18-.32) but not'fbF farmerS (.09 ~i Hg/yr., CI--0.03-.21). These results'ilre-cengruent' with prevltfus's~.i(dH5"tNSt haVe 'shown-decreased cardiovascular~aion+ bidity and mortality among farmers. The possible causes of this pro- tective effect are explored. ABSTRACTS 27 TIMN 322484 ro
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Rick T. Zawadski PhD., Research Dir., On Lok Senior Health Services Eileen Kunz Project Coordinator On Lok Sem or Health Services RISK-BASED FINANCING FOR LONG-TERM CARE: A NATIONAL REPLICATION Can a service organization provide higher quality long-term care at a competitive price by assuming full control for all services? Since 1983 On Lok has been demonstrating just that. With fixed capitation rsimbursement frae Medicare and Medicaid, On Lok has assumed full financial risk for the delivery of all health and health-related services to an exclusively frail long-term care population. Would On Lok's approach work in other settings7 In 1986 the Robert Wood Johnson Foundation funded On Lok to study it§ replication feasibility. More than 120 sltes across the country expressed interest; six were selected for close evaluation. In October 1986 legislation was passed to extend On Lok's Medicare and Medicaid waivers to ten other sites. The presentation will focus on: the evolution of long-term care system development and the managed long-term care organization, spe- cifically On Lok's risk-financed long-term care model; the progress of the national replication project and strategies for )mplementat(on, includ)ng implications of the model on current health policy issues. 9{data 8oa Strarnki. Dr.PaIIac LRl(U. 2ZospecL 9i11.. BaLLm.. Tiu 770641 ,rax a,. -w. i~.4. _ h+i•~ it" ot Ts~a erlta Ys1ao(x SsOh[L tllghrl ItaiTl9riau Dl2rislOS Or fa7WL*.rliYL )1s98IQ( PUea, 119MKROQC aS5f3T37P RL4IIIAM 'ttds cassareh acplord & seMd,iogy for tsc)mlogy aae.sosnt within tAe healtb indutry. 'Re cw studied w diffusion of external rell-voluse infusion p.ap (SVIP) at a large cancar tceata,t and rssesrch e0mec. This p.p.r r.pmrts tta dewlopsent a'd testing of a practical diffusion rodelr and the tise series analysis of SVIP diffusi~Fat this Lstitution. SVIP adoption ani utiliration for 19s2-19e4 wer. ~ 'o.lly contincted froa prescription rscocds DF14,979). Moption and u.e theories wsn applied to test .eve ait diffusion tad.ls fourd t(uongh literature review. 1tr Candidate Adoption-Oae (CA-0) diffusion paradige dewloped foe this atudy vr g.rsane. rawring uti- lizaeSou as op;Dsed ba adoptioa behavior, OM-D ore aoapucsateecl eesi ppwlfaL»d the spir emtsdr inerea.r. ~9~ M~llowLg the QI-0 Paradlqs with tlaera a Pre- dicfne, siaple Iinear ragressien teelnique focscast abando,rd use of ine pap - devioe ud eapetrc,Cial drd for its ouaQaitot 1905-19s7. 7!r study concluded. that the sodals sid sse)rds tast.d in this res..rch are ira,ovative and do awo biobedsnlogy. i x Marc A. Cohen, Eileen J. Te11 and Stanley S. Wallack, Health Policy Center, Heller Graduate School, Brandeis University LOHG-TER1f CARE &IS1C SHARING PROGRAMS: WHAT'S IN IT FOR MEDICAID? As the elderly become more knowledgable about the lisdted nature of Medicare coverage for long-term care coats and the financial require- ments for Medicaid eligibility, there will be greater demand for programs that insure against these costs. Currently, states are loo)ti ing for new ways to stem the growth in Medicaid expenditures. In response, a number of private models for the finance and delivery of care that pool risks to pay for long-term care costs are appearing in the marketplace. This papar shows that Medicaid programs can realize savings froe the expansion ofprograes that pool risk for long-tera care costs. Depend- ing on the extent of asset transfer, the costs to Medicaid of an insur individual who enters a nursing hese are between 27S and 60Z lower tham a non-insured nursing hose entrant. The most comprehensive risk-poolin( models are the least accessible to the elderly and save Medicaid the least amount of aoney (eg. CCHCs). Conversely, less comprehensive models are more accessible to the elderly and potentially generate the greatest Medicaid savings (eg. LTC insurance). Finally, we explore the implications of these findings on state strategies for encouraging the development of long-term care risk-poole. Z s W. Grannerna. Ph.D. Mathenatica Policy Research, Inc. 8. Grosssan, Ph.D. Pssblic/Private Ventures METHODS FOR TARGETING COt4ffiRITY-EASLD [ANG-TSRM CARE PROOHAi1S This paper presents the results of a Congressionally rndated study of sethods to identify persons at risk of institutional placesent who could be truted more eost-effectively with home health and other noninstitutional services. Using data from a sample of over 4000 ispaired elderly persons, wltiple regression methods are employed to estirte the effects of alternative eligibility critetia for case rnaged couunity care programs. Important predictors of nursing hoee use are identified including financial resources, Medicaid coverage, attitudes to.erd placement, disability, and availability of support from fasily and friends. Nonetheless, ultiple-regression methods are insufficient to identify a sizable group for whom public costs ean be reduced. The results suggest that eligibility criteria based on individual characteristics (including ispairsant) are likely to be less useful than sechanisr such as preadsission screening for identifying elderly at risk of nursing hoee placement who can be treated sore cost-effectively at home. 1049 ' Greqory de Lissovoy, Ph.D., The Johns Hopkins University WHEN LIGHTENING STRIXFS THICE: HCFA'S DECISION TO PAY FOR HEART TRANSPLANTS Coverage for heart transplants will now routinely be provided for 'Medicare beneficiaries. HCFA has projected that 65 covered heart trans plants will be performed the first year at a wst of $5 million, rising to 143 transplants annually within 5 years, at a yearly cost of $25 million. These numbers appear modest given that more than 700 heart 'transplants ware performed in 1985, and aore than 1,000 (estinated) in 1986. Federal planners badly underestimated the utilization and costs of two earlier Medicare-funded organ replacement therapies, dialysis for end-stage renal disease, and home total paranteral nutrition. Will history repeat itself, and heart transplanation )»coee yet another huge drain on the Medicare trust fund7 Factors in the growth of the Medicare ESRD program, as documented in a new study performed by the author, are contrasted with seasures HCFA has taken to limit growth of the heart transplant program. Results of this analysis suggest that the size and costs of the heart transplant program could easily exceed projections.. 32 ABSTRACTS ftoseman. Cvril. Uy of Hawaii CRITERIA AND PRCtCEDURES FOR REVIEWING TECHNOLOGY AC(lUISITIIXN IN LAR3€ HOSPITAL SYSTEMS; THE CASE OF THE U.S. VETERANS ADMINISTRATION '- DRS-generated and tiudget-reduced cost-containment measures has focused hospital adeinistratars' attention on Justification for expensive equipment. In large,.multi- hospital systems with diverse teaching and research responsibilities and substantial commitment to state-of- the-art medical specialization in diagnosis and treatment there is a special need for multi-level review of proposals for acquisition of expensive equipment. The author has spent the first half of 1987 while based at Region VI San Francisco offices of the Veteranf Adeinistration, interviewing key participants And analyzing development plans, equ# pment requests, and review documents pertinent to technology development in VA hospitals in the westernmost region of the U.S. The focus of the proposed presentation is on differences in criteria, procedures, and the application of the concept of rationality in technology investment resource allocation among three hospitals, the district office, and the regional level administrators and planners. E. I. Chatziandrecu;, K. Carlson2 H. lleinsteinl A. Mulley2, 1Harvard School of Public Health, 2Massac#Wetts General Hospital, Doaton, MA COST-EFFECTIVENESS OF EKTRACOBPOREAL SHOCK WAVE LITHOTRIPSY Recent technological advances are changing the.surgical approach to urolithiasis. A decision and cost-effectiveness model was developed uning a Harkov, pprocess, thaLwill inform clinical and policy decision inkers about the effect and'Sost of the three alternative techniques for stoas removal: Oper surgery, percutaaeous extraction or ultrasound lithotripsy (PUL) and extracorporeal shock wave lithotripsy (ESWL). We evaluated the consequences of each strategy for patients for whom stone rewval is indicated. Estimates of efficacy, complication rates, morbidity and direct medical cost were derived from published litera- ture and expert opinion. Outcosea considered were morbidity, mortality and direct coat. Sensitivity analysia was perforsed for key variables. like efficacy, complication rate, and cost. ESWL appears to be the pre- ferred strategy when effectivene.s rates were varied across the range reported in the published literature. Ilowever, thresholds of which nn invasivc procedure is preferred can be identified when relatiye effi- cacy is varied across a range plausible for stones of different size, location and composition. We conclude that ESWI. promises to be a cost saving technology if it is ueed discerningly. 1050 ;regory de Lissovoy, The Johns Hopkins Universityi Thomas Rice, The :Inivsraitv of North Carolina at Chapel Hillr Jon Gabel, The Health Insurance Association of America ZO!)PE'fITIOH IN HFai.T)K'AREs THE EXPERIENCE OF FIRMS OF£PRING A CHOICE AN1017G ALTERNATIVE FORMS OF HEALTH INSURANCE Esploye.s in a growing numb.r of firms can choose among several forms of health insurance coverage. For example, "triple option" plans offer three coverage alternatives; a conventional indemnity plan, a preferred provider organization (PPO), and a health maintenance organi- zation (14e0). Firms with such multi-option arrangements are in a position to directly compare the performance of each option with re- spect to the range of services, costs of coverage, utilization, and .®ployee perceptions of quality, convenience and satisfaction. Objectives of our study were (1) characterize firms offering Tulti- -hoice health plans (2) sueaarize the comparative performance of alter- utive forms of coverage. The study is based on telephone interviews rith benefit managers in a national sample of over 600 firms. We re- gort findings from a eulti-variate regression that combines interview iata with coasxmity socio-economic and health system data. Results Dffer insight on a major policy issue, the potential benefits of oom- petition in the market for health care. TIMN 322489
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, f Sallv A Smith. MPH. Pamela S. Haines. DrPH. Joseph C. Edozien. LD. Universitv of North Carolina EFFECT OF CALCIUM SUPPLEMENTATION ON BLOOD PRESSURE IN BLACK WOMEN Blood pressure levels in blacks are higher for both sexes at a1P adult ages, and hypertension is twice as prevalent when black populations are compared to white populations, A number of clinical trials have examined the effect of calcium suppiementation on blood pressure in adult notnotensive and hypertensive populations. However, no clinical trial'hes limited the population studies to black Americans. In this randomized clinical trial. 114 black women between the ages of 18 and 45, with blood pressures less than 140 am Hg or 90 ® Hg were randomized to treatment arid control groups. Treatment subjects were asked to ingest 1000 ag calcium citrate daily over a period of two months. At baseline, the mean weight of the treatment group exceeded that of controls (158 versus 147 pounds), and smokers in the control group exceeded those in the treatment group (21 versus 30 percent), but other confounding variables were equally distributed. After two mo_nths of calcium supplementation, in this sample, no differences in group means for either systolic or diastolic blood pressure were•observed between treatment and control group. H. Farmer, M.D., M.P.H., National Institute of Mental Health, S. gittner, H.D., H.P.H., Uoiversity of Haryland School of Hedicine, R. Abbott, Ph.D., Hational Heart. Luag, and Blood Institute, H. Wolz, and L. Hhite,_H.D., H.P.H., National Institute on Aging. CHRONIC HYPEATENSION AND COGNITIVE PEBPORHANCE: THE FBAMINGHAM STUDY In 1976-1978, a battery of eight neuropsychologic tests was administered to 2,123 participants in the Fradogha. Study aged 55-89 years. Performance on each test was examined in relation to left veotricular hypertrophy (as a measure of chronic hypertension) as well as the proportion of biennial examinations over the past 20-30 years in which a participant was categorized as being hypertensive while controlling for age, sex, education, alcohol consumption, and smoking. Those with a diagnosis of stroke were excluded from the analysis. In the remaining sample, neither left ventricular hypertrophy nor proportion of examinations categorized as being hypertensive was significantly associated with cognitive performance. In contrast to other studies, we found no consistent relationship between blood pressure and cognitive performance. P.A. Sytkowski W.B. )Cannel, P.A. i(olf, R.B.D'Aaostino, Boston .. , University School of t4adicine _ CARDIOVASCOLAR DISEASE MORTALITY: MBCHAHISM3 BEHItm ITS DECLINE IN THE FRAHINGEDW STODY The decline in cardiovascular disease (CVD) mortality has been well documented, but the mechanisms remain unclear. To detect secmlar trends that might influence CVD risk factors, incidence, or 'ortality, the population was limited to three male birth cohorts (aged 50-59) within the Fras,ingham Heart Studye 1) aan at exam 2(1950;n-625), 2) snn at exam 7(1960rn=636), and 3) sa:n at exam 12 (1970s~512). Each cohort was followed 13 years. CVD mortality during the period 1970-198_ was 57% less than the 1960-1973 period and 62% less than the 1950-1963 period (p-0.01). Neither prevalence, incidence, nor case s+l.x differ-. ences explained this decline. In this population, the decline appears to be due to improved survival rather than decreased incidence of dis- ease. The third (1970) cohort had a higher probability of surviving 10 years from onset of disease than did the 1950 or 1960 cohorts (p.0.0006). The 1970 cohort had lower mean systolic and diastolic blood pressures and significantly fewer smokers and hypertensives (p-0.05) than the 1950 or 1960 cohorts. Improved risk factor profiles nay have Iinfluenced survival independently by lessening the severity of disease iand/or swy have acted in eonjunction with improved treatment. L. Adrienne Cupples, Ph.D., Nathan D. Wons H.P.H. Adrian M Ostfeld H.D., Hilliam B. ganael, M.D., Boston Universiiy, Boston, MA. _ THE ASSOCIATION OF PRE-.ERISTIHG CARDIOVASCULAR CONDITIONS HI1E FAQGOD- SIS FOLLOWING INITIAL MYOCARDIAL INFARCTI011: THE FRAMIIH'.HAH ST(1DZ The role that pre-existing cardiovascular conditions, includ~ing aagina pectoris, congestive heart failure, stroke, and interaittenr`tlate4tca- tion may have in prognosie following initial myoeardial infs;crliop is examined. The previous occurrence of each condition was dy..FeraitYtd'in the 731 individuals of the Framinghaa Study who experiancea a'tilXGa myocardial infarction during the initial 30 years of follbw upy„ J.ong- term effects on prognosis were assessed by use of the Cax AropdrCi'8II71 hazards model. No significant associations were found. " Stmlt'-"C1Ff prognosis,reassessed biennially, was examined by use of a person-vears method using multiple logistic regression. History-beloEe infarctiod of angina pectoris was only weakly associated (RR-1.5, 95SCL-.89e•2v5§) with reinfaretion, but significantly associated with subai{tygr„'F+(rdiac mortality (Rg-1.88, 1.14-3.11). Previous strokFe was also assocftted<' with cardiic .ortality (HR-6.72, 2.01-22.7). All findings wete3iydy- pendent of agF, sex, obesity, current serum cholesteroqr,:an1 other ir portant risk factors. These findings suggest the iqsortpace of•eertain pre-existing cardiovascular conditions in the short-[era prognosis following initial myocardial infarction. 28 ABSTRACTS KANKAANPAA J and thc FtNMONICA Study Group Nationa) Public Hea)th Institute, Dept. of Epidemioloqy, Mannerheimintie 166, SF-00280 Helsinki, Finland REGIONAL DIFFERENCES IN THE INCIDENCE AND SEX RATIO OF ACUTE MYOCARDIAL INFARCTIDN (AMI) IN THREE GEOGRAPHICAL AREAS OF FI(iI.AND The levels in the incidence, mortality antl case-fatelity from AMI were analyzed in three qeoqraphical areas of Finland. In each of the study ateas, AMI registry has been established as a part of the 4Ni0-initisted MONICA proiect. In the reqistry, all the AMI cases (live and deceased) in the male and female population aged 25-64 years are reqistered. ,In the study, the nid-year populations of the areas concerned were used as.denominators to calculate the incidence and mortality rates. Both in men anQ in women the incidence and mortality ratea increased with age and for all age qroups they were hiqher in men than in women. There was a marked difference in the incidence of AMI between eastern and western Finland: high levels were found in the East and lower in the West. The age-adjusted incidence rates for men varied between 525/100.000 in southwestern Finland and 700/100.000 in eastern part, and for women between 80/100.000 in the Southwest and 143/100.000 in the East (in North Karelia). The male/female sex ratio in AMI incidence was exceptionally high, especially in eastern Finland. 104 J Bridge, M Tormay, L Mascots. Los Angeles County Department of Nealtu Services. LHt3ER-R€PORTING OF HEPATITIS: A COST ANALYSIS OF AN OUTBREAK Outbreaks of hepatitis A in day care centers are well documented, but few reports address the financial and medical impact of not reporti the disease in this setting. An outbreak of hepatitis A(n-18) occured from February through September 1986. Of the 18 cases, 13 (72\),were diagnosed by physicians. Only 2 of the 13 cases, (15%) were reported t the health department. Health care providers' failure to report these perpetuated disease transmission for 7 months. Services provided by the health department, such as education on hygiene and the administration o immune globulin to contacts of cases could have prevented 15 oi tHe t8 cases (83%). These 15 cases resulted in unnecessary morbidity measured 263 sick days, 107 work days and 35 school days lost. Expenses incurre due to doctors office end emergency room'4isits, laboratory tests, IG, salaries lost due to illness, and public health personnel man-hours sh a 515,000 expenditure. Hepatitis A under-reporting estimates range fr 60 to 90%. In L.A. County, approximately 7800 cases go unreported annually. A Preventable disease such as hepatitis A results in increes illness and financial expense when it is not reported. Efforts to impr reporting through increased surveillance and health care provider'adura tion are warranted. Roderick E. Ed®ond Linda H. Frazier M.D. Kathr Ha ruder-Habib Ph.D., Duke Universit Medical nter Durham, N.C. BENEFIT-COST BATIq"OF PREMARITAL SYPHILIS SCREENING IS LESS FAVORABLE THAN SCREENING FOR PHENYLR€TONOBIA, RUBi.2LA AND CONGENITAL SYPHILIS. Ia the 1940s, "premarital syphilis testing (PHST) progress wara anacted. In the last decade, all but 16 states have repealed PMST laws, arguing that progr& were economically wasteful due to low yield. In this study, PMST yield data was collected from state health departments. The net benefit and cost of reporting state programs were calculated in terms of dollars. Probability estimates from the literature were chosen to give maximal benefit to PMST. Benefit included averted health care costs and potential wages; screening cost was $23/person. 231 new cases of syphilis were detected per year (0.0015 of those screened). Preventable morbidity included aortitis (10Z of new cases detected), neurosyphi7.is (8%), congenital mestal retardation (4.8%) and neonatal deaths (2.4f), The PHST benefit-cost ratio - 0.7. This ratio was significantly lower than that for P&U screening (ratio - 1.37), rubella scYeaning (8 to 27) and prenatal screening to'prevent congenital ayphilis (3.8). Although this study does not address psychological issues isgarding contraction of syphilis, we hope that this economic dati: ciill aido in future debate concerning the repealing or continuance o£ the PMST_ " Bell :0H. S:a11ay, :D S. :,ei;ers cD, A:.. Groth-3uncker, MD {onroe County :(ealth uepart::ent and St. John's :(one, Rochester, rew 1'ork FALSE POSITIVE TUBERCULIN REACTIONS TZTH APLISOL , While investiaating qursine houe contacts of a deceased parson with prob-J able tuberculosis, higher than expected conversion rates were noted in staff aar;inally associated with the suspected index floor. Suosaquent testing with Parke-Davis' Anlisol revealed that 52 of 483 staff persons (representing o`% of the hove's SE0 personnel) had converted their PPD status within the previous 24 ~onths. Intensive clinical, radiographic, and environmental assess:xnta revealed no source. Repeat testing with Connaught's Tubersol 2eaonstrated that 19/40 (49.5z) were false positive reactions. False positivity dit; not correlated with age, birthplace, raee, size of reaction, quality of reaction, or history of possible ex- posure to endeuic atypical mycobacteria. All persons with false posi- tive reactions haL had one or nore previously nevative PPD reactions with Aplisol. Twelve persons have refused retesting with Connaught to date. Five staff persons had been•treated with I&1 prior to our find- ings, and IH"d would "nave been recomended for 7 awre. 17e believe this phenomenon represents sensitivity to impurities in Aplisol which develops in certain persons undergoing serial PPD testing with this oroduct.
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. n onlo . tsLrBda, +. ., .-P.H., Colle e of Medicine, Rural Health ce, nivers o zona. ~ „ BARRIERS TO HEALTH CARE AMONG HISPANICS: EVIDENCE FROM THE HISPANIC HEALTH ANU NUTRITION EXAMINATION SURVEY. Data from the 1982-1984 Hispanic Health and Nutrition Examination Survey (HHANES) show that less than one-fifth of the adult Mexican American population in the Southwest report that cost of care is a :na,jor barrier to receiving health care. Of the remaining 12 barriers to heslth care examined, more than 50% of those who report that these are barriers indicate that these barriers actually prevented theai from getting care. Less than 3% of the sanple indicate that cultural bar- riers (lack of Hispanic staff and lack of Spanish speaking staff) are impediments to health care. Additionally, barriers to health care are examined with respect to gender, seif-reported ethnicity (Mexican, ,qexican American/Chicano, "other" Hispanics) as well as varying levels of acculturation. Results indicate that there are significant differ- ences between specific barriers to health care and gender, self- reported ethnicity, and acculturation level. Isplications for "mproving the delivery of health services to Hispanics are also discussed. Ellen L Glascock ph D, St. Francis Colleae, B_rooklvn NY.i kOND:N° WITH AIDS. Although much has been written about risk, transmission, treatment, and experiences with rIDS.since its identi- fication in 1981, almost all of that coverage has been focussed on male PWPS. dince 1985, popular literature and media has began to explore AiDs among women, but little has been written of a descriptive nature. In particular, differences between male and female pWAa' experiences have not been addressed. This paper will seport on existing literature concerning Women With 71IDs as well as offer preliminary findings in a group of women in lfew York metropolitan area. 1057 Olivia Carter Peter Ger en Pedro Lecca * Nat ona Center for Hea th Statistics, *University of Texas REPORTED ASTHMA AMONG PUERTO RICAN, MEXICAN-AMERICAN, AND CUBAN AMERICAN CHILDREN: HHANES, 1982-84 Asthma rates for Hispanic children living in the U.S. vary greatly by national origin; Puerto Ricans exhibit some of the highest rates in in the U.S.. while Mexican-Americans exhibit some of the lowest rates. Data from the Hispanic Health and Nutrition Examination Survey (HHANES), conducted in 1982-84, were used to examine differences in the rates and correlates of reported physician-diagnosed asthma in children from three Hispanic groups in the U.S.: Mexican-Aeericans, Cuban-Americans, and Puerto Ricans. Data from the second National Health and Nutrition Examination Survey (MHANES II), con-ducted in 1976-80, were used to estimate asthma rates for non-Hispanic white add black children. Of children ages 6 swnths-11 years in 1982-84, 20IX of Puerto Ricans (n-914) reported having had asthma in their lifetis:e compared to 4.5% of Mexican-Americans (n=2761) and 8:85 of Cuban- Americans (n•291). Puerto Rican children were also more likely to report having current asthma and to wheeze during the physician's exam than did Mexican-Americans or Cuban-Americans. Asthmatics were described by use of inedications, health services and functional lisitations. Cheri Pies MSW MPH; Brenda Eskenazi Ph.D.• Amanda Nevstetter. MSW; Christy Shepard R N• Universitq of California, Berkeley. AIDS-RELATED VIRUS SEROLOGY IN A STATEWIDE SAMPLE OF LESBIAN5 WHO HAVE USED ARTIFICIAL INSEMINATION BY DONOR. In 1985. Australian investigators reported that four women who were artificially inseminated with semen from a donor mho later tested posi- tive, were all antibody positive. The purpose of the present investi- gation is to examine in a more comprehensive study the transmission of the AIDS virus through artificial insemination (Al). We have chosen to study lesbian women because lesbfana, as a rule, do not engage in hete- rosexual intercourse, and therefore we could eliminate the contribution of specific sexual practices. In addition, lesbians often choose gay donors and the incidence of AIDS among gay men in California is high. In a pilot study, 48 lesbians in the Bay Area tested negative for antibody to the AIDS virus. This study was expanded to include lesbians statewide. Participants'are tested for the AIDS antibody and asked to complete a questionnaire eliciting information about donor inseaina- tion, sexual, health, and reproductive history. As of January 1987, 20 lesbians have participated. These women reported obtaining semen from 14 homosexual, 10 heterosexual, and 4 bisexual donors (6 addit- ional donors were of unknown orientation). One homosexual donor has a known positive antibody status, and another died of AIDS 3 years after donatinK semen. To date all vomen have been seronegative. PA Selwyn*, EE Scheenbaua*, Al Feingoid*, M Mayers k, K Davanny+t MF Rogera* et al., *MonteficraMedicalCenter, Bronx, NY., **CDC, Atlanta, GA. PREGNANCY OUTCOMES AND PERINATAL TRANSMISST-ON OF HIV IN IV DRUG USERS. Since 7/1/ 85, we have monitored pregnancy outcomes among female IV drug use in a NYC methadone program enrolled in a prospective study of HIV infection. F men receive antenatal HIV antibody (Ab) tests, counseling, and physical exam: Infants are examined at birth and at 3 month intervals; card and periphera: blood are tested serially for HIV Ab, and cells stored for HIV culture. There were no dif ferences observed between HIV seropositive (SP) and seronel ative (SN) women in the frequency of pregnancy, early or late adverse pregnanr outcomas,or elective termination. No pregnant vomen developed AIDS(at ase of 26 vks.past-partumfollov-up),although pregnant SPs developed generaliz lymphadeoopathy at a slightly increased rate over SP vomen not becoming preg- nant (O.R. 3.3, P(.07). Of 16 infants of SPa and 30 infants of SNs,thera vere differences in gestational age, mean birthweight (2860g vs. 2830g),or neonat complications. Of infants of SPs. 12/12 had HIV Ab in cord or neonatal blood ( 0/ig of SNs). By a mean of 27 vks. follow-up, 6/12 (50I) infants of SPs remaina P, and 6/12 (50S) became SN. 5/6 infants remaining SP and 1/6 infants becoai N showed possible signs of HIV-related disease (eg; £ailure-to-thrive,lymp denopathy,multiple bacterialinfectfons). Results show thac maternal HIV Ab was not associated with adverse pregnancy outcomes, although SP pregnant vomanmay be at risk for progression of HIV d Data also suggest that perinatal transmission may be -50Z with ease status . a subatantial numberof infected infants showing signsconsistentvitn MIV- related illness. Scitovaky Anne A, and Clinn Mary W., Palo Alto Medical Foundation, Palo Alto, California USE AND COSTS OF MEDICAL SERVICES BY PERSONS WITH AIDS IN THREE PRACTICE SETTINGS SN SAN FRANCISCO: PRIVATE PHYSICIANS, PUBLIC HOSPITAL AND PREPAID CROUP PRACTICE We will present the early results of a study we are currently con- ducting of the use and costs'of all medical services obtained by a group of persons with AIDS in San Francisco over a period of 12 months in 1986-1987. Three groups of patients are included in the study: c~o tients treated by community physicians (N-92), those treated at the unty and city hospital, San Francisco General Hospital (N-49); and those treated at a prepaid group practice, Kaiser-Permanente (N-75). We villflistinguish between patients by survivor status (died, lived all 12 months), by initial diagnosis (pneumocyatis carinii pneumonia, Raposi's sarcoma, neumoc stis carinii~pneumonia AND Kaposi's sarcoma, and all other infectious diseases , and by practice setting (private physicians, public hospital or prepaid group practice. This is the first study which has attempted to obtain data on the use and costs of all medical services by persons with AIDS, including not only hospi- tal and physician services but home health, nursing home and hospice care, counselling, and various non-traditional services. Roxanne Andrevs,SysteMetrica; Margaret Eey~s, SysteMetrica; Penelope Pina. HCFA; Jec ie Ka on., ateNetr es. FOOR YEAR CHAN4RS IN COSTS, TREATMENT AND CLINICAL MANIFESTATIONS 01 AIDS AND ARC IN MEDICAID PATIENTS IN CALIFORNIA Accurate estimates of the health care costs for treating AIDS patients needs to take into conlWeration the changas in the disease's clinical manifestations and treatment protocols. It is generally agreed that eosts par person are decreasing due to shorter hospital stays and shifting treatments to the outpatient setting. We examine tbase changes in the Medicaid AIDS and ARC populations using data from a unifors person-lavel Medicaid claims data base (Tap*-to-Tape). Persons with AIDS and young adult wles with ARC wre identified in this data base for California for 1981 through 1984. The changes !n costs par person, ix of health services provided, and clinical manifestations in these patients are presented. The findings are discussed in terms of future trends in health care costs, variations found in previous cost estlaation studies, and the increasing impact of AIDS and ARC on the Medicaid program. R,~,Mrt L cohen N D 1 paul A Moore. M.S,w.l~fawrence Wex].er. PhD New~ w ang HOSO ra : r_e_rmrat on, New York. _ N.Y. ANALYSIS OF THE EFFECTS OF RIS1C BEHAVIOR FACTORS ON HOSPITALIZATION OF PERSONS WITH AIDS: THE ERPERIF.NCE OF A LARGE METROPOLITAN PUBLIC HOSPITAL SYSTEM The NYC Health and Hospitals Corporation (HIiC) is the largest single provider of care to hospitalized AIDS patients in the country. Eecause of the epidemiology of AIDS, iDiC has extensive experience with patients from all of the major population groups most at risk because of sexual and/or drug use behaviors. over time, the patient mix has undergone changes in demographics and risk behavior. Data will be presented describing primary and secondary diagnoses, length of stay, mortality rate, alternate level of care status as a function of high risk behavior, recurrent hospitalizations, and lifetime hospitalizations. I ABSTRACTS 35 TIMN 322492 .~
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Randall S StaFFord MRS• Kaiser €oundation Health Plan, Central ,,,, Office. Oakland CA. THE CHARACTERISTICS OF AMRtrLATORY CARE l(EASUREMFltT SYSTEMS The expanding role of ambulatory care services combined with a competitive health care system has made ambulatory care measurement a crucial concern. Several systema of measurement have been formulated to quantify the provision of services by practitioners, clinics, and/or health care organizations. These systems may help solve problems in reimburscment, health management and quality assurance. This paper presents an analytical frameqork that organizes meas- urement systems on the basis of three fundamental characteristics: 1) a system's unit of ineasurement or level of generality (eg. by procedure, patient visit, or patient-year), 2) the variables used to define categories of health care production within a system, and 3) a system's method of assigning relative values (weights) to the defined categories. This analytical framework permits the evaluation of a system's reliability, feasibility of implementation and poten- tial for introducing incentives that affect medical practice. - Murazzi PhD Mercy Hospital Miami Florida and Thomas M. DunaY8, )rPH Dept of Health Services Admin Florida International University, Niam 1yFlrida. ', , INTERNATIONAL NEINORKS EXPAND HOSPITAL MARKETS AND REVHNUB Hospitals facing uncertain and unstable economic prospects have°faua"t increasingly necessary to search out nev sources of revenue and ways of penetrating or enlarging their available markets for a greater sbasa of patients needing their services. The South Florida coss+unity of€ats as• cellent conditions for local hospitals to expand their marketing poten- tial across international borders because of its bilingual, multi-ce~- tural and tourism-attractive characteristics. Mercy Hospital i+r4f2-i° ias particularly capitalized on these unique advantages to inerease its itilization in recent years by creating international networks of pa- tient referrals through carefully fostered relationsftips=ath physl,sdbapf in several Latin Ameriean and Caribbean countries. It has promoted a )rogram of postgraduate medical education exchanges for several physi- cian specializations both in Miami and on the home sitas of internation- sl physicians. It has also restructured many of its hospital features to acconmodate this growing international patient demand while sima3~ taneously balancing its own local com.munity character iiith a domestic aarketing nrogram for the majority of its users from traditional ser- aice are This paper analyzes the growth of international markating. 1013 Olive H. Moase M.S., Modi Pontio, and Collins 0. ,Siihihen uwa,- .."" The Pennsylvania State University, Cniversity Park, Pennsylvania NUTRITIONAL ASSESSM:NT OF STUDENTS ATTENDING GRADES ONE TO SIX ON GOOD- ENOUGH ISLAND, MILNE BAY PROVINCE, PAPUA NEW GUINEA Weight-for-height (N-1028; all students) and twenty-four hour food recall (N-280; grades 5 & 6) were measured in order to assess the adeq- uacy of food intake amongst primary school children. WHO W/H standards revealed the following: 21% were the recosmmended WJH, 71% were within 5 kg. of recommended W/H, 5% were more than 5 kg. underweight, and 3% were more than 5 kg. overweight. Food group evaluation indicated that the average daily intake was 1.6, 2.8, and 7.7 avg. of protein, protective and energy foods, respect- ively. While 65% consumed foods from all three food groups, 24% consumed no protein food and 14% no protective food (2x consumed neither protein nor protective food). The variety of food available varied from commun- ity to community--- 3-11 different protein foods. 7-15 energy and 8-18 protective foods. Both average daily intake and variety available indic- ate that protein is in short supply. It was concluded that the Divisions of Education, Health and Primary Industry use the findings to jointly intensify and integrate their respective functions in order to promote better nutrition. Albert Chang, M.D., M.P.H., Raul Carrillo Silva, M.D., and Beatris 0_ ILojas Torres, M.D. Ls:LA School of Public Health, Los Angeles, California, U.S.A. ar,d Secreataria de Salubridad y Asistencia, b(exico. City, Mexico. CHILD MDRTALITY FRCM Ls7J11AIFS IN MH)(ICO Injuries represent a leading cause oY childhood mortality in not only developed countries but in developing countries as well. In Mexico in 1981, injuries represented Lhe third leading tause of mortality in preschool age children (1-4 yrs.) and the first leading cause of death in school-age children (5-14 yrs.). During the period of 1977-1981, childhood rates due to gastrointestinal diseases and acute upper respiratory diseases have decreased significantly while mortality rates due to injury have remained steady. Calculating "Potential Years Lost" ('PYL), years of life lost attributed to injuZies actually increased 4.6% . While injury deaths represetfEed 15.21 of all PYL in' 1977, they represented 24.1% of all PYL in 1981. A National Council for the Prevention, Attention and Control of Injuries has been established in the Secretaria de Salubridad y Asistencia in Mexi.co. Given the increasing role of injuries as a cause of childhqod mortality, the establishment of similar injury preventlon prograrns must be considered in all developing countries. Carol B. Harmann and Patricia E. Bailey, Family Health International TRADITIONAL BIRTH ATTENDANTS (TBAa)• FILLING THE NEED FOR BETTER HEALTH STATISTICS In many developing countries, TBAS attend a higher proportion of births than any other health care providers. Although many are illiterate, TBAS have proven to be a valuable source of information. In the county of Trairi, Brazil, TBAs complete simple questionnaires and pictorial follow-up forms with the assistance of community mes,bers. In the Rarava region of northwest Zaire, TBAs make oral reports to Literate health w rkers who record the information in a "birth registry". Both studies obtain information on prenatal and delivery-related care, referraLs to medical faciiitia , and maternal and infant survival. They show that innovative apprnaches can be used to halo complete the picture on home deliveries. Josefa Ippolito-Shepherd, Ph.D., consnltant, PAHO/WHO Robert H. L. Feldman, Ph.D., University of Maryland HEALTH EDUCATION STRATEGIES TO PROMOTE PREVENTIV€ HEALTH BEHAVIORS, THE CASE OF ARGENTINE HECORRHAGIC FEVER Argentine Hemorrhagic Fever (AHF) is a major public health problem in Argentina. AHF's etiolovical agent is a virus that is spread by field mice and affects mostly male rural agricultural workers. To promote health behaviors conducive to the prevention of AHF, this case study examined the effect of conanunication and education strategies on inten- tion to wear protective clothina and intention to obtain a vaccine when it becomes available. Three hundred and six people living in the ends- aaxpidemic area of AHF participated in this study. Results indicate that the cea.eunication and educational intervention carried out in the endemic area reached the majority of the population. The largest num- ber received information through televisiod (74%) and radio (70%). Other major sources included newspapers, magazines, brochures, and phy- sicians. In terms of preventive health behaviors, 90% reported the intention to obtain the vaccine when it becomes available, and 44% re- ported the intention to wear protective clothing. Thus, the results indicate that mass media campaignsmay be a useful approach to encoura- ying preventive health behaviors. This would be especially pertinent in the near future when a vaccine becomes available. Kathryn Lamino R N M 5 M P H Serahf6 DeonBn M P H Daniel P Alford. MA.H.. Wtlliam J Bictcnell M D M P H Bost_nn Untvarsitv 9ctmol of Public Hralth ACADEMIC PREPARATION FOR THEINTERNATIONAL HEALTHJOB MARKET: WHAT IS NEEDED? A qu®I itative descr•iptive study was undertaken to assess perceived discrepancies between the axdemic preparatlon students seek, prevlous work experlence and actual employment opportunities in international health A growirKl number of students, at Boston University Schooi of Public Health. choose internationel health as a focus of study. The criteria, which promotes job marketabii t ity in th is competitive f ield, b of interest tobothstudentsandfacultyadvrsars. Thisstudywnsideredthroecateqoriesof employers: private non-profit, private fa•-pro(it and pubilc aganties/organizatlons, to determ ine the cr iter ia fo Tentry-lerel candidates, avei labl I i ty of internationnl health employment aod racent cbarges m focus. The availabil lty of rnternalia aial health jobs, overseas and U.S.-based, were examined, as wel I as, what type of t0ucatton and previous experience is mostmarketeblefor people seeking international health careers In additlon, sctnols o( pubtic health were surveyed to determ rne the overal l student rntefest in international health. We report on these findings :Wrrllynn F. Smar, Pt.D., Norttrcrn Tllino zs Universit'• °llen Wr der M'ue~~, H.P.Ii., Proj, H;t Car•~cern Litorn;tional :.:7lC.iSATi{+L- A t0':,LTH MXMltO' R TYALNIY ?I~:?2AM 'FF~i~; Paper cresaits data on a nroject Avah~tr d tt°alth :aorvr to trAinirsR ^r(+•!ra" in P3ni]a N~•A (',i)in ea. Thx f•+cus ~f tnP multi- *^~thas Pvdluatio, was two fol,'. F irst, it raoritoreri initial 'roject ?:ncrle~et~,.arian and asseSSr' t.'le qutcw>a ut tr+:n.^^ dt four sifferent sites. •Lhis evaluati on us:d t•a^,ueE to ase-^ss ,l cronress in skill ano ';nowl edan ar~uisi*.)on, an•: ::1 effrctivenPSs of field epplication g IJy t.a•? .:ASe 1eV•'1 'lqelth ..'or:Ers. Second, t`:e pruject p ut io*.o nlar:m Tn nn~oina r.waiuation systrtm that a) used a:>erf orT.ance au+ra Ls,s ) ~mcess to on~.tor oror'cer activity a~xi ~system *~ on~.t orsu~mrt for c~r~r'vrs, .am h) vseo a's3eic cecision ratrix to :,sses s r~a;ress to:ard obl•~ctivr's set by villa,'e, leadart, base 1•rvel • +orY.~rs ar~~ :~~aittt rrlivery . S•~Ste,'. deC1510n--^aY'?rs. i TIMN 322466 ABSTRACTS 9 ~ r ~
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Fellqy+ing C. Lin,M.D.,M.P.H., Toa Papsdilros,M.D.,M.P.H., Narmen A. Dean,M.D.,M.P.H., Patricia Powers,R.N.,M.S. Depar(r,lent of Health and Mental hygiene, State of Maryland. INFiAFNZA VACCINE EFFICI(CY IN NURSING HCHES - MARYLA\D EO.~PRI1dxE Annuai vaccination with Influenza virus•vaccSne has long been rernn- marded to all elderly persons and those with ci•i,enic medic.al ccldi- (:iona to reduce the risk of death and pr>4(arortia. Betwee() January and March 1985, outbreaks of influenza due to Infl(leflza vizvs type A H3N2 were laboratory confirmed by throat swab cult(lre•or four fold rise of ant;)cdy in acute•a(rl convalescent sera were (3ocunented in seven nursing i}vnes in Maryland. A.^ntr3 821 residents of the 7 nursing hanes.181 slet the case definition of influenza with an over- all ~ttadc rate of 22 t. The attack rate in each nursing hane ranged fran/10.58 to 40.7%. 383 residents had received the Influenza virus vaccine for that season. Ama)g them, 81 c.ere digmsed as infleftza cases (21.2t), as compared with 100 olt of 438 unvaccinated persons (22.8%). The overall vaccine efficacy was only 7.4%, ranged f" less than 0t to 42.51 in 7 nursing hrsnes. Our data deronstrat.ed that the vaccina does n(rt protect the elderly persons fma inflenza p.tlfectial. P. DeCourcey, MPH (Ma. OPH); P. Etkind, F@H (Ha. DPH)q H.A. Barry, Nil jBoston Dept. of 8ith. and Hosv.); L.H. Mofenson, MD ('Ma. DPH) A PS&TUSSIS OOTBREAA FOSTERED BY LOR RR4UNIZATIOH kATES An outbreak of 27 pertussis cases occurred in Boston from July through September, 1986. Diagnoses were based on at least 2 weeks of cough; 4 cases were laboratory-confirmed. The age range of cases vas 2-60 yrs. The median age was 5 yrs. Of the cases, 17 (63S) were 7 yrs of age; 10 were adults. Sixteen cases were students and staff at a private, 49 student school in which 40% of those enrolled had religious exeseptions to the State's Isaminization Law; 4 cases were playmates of students; 7 were household or workplace contacts. Two of these were physicians, raising the possibility of nosocomial pertussis. Control s/easures in- cluded erythrosrycin prophylaxis of students, staff, and contacts. The school voluntarily closed for 1 week due to an 83% (5/6) attack rate among staff. Two issues were raised. Pertusis is a disease of adults as well as children. 2) In spite of mandatory isaminization laws, group<_ of susceptibles continue to exist and serve as foci for outbreaks. These groups need to be identified and immunized whenever possibie. Sonja S. Hutchins, J. Escolan, L.E. Markovitz, C. Hawkins, A. Kiebler, R.A. Morgan, S.R. Preblud An Outbreak of Measles Aaong Unvaccinated Preschool-Aged Children Fros July 14-Decesber 12, 1986, 258 confirmed cases of measles were reported to the Dade County Health Department. Of all patients, 77% were <5 years of age, 41% were <15 months of age, and 36% were 16 sonths-4 years of age. Of patients 16 aonths-4 years of age, 89,2 were unvaccinated and could have had their measles prevented. Because of the large number of unvaccinated children, a case-controi study was conducted to evaluate risk factors for not being isatlLnized. Thirty-one unvacclnated patients 16 swnths-4 years of age uith telephones in the hose were compared to 31 vaccinated cos®unity controls selected by random digit dialing. Compared to vaccinated children, those unvaccinated were more likely to receive health care from the public sector (0R-5, 95SCh1.5 - 13.7), to have single mothers (OA-S, 95XC1-1.3 - 13.7), and were lees likely to be age appropriately imunized with DTP (OR-3, 95XCI-i.1 - 10.4) and OPV (oit-17, 95XCI-2.9 - 94.8). These data auggesc that unvaccinated children were of lower socioeconomic status, and were more likely not to be in compliance with other f®unization recommendations. 1043 A11t. ). !tn[h,n. ysR t~a, lhyltts A. craf. ?RU: `ICrr1±3. aoSM. M.i~rirr,o af 9e,lth Serrt[t. SClYlC[f to 9(Ca elnt WC4]It nSr QYrLOnaXr al' A TAtiXrASaV VlcllKe/F YILT ,LAla/rML - Ib- ate lrnitM. pn[b necloeullY +M fa [M S[t:. nf %erth taralln+. bu 9<tn r.catntzed i aaloi r Nt[er af fi!{b-rttk w.tn tneo h.al[R ur. r ni<ef. Altbeuth CIC a.n ,r a 9rlr[Y porcfielecthrou{b Mitcb ..aa. en i chs hsaleh c.ea aYt[u. !t Lt s adja.ct [s kalch p[air:ua• Thtrator.. perttclpiclov olethatesr{te pepolitton tv a!C ta dtptndtoc oq cka a+etae to Micb coardlna[N. [e.prahtnrlrt. blib-ywllty bcaich pre{rs a[e asallakta, acceulkl.. snL accapc- skla [o tha ur{ec )opuls[toa. alstoricsllY. [ha cc[tiertc.i fuMlsa nf pra{rar fer .nw (VIC. e9 .nl failY ptaanlne) hs foa[trad the deralap~nc of a f[iirntN saxriet dallr.rY sYacea. ta raepnn,e ee eba n.al te t.ritt stsvStat u hSib-rtak por.lc[looa asd .aka optirl as. of 3iattr! rt.aurcas. cba suff of [ha e.[aroal tnd 0,11d C.ra Sattlo. (eCC). aarth Carnltea a.parerac af L.u t<tourcaa. eirlslaa of a.altb Strracta, hsa da.atopM a w./Qu. tecat.ul .csatte••c a x.aiiiraca sYt[... ifiia c pra- atnc affott of cM aIC. aCa. aed r,ellY plaslea troirar m Uutify cartac ,ep.eLClorts. t tM dt{ret of t n1ca rsoscrsrio. 1aco can{K pyalaclor . . u io. a.l n[ 1 uwd. td.ntlfY t.man n tlie®t otliLatlea af aa[ritr. .r nstin Cfsw at1-1- chroup. [M dat.lvpra at yprqctan MlLetr. trat.fK. er.wlestlw. W taN.fef1 .+af.etate.. Y1La prawatule. ri11 d.itnwta thla ptrsaa. a!t w da.alspde 1. 1att1 Cmi1r. t.cl.dleas a da.erl,ttt. ef * rcarwl s.1 tHlL aara wtttsra 1nJetei t1a Ktliatlw K a.s1.1 v.rkalaa cachat{ws n AuL eM e1itK Md pra.id.e Httfttti'e tf Iex .a.ierl tJtt t.iiastlaa W saalrKa et d.u .a cM rq.isttK la sad o! wa.tta. tY t.raa ea.rdlaatiw ttisr /rryra< llsi rd. tha Ja*aleps.ae mf f.eel tare) pnflLa t. dab[>rlae cie[atxarlsttet ttlA Ldlnrca servlwat aM r.ra.tl...f tacat paralstSar. rlaall). tka Sqilratis.. ee Wa t.a.treb ad dt.alo'ant pexsts vill M enlav.d vltl qttlal aWYtaL w!t. 1>ltet w M114 darelqrt !er tn. sarch Car.lir mc hoirta. t.ross, Hudrey 7?h.U., J.D., Duke, Sharon, b.P., Kenny, Mary, B.R., DsCoila, Sa11y, M.P.H., Columbia Unlver•slty School of Public Health INSTURMENT FO.n. P'iUi+NI TTqTIVE PSSESSMENT OF G'HEPIri)"AL NUTRIiION CARE SERVCES An instrument to quantitatively assess prenatal nutrition care servlces has not been previously developed. In collaboration with the New York State Health Department, such an instrument was developed and tested at ten clinical sltes including urban, rural, hospital, clinic and private and public services. The instrurnent correlates data from-reedical records review, laboratory and clinical assessment data, and interviews and observations of patients and nutrition staff. The tool is useful as a guideline for assessing clinical protocols, as a c;leckl_ist for evaluating the integration of nutritiur. ter•viees, as an instrurnent for d(eterrelning continuing education and technlcal assistance needs, as a baseline data collection model for on-going comparisons of changes in and within services, and as a basis for determing costs associated with services deliverv. Howard N. Jacobson MD Dirsctor The Institute of Nutrition U v Nccttt-C a A HEALTHY PREGNANCYi THE STRUGGLE TO DEFINE IT How to daflne a "healthy pregnancy" in terms of mother, the infant, the family has bwn an elusive challenge for the past half century. i) '40s and '50s, the need for such a definikiCn was mainly of intarat academicians and researchers. That severe problems are oaused by lack of a suitab2s deLinit<on became vary clear as a result of the an the federal government into the dir.ct sarviee aspects of maternity infant care services in the 196os. These diftlauIt;lts coul.d no )eng ignored foDowing the enactment in 1972 of the US DA's special supplsm food program for women, inEants, and children (the WIC Program) required an evaluai3en of the medical benafits of the suppLemental How does one design such a benalSt analysis when the desired ou with raTrd to both the mothar and har infant, are ra)atively und unspac[flad and, hence, uncisaY? The steps taken and the recent advances in intarventlon analysds, in Quality oL' ISta Scales, will be described with the hope that in the sevaral years, the application oC t31ese recently developed asaea approaches wil)l provide the bases for the much needed and lon 1044 dohn Seffrin Ph.D. Chairman De tment of Health dc Safet tleatlofl ana IJnlve THE ACS BRINGS HOME THE DIETARY GUIDELINES FOR CANCER RISK REDUCTION A brief description ofVe development of the ACS nutrition guidelines will be followed by a pFtsentation of how this Information is being disseminated throughout the country. Program Implementation barriers and strategies will be discussed. Jfibn R ieisburgc- Aseriean Eealth Foundation Vlhatta, N.Y. 10593. Q'FEOSIiE CAIiOER PRbVID7TI0M ffiOOGH AN UISkRt4TAf0)IIR) OF TbE WC8dNI91 110'lS7SIOXlL CIRCLY0GENIC3I3 Frca multidisciplinary studies, ee conclude that cancer of the breast, p tate, ovary', endosetrif>e, colon, and probably pmcreas are associated esterll nutritional cOstoss: a custteax7 total fat intake of about 4 calories, a relati.e3y loe intake of vhole grain cereal fiber and ala calcium. In contrast, cancer of the stosach and esophagus relate to tinct nztritional habits, use of sulted, pickled and ssnlo.d foods, as Orient, especially Japaa, and isn parts of Tasteia Europe. The ®derlTing rehmir am partial7y mderstood. Yost fate (ezcept and fish oils) inerease bile aoid bioqnthesis and lead to praoti tim ia sad colon cancer or arfeet hoammal balanees and thus prcm sensitive organs. Ceree3.fiber inareases stool bulk and dilutes and prc.cters in the colon. Calci(ss eontrols oell duplication Lzaroiis modulates these effects. The relevant gaaotoxio care7. not yet Imoea, but .p be forad during oooidng. Current recefor effective preventive actifas are total fat at 20% of oalorieyield a dat7, 200 g stool, a)da ailk or other calcium source, I dai17 ezercise. Ye. lresearch will serve to refine current concepts. ABSTRACTS 29 TIMN 322486 I
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Chudley E. werch, Ph.D., Dean R. Corman, Ph.D., Pfiil_lip J. Marty,Ph.D. Janet Forbess, M.A., Barry Brown, Ph.D., L'niversity of Arkansas CLARIPYING THE UTILiTY OF THE BOGUS-PIPELINE: EFFECTS O[9 ENHANCING THE VALIDITY OF SELF-REPORTED ADOLESCENT DRUG MEASURES. _ The effects of the bogus-pipeline on self-reports of expertmentation,frequency, intentions, beliefs, and attitudes related to various drug use was examined. One hundred and ninety one adolescents (x age - 11.74 years) were randomly assigned to three conditions Including: 1) a bogus-pipeline with saliva collection, 2) a bogus-pipeline only, and 3) a questionnaire only control. A significantly greater pereent- age of subjects in the questionnaire only condition (28X) reported having experimented with alcohol, compared to those in the bogus-pipe- line only condition (22%) and the bogus-pipeline with saliva candition (21%). Ko significant differences were found across conditions for self-reported frequency of drug use, intentions to use drugs, and be- liefs and attitudes related to drug use (p > .05). The discrepancy among studies suggesting a validity enhancing effect due to bogus-pipe line procedures and those suggesting no effect may be accounted for by age, experimental setting, the population under study, and drug types. The broad, unquestioned application of the bogus-pipeline in smoking and other drug use prevention programs is not recosqmended at this time. Lily S. Hsu M.S.,R.D., Office of Nutrition, Division of Family Health Services, Massachusetts Department of Public Health, Boston, MA COM@REHENSIVE NUTRITION EDUCATION FOR ALCOHOLICS IN PRISON Chronic alcohol intake adversely affects nutritional status by alter- ing digestion, absorption and mtabolisa. Nutritional status us fur- ther aomgromised by erratic eating habits and poor food intake. To address these problems, a nutrition education program (NEP) was devel- oped for a oo-ed corractional facility for alcoholics. Goals of the NEP were to provide the best possible diet for recovering alcoholics, increase the nutrition knowledge of inmates and foster development of positive eating habtis. The f>EP included a seminar for the eounsellinc staff, sessions for the inmates and a workshop for family and friends. The foodsarvice director, with technical assistance froa a nutrition- ist, modified the diet to follow the Dietary Guidelines and meet the nutritional needs of recovering alcoholics. The NEP was rated highly by inmates and staff on evaluation. Support was also exhibited by a petition from the inmates requesting nore nutritious foods in the ven- ding machines. As a result of the positive response to the NEP the administration plans to incorporate the NEP into its treataent prograa The NEP model and policy recomnundations will be discussed. Mfchael D. Newcomb, P:.D., University of California, Los Angeles GETTING HIGH Af SiORK OP SCHOOL: PREVALENCE P"^1 CORRELATES OF DISRUPTIVE SUBSTANCE USE Self-reported prevalence of being drunk or stone~ 1;rhile at work or school is examined for nine drug substances in a comaunity sample of 739 young adults. Thirty-one percent reported beinp high at least once at work or school durinq the past six months. Alcohol was the most prevalent class of drugs used, whila marijuana was the troost frequently used specific substance in these contexts. The highest prevalence of use was found in Junior colleges and full-time emloy- Pient, while lowest use was reported at universities. 1en reported significantly more prevalent use of beer, marijuana, hashish, and a composite score of any disruptive use than did the women. Dis- ruptive substance use is rarely limited to one drug; if one substance is used, the hazard rate of using another drug increases to several times its baserate. Although disruptive substance use was largely unrelated to rsost measures of personality traits, psychological functioning, and social support, it was significantly associated with low law abidance, low injury hysteria, and high liberalism. Roderick D. Duquette, Ed.D. University of Wisconsin at La Crosse ARE AN INDIVIDUAL'S ALCOHOL USE PRECEPTIONS USEFUL IN UNDERSTANDING HIS/HER DRINKING BEHAVIOR? Despite changes in law, policy and educational programs college students continue to abuse beverage alcohol. This project attempts to understand the preception's of college students relative to their drinking behavior. Using 1,000 randomly chosen students, data was obtained regarding: drinking behavior, positive and negative influences on drinking be- havior, demographic variables, individual beliefs regarding outcomes associated with drinking, the Individual evalution of those outcomes, the individual beliefs concerning important others and)br group_ feelings about drinking and the Individual's motive to comply with these referents. The data is being anal,)eed using correlation, multiple regression and discriminant functionanalysis. This.study may suggest differences among moderate and heav -a~Ital users is the result of different preceptions surrounding drSnking behavior. Jean T. Shopt, Pamela C. Cartpanelli, T.E. Dielman, and Amy T. Butchart; The University of Michigan (Supported by NIAAA Grant Number AA06324) CORRELATE,c OF ALCOIiOL USE AND MISUSE AMONG YOUNG STUDENTS In evaluating an alcohol misuse prevention program, variables from the conceptual model were assessed as correlates of alcohol use and misuse among young students, including: exposure to peer use of akohol, suscepDbiliry to peer ptnssum, interaction of susceptibilit} and exposure, internal locus of caltrol, and self-esteem. Correlations were calculated on data collected from 565 control group students who were in Grsdes 5& 6 at Pretest and Posttest 1(5 months later) and in Graks 6 & 7 at Posttest 2(17 months later). Analyses within each of the 3 testing occasions revealed significant correlations of oxposure to peer use of alcohol (.21 to.57), susceptibiliry to peer pressure (.26 to.62), and susceptibtlity/ exposure interaction (.26 to.65) with all dependent variables: alcohol use and 3 indices of alcohol misuse (overindulgence, trouble withpcers and trouble with adults). Self-esteem was assessed as adjusttnent in 3 areas: schoo ,1 family and peers. Of the 3, school adjustment was most often significant: with alcohol use at all occasions (-.22 to -.34), with 2 of the 3 indirs of alcohol misuse at Pretest 4-.13 to -.22), and with all 3 indices of alcohol misuse at Posttests 1 and 2 (-.14 to -.28). Similar significant correlations were also found between Pretest independent variables and Posttest 2 dependent variables. Multivariate relationships are being explored. Posttest 3 occurs in May 1987. Results indicate that recent prevention emphasis on peer pressure resistance is appropriate. Jon lrolf, PhD - Johns Hopkins Sch. of Hygiene and Public Health JeannetteJohnson, PhD - Lab. of Clinical Studies, NIAAA PHYSICAL HEALTH AND MENTAL HEALTH CHARACTERISTICS OF CHILDREN AT HIGH RISK FOR AL(DHOLISN Recently the media has called attention to increased health concerns of adult children of alcoholics. This reflects a growing social movement among these adult offspring to require new diagnoses and services to meet their perceived special health problenu. Most data supporting the claims of this wovement have come from retrospective self-reports and clinical case studies of adult offspring making etiological linkaqes ~di..fficult to prove. Longitudinal studies of minor children of alcohol- 'ica are needed to explore causal linkages of this group believed to be at hiqh-risk for alcoholism. The prospectively controlled NIAAA study 'is finding important differences in rat'bs of somatic complaints, health concerns, affective and cognitive problems for minor children with an %lcoholic parent compared to controls. The present report summarizes these differences and discusses their health and preventive services inplications for offspring of alcoholics. *?ia A, Lse Ph D psp4taet of Wpa Wans Stata lbi,vstaity Detroit !4 ALCOHOL INTAKE AND ALCOHOL PROBLEMS AMONG COLLEGE STUDENTS ' GROUPED ACCORDING TO ETHNIC AND/OR RELIGIOUS IDENTITY Ddnklnj roluses and ptcbl~ fee college atudants araupsd aoxedinQ to Irish eatholie, Jsrlah. Ytita rtotaspnt, gLek, and Ctiare identitias wera determined aA ranlsC. pesults naes obeain.A frea. a 19Q4 qumtirsnaiti sta.Ya!' of nina v.st eoast collepa t.µu.a cooductd by the Alaohol kuaatch ,xow, Hadical Rpeateh Ilmtitute of Sm lYSSd.soo. Alocbpl intake ws drterainsd by a 30-day lkinh Volur srwra, and drinkitq ptoblr s+ srsw=ed with a 24-itas NsQatise Dcin)dn7 Gmssqumocas scale. RankSnPs ssn ct>Qecad to atlmTeliqious gtay ran)dW within the general popalatice. Itiah Catbolic and ebinass studnts ba4 the highest and Iasast drink wluaes, respectively, rddngt that an t7yinl fer tbeu qtotipa within tbe go®caF- populatirn. Drinkltp larsls am? 8ladt stuisats, *bo bad the hiqhst ptoputim of ahstaitrrs, ranked loiwc than withia tta gener+l populeticn. tazile Jewisb Otnups are often thszactarizad by rather low ratas aC•> drinking and drinking 1rob>ems, it" student drinkinU did aot diffe sppcedably ffa Vhite Ptvtastant studmt drinld:q. lraq tbws mllege-studeat ytapa, thae w a perfect cvttelatiw between rankings m drink voluw and rac41n7s m drin)dn7 ptoblem. itde<stabdiap thaa diffetential drinldtq patterns for mila0s- ape .tlno-ieyiqious qtaiq sbould cmtributa to an utderstanditq of diffst.ntial drinkinp lerols ia general. Patricia A. itadden, H.P.H. Prevebtion Research Center, Eerkeley, California ALCOBOL AND TOBACCO USE ON PRIME TINE TELEVISION (1985, 1986) Alcohol and tobacco appearances from a aample of 168 hours of fall 1985 and 173.5 hours of fall 1986 prime time television programming were studied. In addition to frequency of alcohol acts, soci{kl context a3td arotivatiod for drinking ware studied, as aall as demo- graphic characteristics of drihking versus non-drinking characters. Particular attention was given to instances of heavy drink+_H)(; negatiSeand positive evaluation and eor.seque.*.te8 E7tpreesed or experienced by characters, drinking coupled with high risk activity, and youth. Preliminary results indicate alcohol continues to be television's most frequently shown beverage, portrayed-as glamourous and appropriate for uqe when characters attempt to cope or escape fron,problesm. lobacco use appears to be on the rise. TIMN 322458 ABSTRACTS 1
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1064 Jersld Shapira, D.S.W.,.M.P.H.. Professor, Department of Social Work €ducatipn San Francisco State University ibdals..aad,Philosophies of Brief PsyctmttlFCapy in HNOs~: The Institutional•Iatarfdc~a Se[vicr: and F9_nancial Accountability Thi.e.4aper pffers a critical. examfnatiAn.of the emer9ence and wide- spredd adoption of.btLef_pSyFhptber_apy.as the rimary course.af•sdeal tiea.Lth tptervention in, W"As,,._-It presents the eemedts' and basic con- cepts_of.,leading models of briet~psycnQtherapY, and identi~fies fin'd discusses the philosop)7,Y of treatmaqt for eacfi model. The paper ridzt rgportS, ya findings.,frDnt 4- series of intensive interviews conducted with.nenta) health staff in tiNOs lotaTkd in_ a largq.a)etr,opolitan-area. Tftfse interviews explored the leading influences upon th~ese therap3sts as tbey;44rpcture¢.-the,;.cQ.urse and content of tr.eatment. Tfie-re.sul-tt fnd{cated.a strong'connection between the financi,al_$nv ent of the HMQYacfftty aed-tfa brief psychotherapy model utfl'i'tdd~rom~ The iwplir.ac4 tioas o'f such a relationship are examined with regard ttf both tha psyr,qqtbermpeu~tfic exgerience of the indiyidual, patient, ahd the `ourst and quaidty of inentgt health-servtces,in the United Stat.es. D. Solet, University of liichigan School of Public Health S. Zoloth, Hunter College School of Health Science D. Michaels, ltontefiora Hospital Dept. of Social Tiedicine C. Sullivan, United Papexyorkers International Union J. Jewett, Hunter College School of Health Science PATTERNS OF MORTALITY IN PULP AND PA?ER 'MRKERS The production of paper products ia the ninth largest industry in the U.S. Recent mortality studies have increasingly suggested a pattern of elevated mortality for cancers of the hematopoietic system, lung, and gastroiatestinal tract for workers in pulp and paper production. A proportionate mortality ratio (P:IIt) analysis was performed on a co1- hort of paperwvrkers who died between 1970 and 1984. Despite rela- tively small nuabers of deaths overall (n-201), the analysis showed statistically significant elevations for all malignancies (PMR-131), lung cancer (PHR~151), lymphosarcoma and reticulosarcoma (PHR-441), and leukemia and aleukemia (PMR-279). There were no significant elevations or deficits for causes of death classified as non-malignant These findings taken together with previous results suggest the need to identify possible associations between specific production pro- cesses and elevated cancer risk. Marc P.Freiman, Health Economics Research, Thomas G. McGu$re and Randall P. Ellis, Health Data Institute _ THE RESPONSE OF HOSPITALS TO MEDICARE'S PROSPECTIVE PAYMENT SYSTEM IN THE TREATMENT OF PSYCHIATRIC ILLNESS Admissions to psychiatric hospitals and to psychiatric units within selected general hospitals are excluded from payment by Diagnosis Related Group (DRG) under Medicare's Prospective Payment System (PPS). The remaining psychiatric admissions to general hospitals are reimbursed on the basis of DRGs. In response to PPS, both covered and excluded facilities are altering their behavior along a number of dimensions. in this study we analyze these responses utilizing data for the entire population of Medicare psychiatric discharges in both 1984 and 1985. Initial results indicate substantial responses on'the part of hospitals in reducing lengths of stay and in improving diagnostic coding. This study is also analyzing changes in hospital costs, as well as transfer and admission patterns among general hospitals with and without units, private psychiatric hospitals. and state and county psychiatric hospitals. 'R)cFa-r3Ti.-Frank and Catnerlne n. vacKSon Health Services Research and Development Center, Johns Hopkins University The Impact of Fixed Budget Hospital Financing on Psychiatric Admissions In recent years considerable interests has focused on prospective payment systems as a cost containment mechanism. At the same time concern has been raised about the application of pe r case prospect~ve payment to psychiatric cases. Among the alternatives roposed have been ca itatnTl and fix?dh@uaJ$gt ro1~ectiverepa~mn~ ~fiys tP f~ sg of aymepnt a ow meni~ p~ov ers mo ex 6i1 t in rov dn var~ous mixes of services than do payment systems based on a fixed fee per admission. At the same time there are strong incentives to reduce all treatment and particularly hospital admissions. This analysis reports results based on a sample of rural counties in New York State. An experimental prospective fixed budget hospital payment system is compared with a prospective per dieW payment program. A key dependent variable is the psythiatric adaission rate to acute care general hospitals for 34 rural counties in Mew York for 1980-1984. Preliminary analyses were conducted on this panel ef counties using a multipie regression fixed affects model and a variance components model. The results indicate that psychiatric admission rates decrease on average 14 percent when a fixed budget hospital payment system is present. 1063 ' Martin Donabedian, Private Consultant TRE INVLSI&Lg HAND A one man show lampooning and otherwise ridiculing the diraetion of health care programs as practiced by the public and private se6tors. Using satire and light sarcasa, carrent health care policies, pre- graas and praetices will be exposed for thae shaa they contain. The irony of well meaning programs which result in unforseen negatiw effects will be parodied. 3pacial attention will be reserved for the well fed and cared for politician, policy.aker, and adainistra. ten,who swuths platitudes In his faith in the ai.ighty invisible hand of capitalisa to solve all probleas if we all work hard and remain patient. If the cool touch of that invisible hand makes the problem freal people) disappear, well,,,,..., 38 ABSTRACTS K,F,. Malone. T_p,. Hoeosell,. J.R& pa11,>7g, H_SL Y1.9L7a. SL 81 )L =d Hutchinson Cancex Besearch Cent= TOXIC SUBSTANCE EXPOSURE AND CHRONIC LYMPHOCYTIC LEUKEMIA As part of a population based case-control interview study 427 cases of newly diagnosed chronic lyaphocytie leukemia and 1683 general population controls in 4 geographic areas were asked if they had ever been "hiahly exposed" at home, at work, or elsewhere to one or more of a list of toxic substances or to any other substances not on the list. These substances were then categorized into 20 chemical exposure groups. Odds ratios were adjusted for age, sex, race, education and geographic site. Subjects exposed to organic high polymers had a relative risk (RS) of 9.3 (95%CI=3.2-27.1). Prior exposure to acid-containing chemicals was associated with a RB of 1.9 (95%CI=1.0-3.5) Increased RE's were observed for expoaure to aliphatic hydrocarbons (RR=L.4, 95%CI=1.1-1.9). For the other substances examined, 95% confidence intervals included the null value. Further research is needed to verify these findings, since these substances contribute substantially to the exposure profile of certain occupational groups. Raymond Y. fiem=rs, MD., 4ayne Wte Universfty, Department of Family Medicine, Detroit, Michigan 4 2D18 COLOM TUMORS IH PATTERN AND MODEL MAxERS WORKING WITH METAL Excess prevalence of colon neoplasia (adenomatous-polyps) among Pattern Makers has been well documented.' Initial assumptions sug- gested that workers exposeito wood dust were primarily at risk. Recent experience with the examination of pattern makers in The Detroit area has yielded preliminary results suggesting that thosh classified as metal workers experience the excess risk for neoplasia. Medical, work histories and sigmoidoscopic examinations were performed on 1481 participants. Biopsy specimens of polyps were inter- preted by one University pathologist, and polyp presence was linked with each individual's occupational history. One hundred individuals with adenomatous polyps were randomly matched by'age with two parti- cipants having no polyps. Using union classification as a surrogate for pfrmary exposure, individuals with adenomas were more likely to be classified 'as metal workers (P = 0.06) than wood or plastic•workers. This study suggest that a metal'felatFq exposure (e.g. cuttinj ofl~), and not woo3 dust may be the cause of excess colon cancer in these workers. an F uen o emi Eeden Ste ai Qy,'3L~ hen K., weis niver Noel y or was S., Strader, Cliff. 6e n9ton, e_attle~ w t. of CUPATIONAL RISK FACTORS FOR TESTICULAR CANCER. Previous reports have suggested that white collar workers and farmers y be at increased risk of tesicular cancer. This study was based on elephone interviews with 330 20-69 year old white residents of western ashingtonrho were diagnosed with a germ cell testicular tumor in 1977- 1984. Their occupational histories were compared to those of 657 men from the same area identified through random digit dialing. Classifying n by the occupation at which they worked the longest, the risk among ite collar workers was only slightly higher (OR•1.13, 95% CI .86-1.50) then that for blue collar workers. While there were somewhat more farm nagers among cases (4) that would of been expected on the basis of thq cupational distribution of the controls (2.6), there was a deficit of' farm workers and gardeners (observed/expectede 2/9.7). Among white Ilar occupations with excess risk were administrators (47/33.1) and sales (30/22.7). Among blue collar jobs, electricians (10/4.2) appear td be at excess risk while vehicle and equipment mechanics showed a de, creased risk (22/33.1). These results suggest white collar workers as a ole have, at most, a slight increased risk of testicular cancer and that there is no consistent evidence of an association between farming nd testicular cancer. , TIMN 322495
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ptichael H. Fox, Healthcare Mesagement Consultant p3,lyavkes. Yisconsin PARADIGff Fo$ FAILURE: LES3!ktS OF' A MEDICAID HNO Efforts to extend cost cor,tainaent into Ifedicaid delivery systsaa have recently gained widespread acceptance at the State level. One product of this effort has been the creation of prepaid health plane composed almost exclusively of Medicaid recipients. This paper looks at one such entity and the canceptual basis for difficulties which have stood peganei~y October,s1984cinaMilraufce~e £County provid dna catalyst vfor the foraation of a health aaintecance organization (ffiW) coaposed exclusively of community health centers (CiiCs). The FNJ, HealthRea,:h, was created as a means by which the CHCs could retain their existing Medicaid patients. Politization of policy decisions which berwafitad individual centera at the expense of the HMJ, insiatance on operational control at the Board level, and an infusion of systes development based on fee-for-service and graat-funded delivery of eare have each played a significant role In preventing the success of this venture. In order for of£orts sueh aa these to succeed, participants must both believe in the concept of quality health care in a prepaid systes, as well as be able to put aside cooapetitive instincts which currently set CHCs against each other in trying to garner ever dwindlin¢ amounts of federal health care dollars. oa I S. Co_loner i. Sr. Staff sA~oai<ni t. JNa - e. eaw ce a O a-paLQ ltn c 0 ea are Directo oung* SSBVICS USAC6 DFFBa718NC8SCMi03Xf EHHOLL66S~IW0. 'fl}it IFIPLICATIONS OF Under a Robert Wood Jobpaon Foundation traat, University &ealth Care, Inc. has offered pre-paid susnaged care to approxis,ntely 900 aedically indigent persons (county General Assistance clients) during 1986. Tk~s paper analyses the health care service uaage of ~hese a~edica~11y indigent Fi10 enroliaes, with a.ve pecific easpftesis oa ideatlfyiag ttsat subset of anrollaes who intensil utilize aecroi eg and generate th¢ aa,ior costs. (Preliiinery data indyicate that onlq 16'Y of tha Oeneral Aaaiatance gnrollees account for ?,5% of the p~oaram coata ) Tha ipteot of this anelysis is to cetermiae wnether spec al progra. ~aterventsans, targeted apecifically to khia troup 4f high usersa (aiach as intensiva case manageaant or specialszed beaefit configuratsons) nre an appropriate aechenisa for reducing ovaralMl indigent care costs. a on the variation iTS d~'stribution of services a.ong enrollees, and attendnnt costs, will he presented, together with a discussion of the i.plication for 13~10 operations. David K. Dau h fICFA• Mar aret 0'Brien S steMetrics• Penelo e Pine A; and r7 owa ysteMetrics- FINDINGS FgOM TNE MEDICAID TAPE-TO-TAPE PgOJECT: CALIFORNIA, GEORGIA, MICHIGAea, NEW 2OgL AND TEKNESSEE 1980-1984 This study sponsored sy the Health Care Financing Adainistration coa- pares Medicaid anrollaent, utilization, and expenditure patterns for selected states and years. The Tape-to-Tape database was utilizad, which is based on Medicaid elaiss and enrollment fLles. Study results coapare thase differing Mediu id prograas in t.rss of expenditures per enrollee as vall as age, sex, aad eligibility group characteristics. These findings provide insights l.nto the range of variations across Medicaid prograas. In general, all utes sbov relatively low use of ambulatory services among AFDC encolleas, high drug use aaong the SSI population, aad very high use of long tara care services aaong the aged. Stacas were very different in: the proportion of the poverty population covered by Medicaid; the coapositioa of the Medicaid popula- tion; and the allocation of prograa expenditures across Hedicaid ser- vices. For exasple, Tennesaea and Georgia both allocate ore than SOZ of expenditures to long tara care; California allocates a such lower proportion. gelative to medical care cost inflacioa, Medicaid expendi- cures per earoilee have declined over tha ciae period. Roxanne Amdrsvs S sea!lecries• Martin R.uthar HCFA vanesaa Nora yste trics; Suzanna d s, SysteNetr es. pYOV'IDER PARTICIPATION IN MEDICAID: ISSUES IN ACCESS AND QUALITY Congress created the Medicaid prograst to provide certain groups of poor persons with access to uinstreaa health care. Provider partic- ipation in Medicaid affects both access to aainstreaa care and the availability of adequate health resources for these poor persons. Health care provided outside the sainstreaa and care concentrated in the hands of a few providers raises concerns about quality. To ad- dress these issues this paper exaaines characteristics of hospitals, physicLans and nursing hoeu providing Medicaid services In California and Michigan. Ye use data froa a unifora Medicaid claims and provider data base (called Tapa-to-Tapa). We also obtained provider inforaa- ' tioo fros the ANA Annual Survey and the Medicare/Medicaid Autoaated Certification Systea. We exaaine provider participation rates, the distribution of reiabursesents among providers, characteristics of pr vidars with large sh.res of total Medicaid raiabursssents, and re- source availability by using provider to population ratios. We relate the access and quality of care Laplieations of the findings to currant treads in the health industry, such as the increase In for-profit hospitals. DannLe Pre:com S scnNatrics Ine. &oland :feDevLtt S acaHatrlca Inc. Yarcia [ut er Daalth Care inancing Adminiscration, and avid Baugh Health Cara Financing Adainistracion. COST CONTAINMENT IN THE CALIFORNIA MEDICAID PROGRAM During the early 1980s the Federal government and the State of California initiated sweeping policies designed to curb the rate of growth in spending for Medicaid services. Beginning In 1981 Congress offered the states greater flexibility !n prograa design and reduced levels of Federal finaicial participation. Responding to these Federal initiatives and its own fiscal constraints, California atbarkad on an innovative systea of cost containment which included $alective contracting with hospitals and soce restrictive standards for enrollment. This paper assesses the effects of these policy LoLtiatives using a coaprehensive longitudinal data base of California Medicaid enrollment and claims. It examines trends in enrollment, utilization of and expenditures for health services that occurred during the 1981-84 period. It relates these trends to the budget constraints and policy changes of the early 1980s, and explores the implications of these trends In teras of access to quality medical care. lauglas /. kadlae, f~.p.8. aed Inaette M. Chica, M.P.N., pepartaent of 4ealth Po!icy ard Eaaageeest, College of Pubiic riealth, Ihiyersity of Sasth Florida, Aaaa, Flarida A COVT-Err_"CTi'1€REii E7AlEDATI+A OF L,LSE tlAIAEENLYT SE4VICES TO FL1RS:A'S iffI1CAIC €L:`vi3t€, Er.1CALLy IEPElqElU EiDERLi YITg CAREDiVERS. ?u Florida peparteent of Kealth and Re.*,a5ilitative 5srvices 14RS1 atd tfe Vate•ans Aoo`tnlstratla: tVA1 is Florida {Iistrict 121 ae 5splesenting a ssips ceaperatbe dsaaastntion for eedially depeadent elderly a:A beir careglvers sedtr De/icaid waiver. The pro}est's acroays, 'T.€.A.C.H.', represents the thrust of t`,e service to be delivered -- Trainiag the Elderly And their Careqtvers at Doae. One of the policy issses to be ievestigattd ls the cast•effectivs:uss of the TEACR approath to servtng the needs of the frail elderly and their caregivers cospartd to tSe sechanise of routlne care used is t5e coeparisaa po;ulatioe. T1e TEACg service espenses tfer nst sanagesent, princtpal caregiver traintng, etc.) and cllert's cse of services are e=pected to Ce less costly withis case-stc groups aid within sw vivar Ue1gth of tist is stcdy) greaps thaa overall health urvicl eapenditu:u of the ccepuisaa poaulatlon. Casty er soothly total cests far these sanaged cues eay differ widely fres oses aot provided with a gvided use of the health systes. The plaeaed analytical aethod centvs ae cost-sffacttveness ratics and covarlazce re9rassiees that statisttcally control for sevsrai factors of cencerA le.g„ years of pCl esperieace is PCB role, years of CA ia dysfuactixa! raadlttea, laitial health cenditttn, etc.l. The prieary pa1!cy qantioa, cast-tffectivmess, Is crattcal to pateotlal replication of the desanstratioa pro)ect. - Sidney Trieger, Health Care Financi.^.g Pctniraigtration (HCFA); Nelda McCa11, SRI International, Inc.; mxl Paul Lic3rtenstein, HCFA Arizona Health r•,are Cost Con:,airment System (AFfCCCS): Adninistrative lsssues and E'rix,7ran c:osts The AHOCGS dsmmstration is a<s alternative to the acute care portion of a traditional MedicTaid pmrao. The sniqueness of the AHCCCS proqran lies in its pro-caipetitive approaches to oontrolli.ng health care costs. These pro-ca:petitive approaches include selection of providers tiuvugh carpetitive bidding, paymerat of providers arxl the state on a capitat®d basis, and incentives for providers ard beneficiaries to restrict sznecessasy utilization. 1his paper reviews the significaat adninistrative issues in the inpletnesstatim arri operation of the dencnstration and presents an estimate of the cost savings of~ttae PFICaS program durin4 its first three years of cperation. - Spike Duzor, wesith Car. .ldministration EVALUATION 0: ACCESS AND SAIISFACTION IN HCFA's CAPITATED MEDICAID D&+f0';3TRATIOitS This paper describes the results of household survey with over 2,000 enrollees in capitated x.,dicaid demonstrations in Arizona, Santa Barbara, California, a-:d Kansas City, Missouri and a 1,000 non-enrollees comparison group. The main focus of the survey was to compare for these two groups their access to, useof, and satia- faction with the medical care received. These three demonstration sites eliainated the traditional Medicaid program of fee-for-service health care and replace it with innovative programs featuring a mandatory systeR of prepaid, capitated payments for all health care. TIMN 322464 ABSTRACTS 7 L 
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1095 'Itochbaua Godfrey H. Univ. of North Carolina at Chapel Hill AEALTH EDUCATION THFARY 8UR THE 1990's AND bzSOND Current health educauion theories, .ostly from social psychology and dealing predominantly with cognitive/affective processes within the individual even vhtn applied to populations, have proven useful for educational apprcaches to health behavior. Such theories will guide us in the future as vell, although hopefully, better and more useful theories will replace or sugsent them. Hovever, there has been a decisive shift in our society's strategies to achieve major behavior changes in the health area on a national scale. Decisions and policies. directly affecting the health behaviors of millions of people are nov made and will increasingly be made in the future in the political, econoaic, lav and other do.ains; e.g. policies related to smoking, AIDS, abortions, health in the workplace, etc. The health education profession will respond to this challenge by adopting appropriate theories and models from such fields as political science, econ2.ics, lav, marketing, etc., and adapting them to its own use. Exa.ples of such theories aod their potential use in health education will be given. Bernard L. Cohen, Gept. of Physics anQ.Radiation Health, University of Pittsburgh A SURVEY OF RADON LEVELS IN U.S. HOMES: RESULTS AND CORRELATING FACTORSI The University of Pittsburgh Radon Project provides measurements o radon concentrations in indoor air to all requestors for a $12 charge, also conducts random selection-no charge surveys to determine average r levels in selected counties and to estimatc biases in the $12 measureme These biases can be largely removed by use of questionnaires. Data wil presented on distributions of radon :evels and on variation of mean rad level with season, with room of_the house, with recent weatherization e forti, with overall weatherization, with window opening, with value of h with household income, with education attainment of the head of househo with cigarette smoking practices, with environs (urban-suburban-rural), Attempts to test the linear-no threshold theory of radiation carcinogen by correlations between average radon levels in counties and their lung cancer rates will be reviewed. Preliminary data do not support that th Parcel, G.S., The Center ror Health Promotion Research and Develop- ment, The Univers.ity of Texas Health Science Center, Hosuton, TX. THE USE OF ONGANIZAIIONAi. CHANGE STRATEGIES AND SOCIAL LEARNING THEORY FOR SCHOOL HEaLTH PROFtOTION A school health promotion project called "Go For Health" will be used to illustrate how organizational change strategies can be conceptually linked with social learning theory strategies to in- fluence children's diet and exercise behavior. In the classroom health education cxponent, aadelinp, skill development, behavioral rehearsal, monitoring, contracting and reinforcement are used to develop behavioral capability, self-efficacy expectations for healthful diet and exercise behavior. Changes in school policies, sta+ practices and roles are used to modify the school lunch and physical education program to enable children to experience and practice the behaviors within a supportive and reinforcing school environment. TSi! approach provides consistent messages from the children's environmen*, cognitive learning and behavioral experiences. Rata I®ri.a, Stanfxd *w,iver-_ity SE[Z'-EFFICX.Y ZHIDQDC Lt98 7H THE Ili'2S, LiORLa - A pA'mvn+r EDUCAITQI EXAHPiB Self-©fficaty tYa+vLy states that a paisrn's peroepti.on of abili.ty to perfon a fuLura behav±or ia a good lsedictcs Of perfonance. It also suggeata foos specSfiu ways f;r anhancirsy SE 1) skills aeetazY and f'eodbaek:, 2) aaneLing, 3) reiirctarpratatirn of pbysiological aysptas and, 4) social reint=O=Klt. , eg m A 12 has mamity Lnaed, lay t~it arti;rits patient aduc&+irn prcgraw haa beaa desit$:.d to etksm SE after it was faund that ehandas in efficacy ccerelatod act>, hictil.y with d=Ves in health status than did cl=19aa in behavi.or. This Pnpar will deacribe the datails of hov SE theocy has lxen directly afplied to paactice. 1094 ' 1MEDICARE COMMUNITY NURSING AND AMBULATORY CARE ACT: PROVIDERS AND CONSUMERS DISCUSS THE ISSUES Innovative federal legislatlon V111 oe explorea co nlgniignc a inguiai- health care delivery model. The model was designed to remedy deficits inherent in the Nation's fragmented and uncoordinated home health care system caused by the existing Medicare program. The legislation expandI services under Medicare Part 9 to encoapass chronic and terminal care through coordinated case management utilizing muitidisciplinary inter- ventions, and provides a way to give health promotion and disease pre- vention services assisting enrollees to maintain a positive state of health rather than dealing with health needs in a reactive vay. The bill addresses cost containment by reducing current home care costs by 5%. The Program will focu on: 1. Positive impact for a variety of health care disciplines. 2. Networking to establish internal and external mechanisms for support of the legislation. 3. Marketing the concept to the consumer. b. Fiscal impact of the legislation on the consumer and health delivery system. Opportunities will be provided for open discussion of major issues and implications. Your presence and dialogue are sincerely requested. 48 ABSTRACTS F---` a Rlo '^ ohacen Mew Jersey at Deoartment of Neal C, Nicholls, E aotteL ~ew Jersev tate _De aartment of Environmen protectton. Z Haft9. 40- P AN EPIDF24ICGOGIC SiSAY tXr RADCN AN) LUNG CANCER AMIX3G NEW JERSEY PCMEN A study was previously conducted which included interviews for 994 Jersey woaen with incident, histologically confirmed primary lung can and 995 population-based controls. Smoking, dietary, occupational residential data were collected. This study currently is being extend examine the association of household radon exposures with lung cancer ci Moce detailed residential data have been collected to determine any addc at which a subject lived for at least 10 years from 1953-1972 (30-10 ye prior to case diagnosis or control selection). At least 506 subjects not meet this residence criterion; of the remainder, an index address been identified for 1216. Excluding houses which have been torn down apartments above the second floor, 1135 addresses are eligible for ci testing. As of May 1, house construction and ventilation surv< installation of 4-day charcoal canisters, and/or installation of 1-; track etch detectors have been completed for 777 (68t). Initial result:, charcoal canisters from 583 addresses show a median radon concentratiot 1.5 FCi/L in the lower level (usually.pasement) qf the house. Fourteen cent had concentrations above the EPA guidance level of 4.0 pCi/L. A. G. SC01'f h% INDOOR RADON REMEDIATION Regional radon sur.eys have found that there are many parts of the U.S.A where occupants of a significant number of the houses receive exposures t radon and its decay productA.vell in excess of the current limits for occupational exposure of uranium miners. A number of moderate cost remediation methods have been developed to red radon concentrations in houses, and are currently being tested by the EP and others in Pennsylvania, Maryland, New York and New Jersey. Examples the routes by vhich radon enters houses from the ground, and of moderate cost methods to prevent entry will be shown, and the performance and coa will be discussed. Howard H. Prichard University of Texas,School of Public Health, Richar< To__ohes Argonne Natiomal Laboratory, and Robert L. Flaischer General Ele ~RE~CENT DEVELOYlO*2fIS IN RADON•E7POSURL ASSESSMENT The documentation of past exposures to radon daughters in the residanti setting is complicated by the lack of measurements in previous residenc and the uncertainty involved in extrapolating current measurements into past, especially when substantial modifications to a dwelling for energ conservation or other purposes are known or suspected. This presantati reviews several phytical, techniques which offer the possibility of ds mining lifetime exposure on the basis of direct examinations of the s and/or certain personal effects. Lead-210, a long-lived member of the decay series, is known to accumulate in bone, and given a sufficient cv ive exposure, can be assayed by appropriate radiaiton detectors placed around the supjectL head. The possiblility of using Lead-210 accumus in structures for quantification of past exposures is also being axamin It may also be possible to develop and observe alpha particle tracks in certain plastic products, particularly eyeglasses, as an aid to aaessi individual exposure to alpha emitting aerosols, presumably radon or tho progeny. TIMN 322505 I
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Thomalf P. Grosr. :,M)tPH Robert P. Hise 1•ID tlPH ~ Deanne E. Knaptr. c'h.D., U.S. Food G Drug e, A in, RockVill HYPERTENSION THLRdSPY: TREiIDB II) THE U.S. FROM 1973t0 1985 Hypertension, a major pbbLic health prohieai in,the U.S. 3ften requires drug therapy. (4e examined trend-s in outpa- tSentb•aatihypertensive drug"use from 1973 to 14$5 3n the 7.S. Data on numbers of prescriptions and demographic) iiagnostie, drug treatraent, and treating physicians' speci- ilty information were obtained from the I)ationa7. Prescr' tion Audit and Hational Disease and TheraQeutic In exa-oa go ng surveys of pharmacies (4IPA)• and office-based nhysi- -ians (NDTI) z f,)ethods includeE-adjustmente; oK ds11g. use ~ata foz the fact that several of the antihypertensive drugs lso have other uses. The annual numbers of prescriptions ~or treatment of hypertension progressively increeise$ {128•1 to 208.6 million) over the study period. The demo- ;raphic analyses of drug mentions and hypertensive diag- ;:oses conveyed-a picture of rising hypertenaive morbidity ith increasing ag€), along with progressively greater use ~f corresponding medications. N B. S ce D.Dillon S•Hioa D.L. Cohn Celorado De arts~ent o ea enver tseaae on ro erro ca enveir INVESTIGATION OF 5 HIV-HBLATBD DBATHS IN AN INNER-CITY FAMILY Between April 19% and Dece.ber 1986, 4 cases of AIDS (3 adult 1 pediatric) and 1 case of severe AHC were dis~avered anA investigated in an inner-city Denver feai~~ a11 have died. Initially 2 men were reported as having "ao id'e~tified risk" (NIH) 1 wo.a~ ~as a sexual contact to intravenous drug user (IVDU) ans~ the ANC case as a heterosexual contact to I of the neo. Traditional STU investigations were conducted of 22 faaily~ ~.e.bers and friends nnr the i51~f~tlons~ I°8nve~sti~ations~ifdien~tified > 1 rts~s abndehavior~tp~er Case including IVDU and bisexuality for the ien. The pediatric case died of AIDS 6 months prior to diagnosis of AIDS in ~er aother, and was discovered in retrospect after reviecw of coroner a findings- A11 22 non-cases investigated accepted HIV antibody testing risk assessaent, and counseling. All had previoys1y ~censidere~d theaselves without risk, however, 10 admitted risk behaviora• 6 were IVDU I was a sexual contact to IVDU and 3 were stzual contacts £~o AIDS. None of 13 household mes~iers, including 6 childran were infected. 2 HIV infections were discovered: in 1 of 6 sexual~contacts to cases and in 1 of 2 family me.bers with ri sk factors. Investigation of 5 additional sexunl contacts to eases continues. NIg, heterosexual, and IVDU }nvestigations can be facilitated throuah effective use of traditional STD in~.ervention }ethods to estabIish ~isk behaviors, identify new HIV infections, docea•es lack of household transmission, and bring knowledge of risk prevention to groups who do not consider theselves at risk. Robett L• Cphen, 9zDi 8a91 A• Naora, HSws Iawrence x• Wexlea', ghD- New York Cirv Health an HosOitals Corooration. New York. N.Y. _ PRELIMINARY FINDINGS OF AN UNCONTROLLED CLINICAL TRIAL OF~ AZT (ACidothymidine) -- ON PATIENTS SEEN AT 9 NEw YORK CITY PUBLIC HOSPITALS The N.Y.C. Health and Hospitals Corporation (BHC) Ss the largest single provider of care to hospitalized AIDS patients in the country. During the 12 month period (October 1986 - Septea3bsr 1987), it is anticipated that over 800 AIDS patients will participate in an uncontrolled clinical trial assessing the lonq-ters safety of AZT. Patients are eligible for the trial if they have recovered from PCP (Pneumoc stis c+ rin~i pneumonia). The objective of the study is to prov de for the administration of A?T to eligible patients with careful supervision, and to monitor survival, disease pro9ression, and toxicity. The patients seen at HHC facilities are mueh more skewed towards intravenous drug abusers (IvDA), which makes the HHC data different from the rest of the nation. Multivariate analyses will be presented utilizing such factors as sex, age, race, adverse drug reactions to AZT, length of survival, number of re-hospitalizations, and other clinical and descriptive •,ariables. Fred C Wolf C Raevakv N Soencer Colorado Dept Health Denver 00 NON-ANONYMOUS HIV I8()DY TBSTINO• RBSULTS IN COLORADO In July, 1~ the Colorado Department of Health tCDH2 faplneanted a non-anon us testing progrts for HIV antibody a V1 Testsng Sitea (HTS~ Polieies included collectin= tiea~ identiPiers and risk behavior inforaation on specielly~d~isaed leboratory forsr. The inforaation is not revealed t 1 to ra staff but available to epidemiologists for analriis and follawup. Confidenti lity of records is protected. Ttu'oug;Decenber 1906, 10,476 tests (314.1/100,000 pop) r.ere processed with 13.7% positive at Denver HTg (64.9Y of tests), 9-6% at HTS outsi~a Deavef {19.1 % of tests) aod 1g.6% at ~p HTg providers (t6.0% o~tests). Mast volunteered for testing to_ 2erceived ri~k o~f ipfectioa- Only 1.7% claimed sysp ~ dl)Ytans diseaete altaouga 42. of this group were po.itive• 8KF(os tested were men with 1 1% positive co.pared to 2-2% pos t ve in women. Differences in pe rceat po itive in sam aex preference were: heterosexual 4.1%, bisexual 16s1% and 2n7•3X. Cited risk behavior. ~RH) incl • 18.4k 1 M l claii d positi e) 8.4% clai.ad '1 R11 143.~ pos(~itiv~e , and 33.2~ sexual contn~e~~h ihto•oa~yvi'm~mal ~ien Zlw~s)swbf t ~~tYh~oniyt~•}~%) both mao (78-wi8%), 19.8% itive) and raaen )(~3•~tad0.3~t positiv ). Negatives were less 1 kely tq return far rsaul~s and reventioa unselin than po.itives `7y. ~% vs. p t~ t id~ti ers ailo`as fo~low-q~ of >x»itiv who did not ra~vz~ 12f~a~ t~hose ~wtho~ser~aralnvtertoo (2.1z),iskags ~with sA.tiD~B~repo9~rta~~• aad efficient contact referral. Haasix, Susan E.1,2 and McFarland, Louisel. rouisiana Depar[me..t of Health and Human Resources; 2Tulane University achool of'Public Helath and Tropical Medlcine•, New Orleans, LA. , HIV SEROPOSITIVITY AT AN ALTERNATE TEST SITE IN NEW ORLEANS, LOUISIANA 1985-19M Testing for the antibody to Human Immunodeficiency Virus (HIV)•has been available in the New Orleans metropolitan area at an alternate test site (ATS) since Uune of .1985. Through December of 1986, 815 individua2Sttava been counseled and tested. The cumulativr aeropositivity (SP) in thin group is 22.75. The range of SP by month of t~pting was 0% to 40%. Males who had a history of IV drug abuse (IVDA) and homosexual raatact in the past year (N - 32) had a SP of 56.3I, IV,DA only, 8.3% (N - 12) and homosexual contact only, 23.75 _(N - 247). Males with no acknowl- edged or oth.r riRk (N w 23) had a seropositivity of 9.5%. None of the females, teated.(1L -~,34) were positive. Theae results indicate a significant lev.l of infection in the area, presently concenftYted 'in the recognizod high risk groups. However, the otential for further spread denunds that ennrgy and resources be ~ocused on the HIV problem now. CW Rutherford, GF Lemp, TH P11and, ML Cannon, AC Clevsnxer, MC Ceoxhegan DP Neal, T Temelso, D Werdegar, Department of Public Health, SF, CA, . THE EPIDEMIOLOGY OF AIDS IN SAN FRANCISCO: EMERGENCE OF NEW RISK GROUPS ', Two thousand eight hundred fifty-three cases of acquired immunodefi- I ciency syndrome (AIDS) were reported to the San Francisco Department of Public Health by January 31, 1987, corresponding to an incidence of I 416.5 cases per 100,000. 0f the 2,853 patients, 2,827 (99%) were male, ~ 2,766 (97I) were homosexual and bisexual, and 2,461 (86%) were white. Both the proportion of cases among homosexual and bisexual man and tha proportion of cases among whites have decreased over time, although not significantly so. Three hundred ninety-two (14%) patients had histories of intravenous drug use; 25 (6I) of these were heterosexual men and 9 (2%) were heterosexual women. The number of cases among heterosexual intravenous drug users increased 183I since December 31, 1985, while the number of cases among homosexual and bisexual men with and without his- tories of intravenous drug use increased 66% and 75%, respectively. We conclude that, although AIDS remains primarily a sexually transmitted disease in San Francisco, cases of heterosexual intravenous-drug-use- associated AIDS are increasing disproportionately. 1007 Zt Yia P Haneway f J Binkin F L Trowbridse Div of putrition Centers for Disease_ Controi• L. Fleshhood, Supplenental Food a_nd Nutrition Proxraa. Tennesse. Dent of Health and nvironmsnt ASSESSIHG TE115DISSgg PEDIAT@IC WIC RET®RIOH PATTg&YS WITH LIHK$D BIRTH AaD Sa9SAL WIC RECOBDS To study various socioecononic and medical factors affecting length of WIC participation (retention) in Tennessee, wa used longitudinally linkad pediatric nutrition surveillance records that were also linked with birth records to obtain birthweight and family socio-damographic data. Overall, approximately 30% of children did not return for their subsequent recertification visit, resulting in a log-linear retention pattern. Children of lower socioeconomic status (¢gS) were more likely to have nutrition probless than those of higher Sas; they were retained longer on WIC. Low birthwight children were retained longer than normal birthweight children, and rural children were retained longer than urban children. Black children in rural areas remained on the WIC longer than whites and urban blacks. These patterns are consistent with the WIC program goal of retaining higher risk children. Such retention pattern analyses can be applied to smaller geographic areas to evaluate their effectiveness in targeting higher risk children for continued WIC participation. Beaton D, Leddy T- Rhode Island Departmeot of Health, Division of Family Health A THREE YEAA MATLYSIS OF A PEDIATRIC NUTRITION SURVEILLANCE SYSTBM Pediatric nutritfon surveillance provides useful feedback to the Title V Pediatric Preventive Services and the WIC Progress. Results of the first-three years of the RI Pediatric Nutrition Surveillance Systea are given. The sample included appr,o{(,sately 17,000 children who participated in the Rhode Island WIC Program. Trends indicate au in- crease in overweight status and a.decreatf in iron daficiency`aqeaii. Ovar a three year period, the percentage of low birthweight children on the WIC Program appears to„be iocleasing. Two aajor indicators of aalnutrition in pediatric populatiohl are shdrt stature and uoderweigh[ status.'Our data indicates a ralativa7.y, llow incidenee of short stature and underweight status in thir popula- tion with no significant changpa in 3,'years. Implications of these: results and how they tan be used will be discussed. TIMN 322460 :J ABSTRACTS 3 r I
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1008 Dians Kaschak HSN Diane S.ith HSN Judith S.ith PhD RN ScFtool of rsin Univecsit o Pennsy vania an y Rose, , LaSa le p vers ty anrv,.tyw7 OF INCONTINENCE IN THE HOMEBOUND ELDERLY Urinary incontinence in this country is estimated to affect 38% of the comsunity-residing elderly. It can lead to social isolation and is the second leading cause of institutionalization. The Gloucester county Health Department with funds froa the New Jersey State Depart- ment of Health instituted a urinary incontinence program to evaluate and treat the homebound elderly of that county. At the end of year one, 43 hoaebound elderly (mean age 76) with frequency, urge, and stress incontinence have been seen. After complete evaluation, including bedside cystometrograms, 26 were instructed in pelvic floor exercises, relaxation techniques and bladder retraining. This inter- vention program has been successful thus far in 76.2% of the elderly, based on the decrease in frequency of incontinent episodes from. ini- tial intervention to end of treatment and follow-up. The complete work-up and intervention program will be presented along with iapli- cations for further study. '--- McCusker J, Mundt D, Stoddard A, Cole E, Whitbourne 5, Andrews G. (Division of Public Health, University of Massachusetts, Amherst, MA.; Geriatric Authority of Holyoke, IWlyoke, MA., USA) PREDICTION OF OUTCOMES IN GERIATRIC REHABILITATION outcomes of a geriatric rehabilitation program in a long-tera care facility were studied in 81 patients with principle diagnoses of stroke (32%), and hip fracture (32%). All had been living in the comunity prior to hospitalization and wished to return to the cosmunity. Information was collected on functional status (Barthel) and psychosocial variables at adaission. Functional status was reassessed at discharge and/or at six months after admission, as were placement and living arrangements, and health services utilization. Preliminary results indicate that 3 months after admission, 56% had been discharged to the cosesunity following successful completion of the program. Multivariate analyses indicated that only age, sex, and Barthel score, in combination, were important in predicting discharge status, with younger patients, females, and those with better initial functional status generally eore likely to be discharged. Predictors of functional status and placement at 6 months will be examined. Wilson, Richard Y7., :Iicholson, 4hmas J., Dept. Health & Safety, idestern <- University, Do[J g Green 1CY Tii£ EPICE2IICSqCY OF ARTHRITIS Pl9CNC 'nM ELDERLY IN RURAL I(E*TSVC(Y This project set out to study arthritis as it occurs in the elderly in rural Kentucky. A randan sample of households was drawn fran Powell County, a coimty 75% rural. In households seleoted, all resi- dents 60 & older were interviewed. The final sarple was 262 )wuse- hoods with 398 subjects. The survey instnsnent included derographics, chronic health problens, disability, & umet health service needs. Of the subjects, 66% reEorted having arthritis. It was more cannon atong (sople with 8 or less years of education. No association was found between mability and arthritis. Arthritics had significantly r,are difficulty fulfilling health service reeds than non-arthritics. There was found a clustering effect of several c3ttnnic eonditions with arthritis. 1Vialysis of cvvariance shoo-xd a significant relationship between arthritis and other chronic health problems, controlling for age, education, insurance coverage, & access to a;.hysician. Findings stnd that arthritics, especially in rural areas, have service nee3s not being adequately ret. Other implications are discussed. N.R. NLxSriclc, Fa.D., Syracuse Anivessity PREDICtIIJG DISABII.ITY f+t>JNG t4l[SFE fFN & kltfN: DIFFIIiF3~'S BY SEVERI.IY OF IIi°AIIdENf Not all persots witil chronic illness or impairment are disabled by these probleffi. Disability, c*iirh represents inability or severe limitatiotl on the perfa•++~ of noroal roles (especially work) is a response to impaiiment or diranic illirss. In this framec.orit, personal and societal diaracteristic~ tmy intluence disability. This analysis assesses in- fluences on dis~illty contzroiling for incapacity inposed by chronic illness or impaixtant. Using lio3d.t regression, the associations between deDographic characteristics, at tude, and social roles have been ex- amined for a sa®ple of persons with mild and severe levels of imQairmml The data wed are from the 1978 Survey of Disability and Work. The findings reveal that the factors which influalce disability are similar across all sex/ia~paismmt groups. 'lheyis(ww that to:rmedical factors are stxmigly associated with disability, particularly attitudes regard- ing pain, riredness, self-estemaand work. It is especially noteaorthy that disability asx.g ons with severe inp&ixmait is found to be in- fluenced by non-medi~factors. This analysis provides a deeper utder- stmr3ing of the )tr4c between illness and disability with a specix7l fo- cas on the ro t deri self-est.emt fmm work plays as a deter- ~ l m'*umt of disahilitv mmon¢ ctn-onirallv ill or i~aired oersons, - k9heat, ME, Fiirrlel.blatt, ,7M and Runitz, G, tbunt Sinai Medical Center, `3Y, NY, and San Ftdncisco General Hospital, San Frrncisco, CA 1AP ShB'A_R SC1ifTii:.° r. TM 19C[427 65 pND OJ£R Recent literataure has repOrted a high lsevalence of ab++.+.++r pap srmars in watmi ot= 65. In a study examt.,i„g screening, we reviesaed 565 randanly selected charts of sa,en patients in blo San Francisco teaching hospitals. 230 wtr•+en wese 65 or older (mean age=t3). Coap3red to younger ,.cmen they were ture likely to ?ave refused pap screen;•g (10 vs. 58, p4.05), less likely to have had a pap within 3 years (61 vs. 738, p L 001 snd less likely to have seen a gynecologist (34 vs. 24%, pc.01). Of the 140 paps done, 7 were Class II (atypia). tlane were dysplasia x carcirncha. Tt•vse with Class II raps were more likely to be non-vhite (6/7), had a rrrre frequent history of previously abmxmal scears, and oere nore frequently folloc.o3 by gynecvlogy- Cur results shva a loa rate of cesvi.call dysplasi.:/-arcincma in older, l.ow-inoone women. Possible explanations include a history of prior screening in this relatively well-screened grnig+, a true low prevalersee :f cervical dysplasia/carcinaaa in elderly ata.rn, or siall savQle size. 3ince elderly utaaen are unlikely to see gynecologistB, Lxim3ry care Fhy- aicians should oontSrnye periodic pap screening past age 65 unless a his- taty of technically adequate, Class I pan wesrs can be cvnfirmed. M. Ta back Johns Hopkins Center on Aging, S. Leavitt, a re County Department of Healtb/agingi T. Fagan, Baitimore County Department of Aging and RD S~:+ba, Johns Hopkins School of Medicine. HIOH RISA SCREgMIHG OF T9B ELDHRLY - COSTS AHH BF,lYEPxWS Although a high proportion of the elderly visit a physician one or more times per year, comprettehsive primary care and secondary preventive care is not Widcly available. Screening for high risk elderiy on a-aam basis may be a means for correcting this•deficiency. The results-of a carefully monitored screening and counselling program carried out in Baltimore County; Maryland are reported for such risk factors as elevated blood prassurey-obesity, and high scores on a geriatric depression response scale., Costs and benefits oi the screening program are compared, based,upon obaervationa on 1200 persons aged 65 and above. Also reported are screenidg results of retinal photography; visual acuity and tonometry. A.J. Stark, N. Pagliccia, B. McCashin, C. Jackson - Division of Health Services Research and Develogment, University of British Columbia A COMPARISON OF HEALTH SERVICES UTILIZATION BY ELDERLY HOME AND FACI- LITY BASED CLIENTS ADMITTED TO CONTINUING CARE IN BRITISH COLUMBIA. The overall objective of this research is to describe the total use of official health eerviees by the cohort aged =65 years (N-7250) who were admitted to British Columbia's Continuing Care program during 1981/2. Services of interest are those provided within the Medical Services Plan (i.e. principally physician services); hospitalizations (hospital discharge suaaaries) and prescribed drugs (Pharmacare data). It was found, for example, that those admitted to care at home and still at home one year later (H-3031) had, on average, 8.74 contacts with general practitioner physicians during the year compared to 8.01 contacts for thope in facilities (N-494). However, those in facilities had Emergency Rooa contacts twice as often as those at home. These analyses will be of interest to those who plan for and provide continuing care. The comprehensiveness of the coverage and the publicly funded nature of this care system make the description of total use of services and an analysis of patterns of care possible. H. Smith, MA House Select Committee on A t I~onatd J. Romano realer out east arw4ement ompany. MATCHING ECONOMIC AND PATIENT CARE GOALS IN VERTICALL INTEGRATED FACILITIES - A MODEL OF GERIATRIC CARE This paper presents a patient-oriented model of care coordination tha permits both the economic and patient care goals of vertically integrate facilities to be met in the provision of geriatric services. The model is basem on a 1986 study of options for improved, system-wide coordination of geriatri• core in a multi-level health care system serving the Greater Metropolita- Washington D.C. Area. Services within the health care system range fror. acute and extended geriatric hospital care to home health, skilled an intermediate nursing home core, adult day care, and residential care. Th model provides an organizational structure and process for care coordinatio. that ore patient-based, that ineorporate techniques of screening, assessmen- care pianning and case monogement, and that support both economip an• patient care goals including: efficient operation of a comprehenaive healt care system; appropriate and timely patient discharge ccross care level• improved forecasting of dematd; greater attraction and retention of patient. improved patient access, assessment, care coordination, and monitoring. ABSTRACTS 5 TIMN 322462
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t 3~ 01 t P A Pn D ~ l A N y aa ¢ ve .s a¢t e• • _e • .' ,Juns Sen ro essor, Ok].~ ahosa Clleae of Nursing, Oklahoma City, Oklahoaa 73117 A COHPARISON OF TWO PROCESS HEASURES OF THE QUALITY OF NURSING IN HOHE HEALTH There is a lack of valid, reliable, and clinically practicall instrumea- tation to aeasure the quality of nursing care is the home health setting. Study objectives were to evaluate and co.pare two instrusents using process criteria to easure quality of nursing care. Observations were aade of 36 home visits using the Slater Nursing Co.peteneies Rating Scale and the Schaele Instrusent to Measure the Process of Nursing Care (SIMP). After use, both fnstruaeats were evaluated using•the Waltz and Bausell fnstrusent evaluation criteria. Internal consistency easures yielded Cronback alpha scores of .96 for the Slater and .87 for the SIMP. There was a lack of positive correlation between the total instruaent sum mated scores which .ay indicate that there was a difference in the two constructs. Hovever,' there was a highly significant positive correlation between the SIHP, which is based on the components of the nursing process, and selected nursing process ite.s for the Slater. The study yielded useful results which need to be considered in the search for instruaentation to assist in .aintaining quality services in a coapetitive environment. Ander, Janice and Csrsen, Pamela, DuPage County Health Department, Illinois DEVEYAPHE.'iT OF PUBLIC HEALTH NURSE STANDARDS OF PRACTICE BASED ON A QUALITY ASSURANCE PROGRAM The authors were part of a ooeavittee to address quality assurance in the Nursing Division of a large mid-western (full service) health department. Though there were a variety of evaluation measures in place, 1t was feit that standards by which nursing practice could be evaluated needed to be established. To that end, several specific standards have been written for Antenatal, Newborn/New Hother, High Risk Perinatal, Hypertension, Chronic Disease and Communicable Disease follow-up home visits, as well as for Preschool and Day Care Programs and Blood Pressure Clinics. The establishment of baseline standards for nursing practice has been a group process. It is this process and the outcomes of the Quality Assurance Com®ittee that is the focus of the paper. Assumptions about quality assurance, stand- ards, process and documentation of standards are 'addressed. The goal of the presentation is to increase participants' knowledge in quality assurance principles and to review the application of these principles to practice in the field of Public Health Nursing. ~Cynthia A. O'Neill, R.N., 1LS. i.nstn:ctor, Brigham Youn3 Chivezs.ity I PCffiSC HFAIlIIi NM=' X1TIRtL' ES TC7M1D QUAIZ'P'1 ASSUF7lNCE The ~rpome of thia study was to des-ris,® the trit,,.a..e_of~ health +e ram tawnr:3 quhlity' assuiaire. A 41-LiLSa Likert soal.e as developed and ahei„is*o+e.i to 170 pub}ic heslth peit:emt Were re''++++^ d. Pearson PfaBUCt H'ment mr+aiatin..a oad.,. omvut.d betweeai eight attitude sub.calea, the total atfiittdatyar+++-v, and various dessogr++T ic var3abies. S±ga,iFicanceof t6-tifi.,ai3m-, .latkl.,a,ipe wes detenni.ned. Partial correlations v~.re avmpu+-.tn Clarify tartpin r@1aYirnaliie,_ne- No SignifiCaiit diffpsences.ian attitude were idett tt fi~ aong.~e with different levels of educat.ienaL preparation. T4evkl.g.woeiHia attitudes toward quality assuranee oczvrred on all eight subewle~nd the total measure. Years wor)cinq as apADlir heaitlrtaaas and pezt_ icipation in the Utah QA Pilot Study correlated Ri.*•= r1y (p,4 .A5 Ilevel.or higher) with all eight subscales and the total m®asure. I'lileae findings suggest that the ccnfidenroa dts:!e~,V= mxpm~ in the•fieid and'zecent experience with quality assurance activities '.ptraota positive attitudes ta,ani quality assuraxne. 1070 Mary J. Steiner, Ph.D., Franklin County Health Department, Ohio MARKETING HOFE CARE SERVICES: THE DEVELOPMENT OF VIDEOTAPES FJR USE WITH HEALTH CARE PROVIDERS, CAREGIVERS, AND COt4NNITY ORCANIZATIONS. The Franklin County Home Health Agency receives many requests from professional and commemity organizations to discuss home care services. A videotape format adds variety and interest to a presentation about skilled and home health aide/homemaker services. In 1984, the hame health agency, with the assistance of its own staff, clients and care- givers, contracted with Jeffery Shaw Cosmnications to produce a 16 minute videotape depicting the spontaneous coawnication between the client, family and health professional. Perceptions of the needs of the client, satisfaction with services and the value of the services are expressed. The process of preparation and the actual videotaping of home situations was a stimulating learning experience for the professional staff and also gave clients positive reinforceaent for contributing to an isportant eomunity project. This venture led to the continued development of videotapes such as "Cosatmity Health Nursing Vignettes," produced in conjunction with the Oflio Department .. of Health- The 35 miaute videotape shows selected interaction with '. clients by the public health nurse in a prenatal clinic, in a home , visit with an elderly woman, and a case management conference. ~ K. Snit en, R.V., M.S., Field Ccordinator, Upper Peninsula ia tes treach-.etworTc )'arquette ty alt partment, . (talIIlee,' ~ DIABETFS SELF al"IAMEYf SKILLS: DCES NC6E CARE NAKE A DIFFEREY(:B? Presentation will focus on the development and iDplemxltation of a referral and follow-up network encompassing the entireuppe r peninsula of t'.ichigan and involving 17 hospitals, native American health centers all local health denartments and private hane care agencies. A slide tape progra:a. '"17ie tlpper PenLnsula Diabetes Cutreach HetrAork" (16 minutes) will accanpany presentation. This project supported by a grant of $160,000 funded by the CDC and Hich. Dept, of Public Health. As care is given by cadmmity health nurses, data is collected re demographics of diabetics referred, their :najor problems, and type of care given in the areas of ophthalmologic exams, foot care, hyperten- sion, and pre-pregnancy blood sugar counseling. tajor emphasis on sys- tem of continuing education of the diabetic in self-management skills as well as improving and updating the knowledge and skills of hospital and coammity health nurses in the prevention, treatmeit, and patient education principles of the long terrn complications of diabetes. Jeannine D. Nnldoon, RN. HS, Ph0 Car.didate. Division of__Nureingt n yera ty oL ~faasac usetts at erst. CAPITALIZING ON COMTEMPORARY TECHNOLOGY: VIDEOTAPE NURSING INTERVEN- TION STRATEGT-ES FOR SOUTHEAST ASIAN REFUGEES A three-yaar projict (at the University of Massachusetts Division of Nursing) has yielded a series of innovative health promotion videotapes geared toward meeting the health needs of Southeast Asian refugees. Concepts such as breaking the cycle of tranamissability of communicable disease among newly arrived refugees through basic health practices in everyday life, introduction to the U.S. health care system, the physica} examination, screening tests, immunization and following medical treat- ®ent are d4icted in a clear, non-threatening visual story with Khmer, Vietnamese and English narrations and culturally appropriate actors. Another video discreetly describes the concept and practice of women's preventive health care for Cambodian women. Topics such as the female health exam (breast and pelvic), screening tests, ate. are discussed stressing the role women play in their'continued good health, as well as what to expect on a first examination. Designed as a teaching tool for Southeast Asian refugees, these videos are also useful to health care providers. students, sponsors, and others as a introduction to transculcural health care and education. Jean O. 1Yu..tar M.S. R.N. C. Gale Schreiber H.S. R.N. ~ DECREASING BACK INJURIES AAlONG HOtg CARE WORKERS Statiatics indicate an increased incidence of back injuries among howe health aides. Utiizinq an occupational health model, a program was developed to decrease the incidence of back injuries among home health care workers. This educational program consists of eight teacher-learner modules relating to the correct use of tody mechanics while performing certain skills in a variety of home situations. The modules consist of objactives, teaching content (focusing on impro- vising for the homa situation), AV materials, and ivaluation criteria in the form of performance checklists. 1072 Marlene M. Lugg, UCLA School of Public Health, Los Angeles HEALTH STATUS OF SCHOOL AGED CHILDREN: WHAT DO WE REALLY KNOW? Numerous attempts have been made to assess the health sta- tus of school aged children. In Los Angeles County, an interdisciplinary committee-reeently sought out available data in attempting to assess the health of its school aged children in public and private schools. The resulting publication, "Healthy Children", included recommendations for action to improve health status; but was based almost entirely on mortality data, due to a lack of easily avail- able data. Similar predicaments exist in many areas of the USA, resulting in greatly suspect evaluations of children's health. Suggestions are made for identifying other sources of data such as morbidity data, preventive health services' data, etc., and linking these data items to each other and to mortiality data in order to obtain a better "baseline" of current health status. ABSTRACTS 41 TIMN 322498 I
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A t a:. Bi11Roners MSPU Urbtn L Cormamit Pro rams Universit of KS a oma n y rno~ e n an ea t rvi ce, Holton, PRACTICING WHAT dE i'RF.ACH...AT HEALTH PROHOTION CONFERENCES The University of Oklahoma and Indian Health Service sponsor an, annual Indian health nromotion conference. Part of the conference ob.iective is to facilitate and encouraae the on-site participation of attendees in planned health promotion activities. This active involvement is desioned to enhance aearnina experiences outside the staMard lecture method. The paper will describe the rationale for this objective, types of health promotion activities, methods of implementation and reaction to the experience. NUTION STEW AND FRYBREAD: EsPloyee/Cooiaiity Wellness on the Navajo Reservation A panel presentation regarding the status of wellness programs that have been implemented on the Navajo Reservation by IHS. Topics to be discussed are: training of certified fitness specialists; developing and iepleeenting employee programs; liability issues and responsibilities of fitness specialists; establishing training programs and monitoring activities for other Federal, community, and Tribal agencies; establishing and implementing Area Fitness Standards for practitioners; and in sus.ary are the prograas working and are we getting to the people who really need wellness programs. THE USE OF EMPCWERINC LEAOERSHIP•TRAININfi NITM THE CHEROKEE NATIOR NENTAL HEALTH PROGRAM TO~PROMOTE HEALTHIER PEOPt~E AND COYMUifHFES Iil RURAL AREAS. Presentation of the elements of•Eepoirerieg-Leadership, ineTuding apacif ass~tions;- skilTs,-attitudes ustd in trainingpeo ple. The C#ierokee Nat on Mental Health program promotes individuatand community aepower- bKnt within a-variety of different,heetth related-tonter.ts, ipcl,yQingp (1) In-service'work-shops at a P.H.S. Indian Hospital and rural clinic, focustng on clinical/health issues with concurrent trainin~ in legdersh• (2) Consultation'and participation in cos..unity•meetings, in-house pro- grams and the Tribal Action Cbasittee to develop* integrated plarts tor empowerment and haalth. (3) A new organiz3tion of local rural health-care providel ih Fiental Health and Social. Programs dedicated to promoting and fat'ilitating individual, family and cosseunity eapowerment. Primary Author: Sally Davis, M.Ed. Co-Author: Xen Hunt, B.S. NAVAJO AND PUEDIA INTERGENERATIONAL APPROACH TO CAADIOVASCULAA FITNES£ hyaical fitness is a groving concern among native American populations. obesity and related i:lnesses are on the rise. Hardiness training and physical activity, once an integral part of Indian life, have for the laost part been replaced with a less active lifestyle. A project located in northwestern New Mexico will he described that uses several different methods to achieve culturally appropriate approaches to developing, maintaining, and measuring healthful behaviors. The pivotal point of the program was the identification of rich traditional beliefs and behaviors that promoted a healthful lifestyle. From this s®erged a project that includes different generations and incorporates :ultural traditions into the curricula of the schools. Elder members ~f the community are invited into the classroom to be intervieved by 3tudents about "the way it was." They also give demonstrations of the preparation of healthful traditional foods. Videotapes are sade of these activities, as well as of members of the coosn,nity, including students, participating in healthful exercise within the context of the Local environment. These videotapes are then edited and used in the P:ssrooa, along with other nethods, to demonstrate and reinforce thful lifestyle habits. A aa®ple videotape will be shown. Mitchell V. Owens, Ed. D., M.P.H., Professor and Chairman and Director of Native American Proaran' O.U. College of P.H. Joyce Eisel Owens, Dr. P.H., Central C4lahoma tiedical G-.oug NO SMOKING PLEASE A Regional Health Center phased in a no-smoking policy during a S yea}r period. This program parallels the findings of the Gallup Organization that 87 percent of Americans - smokers and non-smokers - believe companies should either ban amoking at work or should restrict it to designated areas. The program progressed from allowing smoking in permitted areas to prohibiting smoking totally. In addition, only non-a®okers are hired because of the increased costs of smokers to the organization. A Stop-Smoking program was offered to staff already employed by the center prior to the ban. It is expected that the organization may benefit as much as $4600 per year per employee from less use of health insurance systems, less absenteeism, less breaks and less employee accidents. Jean Cha;les-Azure, R,D., M•.P.H.x Lauran Tanccma, CNN: Kathleen Charles, i:•N•, M.P.R. Health Prosotion 11t The VoYksite, Keight `Loss Competitions I.H.S, hat Identified health prosotion as a•progras focus for F.Y. 198E 87. The werksite is an ideal setting for health promotion for s@ployess: This is a•report of tqo very successful worksitp weight loss oontests held at Western oregon and N.A. Washington Service Units. The aedidalrisks of obeaity hive been well documented. Poor eatihcj hab,its and/or physical inactivity play p role in elevated cholesterol, hypertension, cardiovascular disease and cancer. Type II, non-insulin depeindant diabetes is a disease tkiat is often preventable if a person doas.not become obese. This is a progra using the public health.approach to weight loss. It,ysat it's goal of providing a safe, effective weight management progran for staff with limited resources, "Self-Help" Nutrition Kits and rules were used which disFouraged too rapid of weight loss. Thb roeight cont} st approach these two service units had a low attrition rate among IRS participants and-was cost effective. This approach can be the "first step" in weight management/loss progtams for worksites bsfore•aore costly prograys such as clasaea.are i+".+1as="t^?- Leonard, Bruce E. HealthNet New Mexico EAT RIGHT NEW MEXICO, A*STATEWIDE NUTRITION AWARENESS/ EIGHT CONTROL FRO3p,AM HealthNet Nev Mexico is a non-profit corporation that will conduct a ten year health promotion campaign intended to enchance the healthftf New Mexicans by encouraging improve- .ents in the behaviors of physicali activity, tobacco and nutrition. Eat Right New Mexico is the first of three tan week media coordinated behavior change programs introduced yearly. Individuals sign up for Eat Right by purchasing, for five dollars, a kit of information and getting their 'height and veight measured. They return to thu respectivo registration site in ten veeks, receive T-shirta and pins if they hand in a behavior change sheet and loe:e five pounds. Ten thousand people in thirty-three cities anJ tw.: nundred worksites signed up for the program. This Fapvc will describe the purpose, hypotheses, design, methods and results of this health promotion project. 1 on parri.ir rtiffard - a.ivwrsi y ~f 1lexas Z3bodror Jones, Jr. - San Dieao State Universitv THE POLITICS OF PREVENTION IN MINORITY CONAfUNITIE3 The anveaent for health promotion and the•pravention of disease in minority oanunitiu has not had the same impact as in the larger mmuniti*@. Despite the disproportionate impact of disease and illness on minorities there are few evaluations of the probl.!s of prevention within theae special oaemnities. Research abounds on health pranotion efforts in areas which are of primary concern for the larger community but little research has been directed to.rard the politics of prevention efforts in minority oznninities. The paper evaluates the politics and the phila.ophy of prevention which prevents successful intervention within the minority coeeunity. TIMN 322502 ABSTRACTS 45
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William A. Darity. Pb.D., Tsd T:L.Chen, Ph.D.. Harris Pas_tSdes, g. ., c a ia er,'P~D.I Ueor~e• P. Carnada. Dr. P.i., Edward. ,.-4 Scanek, Ph. . and Robert Tuthill, Ph.D., Division of Public Hea1tY PRIHARY PREVENTION OF CANCER (SMOKING) AMONG BLACK POPULATIONS: THE DESIGN,'•,RATIONALE AND METHODOLOGY OF"` A RESEARCH%INTERVENTION STUDY. Thip paper will present the'design, Yationale ind sethods of a research/:iealth education intervention study that was funded by the National Cancer Institute to•,reduce the rate of smoking aagng Black populations. The•theorecieal•framevork of the intervention strategy-was developed vith: refeience to Health Belief Hode2. Adoption/Diffusion Process and Cosaunity Oiganization/System. Theory. A factorial•design i+as "u}ed'to select four cosrqnitiaa in four cities at four strategies (active vs.passive) ind coma,mi€s categories (middle-income vs lov income). A sultistage-cluater sanpling design is used for collecting data from 3600 subjects at project year 2 and year 5. A combination of longitudinal and cross-seccional prevalence study esign is employed. Both pro- cess and outcome evaluation vill-be , conducted. Ra ond L. Cux ri.D. Marcia Griffith i ltaren Sturdivant w®st e ica n er PRENATAL CARING - A WAY TO REDUCE INFANT MORTALITY This paper reports on the effectiveness of an interven- tion method to lower the incidence of low birth weight by educating low-income, black women of Atlanta with pre- natal care knowledge and obtaining their compliance with adequate prenatal care. in 1985, the target area of seven census tracts had 37 deaths per 1000 births. A prenatal teaa exists of six professionals to provide professional prenatal/postnatal care, risk assessment, delivery, family planning, counseling, nutrition, crisis intervention and barrier removal. A prenatal curriculum and handbook (Nine Months To Get Ready, Let Us Help You to Make a Difference) was developed to enhance patient responsibility and knowledge of the 3 trimester growth and development process. Poverty and age have an inter- action in the role of low birth weight. David A. Anssll kD1 Jaequelsn Dillard,RN, and 14reia Rothenberg, ItN,NA Gs6era s u FrT'd`az Zare, o un y oapLCai, UnLeaao, iL BREAST CAtlCER SCRYENING IN A BLACK POPULATION, TWO YEARS sZPLBTF"CL AT An DRBAn PUBLIC HOSPITAL Breast cancer is a ma yor cause of mortality among black women. At Cook County Hospital in Chicago, vhich serves a predoainately black popala- tion only 30% of breast cancers vere localized at the time of diagnosie'. .. in t~e years 1980-1982. A survey of patient records in the largest primary care clinic at the hospital revealed that only 2% of eligible . patients had received masaograss in 1982. A breast cancer detection ', Vrogum, run by nurses and recruiting patients waiting in the clinic as begun in mid 1983. Since that time the proportion of vosen who have received periodic breast examinations has inereased fro. 26% to I 46% (pG 001) and periodic maaograss have increased from 2% to 41% (p4.001). The proportion of localized breast cancer was significantly greater for those women whose breast cancer vas diagnosed via phe scr¢ening program (24/40, 60x) compared to other clinic ueas C45/132, 35I) in the years 1984 and 1985. There has been a significant increase in the percentaSe of localized brea t cancer at Cook County Hospital eomparinV 1980-1983 statistics (31Z~ before the greast C{ncer Dete ti Program as fully established, with ~984-1985 statistics i41Z pG.05~. These data sugRest that the establishment of a breast cancer detection program at Coek County Hospital has had a significant impact on breast cancer stage at the affiliated hospital. Paul B. Siauns, tiPH, Deputy Direetor, Physical Health Servi,ces County of San Diego Department o~HeaI1Ti A CnlPARISOX OF INJURI£S AND DEATHS A#b115 lMJOR TSAUWI YICTIMIS BY RACE: CONFTRMING M NEED FOR STRESS REDUCTION ANONC BU(Cl(S The County of San Diego established an organized system for the management of major trauma victims in 1984. During the ensuing three years, over 9,000 patients have been transported by the trauma system, under a'trauma code'. These transports have been documented on a trauma registry and maintained by the Department of Health Services. This paper shail examine the causes of injury and death among the trauma patients, focusing upon differences between the predominant ethnic groups in San Diego. The paper shall present startling differences between the groups, both regarding survival and cause of injury, and offer strategies• which focus upon stress reduction for Black and Hispanic males. Keith C. Ferdinand, H.D., F.A.C.C. INCR ElSING COlffL=ANCE IN HYPERTENSION IN BLACRI Hypertension among blacks in the Dnited States is coison and asceasive compared to the white population. Improved hypertension treatment is associated with declines in death rates specifically of strokes, and re- naJl failure. However a review of recent data indicates that hypartansi control among bicaks remain unacceptably poor vith high rates of noncor pliance with follow-up and drug therapy. Noncompliance vith therapeuti~ and preventive health adivice is a major barrier to controlling hypert qe sion in the United States African-Aserican cwewity. Compliance is affected by many factors includisg age, nusber of inedica- tions taken, and frequencey of dosage. Percentage of patients vbo fail to take medication as directed may be as high as 82%. Provided convient dosage scheduling and avoiding unaccessary side effects may help improve compliance along with involvesaant of patients in therapy with self soui- toting and progress charting. FSnmination of various options for anti- hypertensive medication and steps for improving compliance are detailed iaeluding aaicius 'channel blockers and ACE ishibtors. Harrettu: Crsee. Coll.as of Pharoucv. Xavier 1'niversitv of Louisisna, Nev Orleans, LA 70125 C4RRENT STATVS OF BLACK HEALTH PROFESSIONAL HANPOi7ER In August of 1985. the Secretary of the Department of Health and Human Services issued a detailed report outlining the critical health status disparities that exist in this nation among blacks when compared to whites. A major component of the problem identified was that while there nay be an energing abundance of physicians and other health pro- fessionals in the nation, quite the opposite is true among minority health professionals. While blacks represent 12% of the O.S. population, they only represent 2.6% of physicians, 2.9% of dentists, 2.3% of phar- macists and 1.6% of veterinarians. The purpose of this report is to prese6t current enrollment trends among black students in seedicine, dentistry, pharmacy and veterinary medicine. Trends over the last several years signal slippage in the already significant underrepresentation of black students. Factors qe- lating to attrition, recruitment, and financial aid for these students will be discussed. •]ennifer Hill-Y H,S.P.H. R N, rard K tz B 5. N.ED Ado~ascent Resouresa CorooratiDn Me c D. • 0 ice o_ f h R M ssour Hea D!OartnCnt THE SCHOIX.-BASED CLINIC AS A HEALTH FROMDTION TOOL TO IM'ROYING THE HEALTH STATUS CF INVER CWY RLACK YOUTH The leading causas of death in minority populations as identified by the Secretary's Task Force on Black and Minority Health are cancer, cardivascular disease and stroke, chemical dependency, diabetes, homicide and accidents and infant mortality. Mhat health promotion interventions can be established and led by members of a school-based clinic team that can impact the health behaviors of today's inner city youth that may positively effect causes and rates of death in the futu:e? Can the objectives of teaching correct utilization of the aeaith care system and promotion of prevention have an effect on the lifestyle behaviors of inner city youth so that they are healthier in the later staqes of life? nne Jenkins, N.A. _ Director- Urban Lea Yv Greater t:ew arteansHea_ sd tartZenter a Parent-Child Center of r rs ren INPLICATIONS OF HFJLLTH-RELATED ISSUES FOR EARLY CHILD DfYELOPlEtR The Urban League Parent-Child Center (ULPCC), established in 1969, is a Day Care Center for both lower-incone children and their r•wthers residing in New Orleans. The ULPCC provides not only the standard Head Start services for children, but the followir.g prograes for ntohers and fathers: 1. GED classes; 2. Parenting skills classes; 3. Cooking and setiing classes; 4. Rutritional c'.asses; S. Yealth Classes covering such subjects as Sexuality, Birth Control, Perinatal Care, Child Abuse, Child (:eglect, Substance Abuse, the Ilorid of (krk; and 6. Job Training. Referrals are also nade for parents and children according to individual needs. Followup data, beginning in 1984, - revealed that 8% of 77 participants uere tested and received their GED. 7toreevar, 10: have had post-high school training; 12: obtained jobs after on the fcb training. This presentation uill indicate our belief that the nodal can ce used in other corcmnities with ?isadvan.aged rathers ar.d their children. 46 ABSTRACTS TIMN 322503
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Dr. ttegory Qorirtmrz+n, E,,aluaticai Officer, Offiae of Disease Prevezticn:n and Health Promotion and Cnaryl Darberg, HI.r.H., Cooraimtor for Sanooil Health Pr*: jec! s, Ofrics of _isxse Pretention and Health Pramtirn ', Findings frcm i:he Natimat 4+ii.)+.»+ and Youth Fitness Sialdy 11 Zhe Oftioa of Disease Preventicn and Health Pramtion, a golicy ofYice within +he U.S. Health SeTvice sponeored a nacirna.l sarvey to I, asaera t~he pt:rai:xl atnasa :s« and activity patterrs of ^h;)Are+ ~ ages 6-9. This is a xntiISiat).on of the NCSH•'S I which exa¢nined neal.th .. related fitness in childrea ages 10-17. Dara were collected from a nationa)l random sar.ple: of o,DUO students in Fall 19S6. Yindings to i be presented include fitness norms ny age aryi aex whi.ai can be used to assess titswse levels of atuoents, rxpariscn with previously I pubtisned naoas, description oz types of activities children .ngage in,', results from parents and teacner questionnaires that address perceptson, ot fitness as we11 as the level of the parent's fitness. Pexiarrndat>a are made for nndit:catim or fitness programs directed at youth=in school and in the oannmi.ty. Also discussed are those factors uhich contribute to health-retats3 fitness. Grey Margaret. I:nlversity of Pennsylvania School of Nursing SIIO;SSAIL LIFE hNFN1S tNID Sfl-IOOL CHILIREAI'S MNI'AL FEALTH AND BEfiAVIOR The impact of st+rcsful life events on 124 elementary school children's rental health and bchavior, and the effect of psychological traits on these relationships, was tested. Stressful life events and mental health status were measured at the beginning and end of a six month semester. Psychological traits were measured at the start of the study. The findings indicate that diildren's rental health status and behavior are associated with the 'ocaurrence of lndesirable life events (I-.393, p<.001; r-.287, p <.001, respectively) and with psychological traits (rr.44S, p<.001; S=.519, p<.001, respectively). Path analysis; controlling for mental htalth status at entry into the study, demon- aits to strated that life events interacted with psychological tT ~ ~prod)ce poorer mmtal health (R = .394) andl~avior (R .454). These results slggest the importance of considering children's recent stressful life experiences in evaluating those with rental health or behavior problem presenting in the school. Akbar Davasi N.S.P.H. Ph.D., Health Education Program, Dpt of Health Sciences, I) no s ate niversity. William Creswell Jr. Ed.D., Dept of Health >nd Safety Stndies, U o no s. BIOMEDICAL INDIC^.TrotS OF CARDIOYASCULAR RISK AHONG ADO(.ESCENTS-BY RACE AND SEX This study is part nf a longitudinal research to determine the risk indicators among adolescents who are believed to be "at risk" of developing cardiovascular disease in later life. This paper specifi- cally examines the differences between the biomedical risk indicators as they relate to specific race and sex groups. Selected clinical measures of health status, which include blood pressure, physical per- fomunce, triceps skinfold thickness, weight, height, and body wass measurements were taken on about 900 9th grade students from Decatur, Illinois. It was found that a significant difference exists between different sexes and races for most of the variables under study. This study emphasizes the need to take these differences into account when dealing with a multi-racial and sexual target population. 1073 ~ Gene Carnicoe, Ph.D., ACBH and Clare Heleiniak, M.D. T}€ ALASKA AREA NATIVE }£AtTH SERVICE MARS SYSTE!(t INPLEMEMTATION REPORT, JANIJARY 1987 In 1985 and 1986, the Alaska Native Medical Center conducted two field studies to detereine the potential for identifying Alaska Natives enrolled in, or eligible for errolleent in, alternate health resources. Following favorable outcoees of these studies, AMIC isple.ented MARS (the Maxieu. Alternate Health Resource Systee) within the hospital. Inpatients and outpatients were screened using MARS, and a series of studies of special populations, including children with handicapping conditions, was conducted. All MARS data dea+onstrates that a large segment of the Alaska Native population is eligible for alternate health resources but not enrolled in thee. Planning continues to establish the systee state-wide. elan J. Le MSw ACSW Univers_it o School of Soc al Work DEVELOPING COHMUDIITy-BASF.D SERVICES FOR CHILDREN OF HINORITY SUBSTANCE ABiUSSRS Host resserch and services directed toward children of sube stance abusers have focussed on the middle and upper income Segment Of this population, ignoring those who live in inner cities and are mmbers of a minority-group. This paper will present the special needs of these children and address issues specific to developing co.unitT-based services for ths. The differences between minority group substance abasers and the general population of substance abusers will be contrasted from an epidaiological perspective. This data will be synthesized with studies of risk factors incurred by children whose parents nanifest substance abuse disorders. Co®sunity-based prograaeatic initiatives will be reviewed and a model program which was designed to meet the needs of this population will be presented. Special attention will be given to capitalizing on environmental factors which show particular proaise ia positively affecting the development of these children. Marilyn M. Lewis, MSSW/MPH; Alice R. Washington, ACSW Highland Hosp:tcl, Alameda County Health ServicilY Agency, Oakland,•CA ~COF7PREHBtiSIVE SEXU_AL ASSAULT SERVICE DELIVERY IN A PUBLIC HOSPITAL-BASED SYSTBM. 'ihis papef 3escribei a aodel with a multi-diabfpiinary, multi=ejyhnic, sulti-eulti,faleoayirehensive appYdhcH'ta't~tB derivery of sarvice to victim of sexual assault. slirvieetr are delivered through a'consortiuu of ooanknity-based agendies•and a public.health agency. The develop- ient of tHd-plvgraa as well as st`atLincr traininlj and coordingtion of service wil7, be discuss'ed. StartAt'in 1984 the objectives tif^the Center are: 1)• to'Fiovide 24-hour medical, 1'aZyal and crisis inter-. ventioiy,SeYSicess 2) eoeeunity educatSonand awarenessF and 3) thera+ peutie intervention'and treatment. Sexual assault ia a severe life crisis. Issues°su.rrounding the assault are addressed by social workers who are'locst7lII"in three conounity-based, d4ntal health organizatiions which £ors the eoneor'tiui. :7ationally, one woman in four and one pan in tep will e3qierieiSca some type of sexual assault in their.lifetime. In 198T,tbs...tAt~j ausyer.of reported rapes natidna2ly was 78,918. Oakisrd ranks 5th iri the dation in reported rapes. Alice A. Lieberman Ph.D. School of Social Work and Jani e L, Thom - son h c a o urs na, versitv o Sout ern Maine INTEGRATING REFUGEE HENTAL HEALTH CARE INTO EXISTING SYSTEMS This paper details the conceptualization, methodology, and results of a statewide survey expkring the pathways by which Southeast Asian refugees enter the mental health system. Providers (physicians. nurses, and social workers) in ten major health and mental health facilities known to serve refugees across the state were surveyed, using both qualitative and ouantitative techniques, regarding caseload composition, circumstances under which refugees are referred for further mental health work-up, and sAif-assessment need for further training in cross-cultural intervention techniques. Additionally, respondents were given a hypothetical case and asked to provide a preliminary diagnosis and treatment plan. Results reveal that very few psychiatric providers, or social workers, report contact with the refugee population, and that refugee contact with provider~ occurs through traditiona] sources of primary care. Social workers appear to be less than adequately prepared to work with this population. Implications for further research and training are discussed. 1074 ~ 0'Hare. MD. Marie Littleiohn. [iyrCle JOD MSW. Carol Mazor. MSW. MaternitY. Infant Care - Family Plannins Proi Yesearch Ansociation of New York City. Inc. NFE cta/Medical & Health TBEi LIHKACE CSHTEta A SECYICE FOR INNER CITY ADOLESCENTS The Teen Linkage Center is a cosannity based program, designed to reduce the incidence of teenage pregnancies and low birthweight infants. It is located in the Brownsville area of Brooklyn; an area characterized by poverty, late or no prenatal care and adolescent pregnancies. The goals of the program are to improve pregnancy outeose; to reduce the incidence of pregnancy among participating adolescents; to assist sale partners and extended family members to break the cycle of poverty. The services provided include walk-in pregnancy testinj, referral and follow-up for prenatal care, home assesaaent, STD education, strnality, family planning methods, and educational, vocational and eaployaent referrals. During 1986, 153 women vere sean for family planning services, 476 for pregnancy testing and 37 young aen were provided a variety of services. There were 1,{64 encounters the aajority of which were for ongoing prenatal counseling. This paper represents a descriptive study of the program and an assessaent of the extent to which the goals have been reached. 42 ABSTRACTS
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Jonathan M. Samet. M 0 , Department of Medicine, University of New Mexi, Albuquerque, New Hexiw 87131 ASSESSING THE RISK uP RADON EXPOSURE: THE BEIR IV REPORT Assessment of the risks of radon exposure was one of the most challengi tasks faced by the Biological Effects of Ionizing Radiation (BEIR) IY-F Committee of the National Academy of Sciences. Epidemiological investi tions of underground ariners and animal studies have established tha: ..- radioactive progeny of radon, referred to as radon daughters, cause lun cancer. However, the risks of lower levels of exposure, as may be enco tered in homas and contemporary mines, remain uncertain. To describe t risks of radon exposure, the cosaittee analyzed data from four studies underground miners with regression techniques. The resulting descripti model was used to project risks for the general population, including smokers and nonsmokers, and for miners. This presentation will sL=ari the work on radon in the BEIR-IV report. J. Klotz, S. Klucharich, J. Hynur, p,..L State Departnent of Health• G. Nicholls, E. Rotte, N.J. Depart.ent of,66vironlental Protection The New Jersey State Program on Indoor Radon The Departav;nts of Environeental Protection and Health are collaborating in a comprehensive prograz to address the needs for testinf .itigating, and understanding the health risks of indoor radon. Through special legislative authorities and appropriations, the two agencies are conducting studies of exposure parameters and health outcomes, encouragir responsible testing and aitigation industries, providing follow-up testir services, conducting extensive public outreach and response, fostering the participation of local health departamnts, and coordinating with federal activities. Rationales for the .ajor program decisions will be presented. Issues and experiences in implesentation will be described. . Ian B. Berger International Vision Care Program at the Dniv. of Houston College of Optometry IH'IL3Q7ATI01(AL 6ISICq CARE Cosson,goalsof blindness prevention and therapeutic interventioa, to-improve .isioa..ahared by dozani of interaational,eye carg orgaaizations aad volunteer groups,have tesulted in aasftiplicitive'i£forts in certain gaogr,aphic areaa vith mi++im-l or no ur. - provided in other paru of the,vorld. This situation cafi be i.pr8ved with inforsation on the needs and demaads for eye care services, inter- organizational-cooperative planning and training increased nusbers of indigenous eye can•persaanil. PRO.,rCI ORHIS - SCOPE AND PROCRESS Author - Stephen Clenn Slade. M.D., Executive Medical Consultant, Project Grbis Project Orbis, the flying eye hospital, now in its fifth year, has visited over fifty (50) countries and influenced the training of thousands of health care workers. Orbis's goals are to fight world blindness and pruwte peaceful cooperation. Orbis has expanded be- yond the surgical teaching eye hospital to become a factor in health care worker education in prisary eye care. Orbis now conducts follow up visits in all countries, in addition to attending and sponsoring off plane symposiums and workshops. The evolution and progress of Project orbis to its current position wi11 be discussed. Anne Paxton MPH Re ional Mana er for W st_ Africa, He en Ke er _nternationa "Helen Keller International, Scope and Progress" Helen Kel-ler-In•ternational works•in developing countries to bring-blindness prdvfption~ and rehabilitation servi,ces to rural. . areaz-where thgI services are presentl•y~ lackinrn. }1KI workryith--tire Ministrier-of-Health tn ksiarr, Africn•n-and L-atin-Amer+can-nattons to -tr0'ti, their heaAth-workers' to de9lvcr eye-care-servites;°--specifiicelly vitamin A s.u4yr plesientativn ta-chil"dren at'•risk-of nutri•tional b9indiress, vrtib9-6ttc- eye ointment•for the preventi-on and, treptment o#•trachama, first-aid f'or-tyLe;tnfuries, and referraT'ot p.atientsrfor-cataratt-aird, otirer svrgery. For' those• whrrse- si'gFrt-is-•lost-irrevocably; HKI establishes 4ommunityd based rehsbiTi-tatien and education that integrates blin'd`c(lildren into classrooms along with sighted students-and 'enables-. blind adults to.lead prod'uctive iives. Jlecauge the same^ vitamin A that.prevents nutr'itional blindness also hilps to protect young children from infectious diseases, HKI's blindness prevention programs have assumed still greateh urgency'as part of the worldwide child's'urvival campaign. a w n, Dean, University of Nouston College of Optometry Cooperation for International Eye Care - Inequitable accessibi3ity to eye care is least in those countries in which.adequate numbers of eye care professionals are well trained to provide primary, secondary, and tertiary care. These are the same countrie's in whicB educational and economic opportunity are avall'able to the largest proportion of the population. Erfgland may have the best distribution of resourcei fot@rnally, but the United States unquestionably has the largest number of well trained eye care professionals and is anpng the'leadinq countries in numbers•of eye care providers per capita. The only reasonable opportunity to mak®.any significant assault agains this calamity is to,bring together those resources in the United State into one force with the mission of preventing blindndss worldwide and the goal of making the full range of eye care available to all of the world's citizens. By merging efforts through an organizational consortium, four major program areas could be addressed. Paul 6. Steinkuller, M.D. International Eye Foundatfh Primary Eye Care in Africa Thti population of sub~Saharan Africa is approximately 500 millio'n"people, of w!gp 80 - 90% live in rural settings, outside'thN caSh economy. 1% of these people are blind (W.H.O. criteria, best corrected.vision < 3/60 in the better eye)"!nd an additional 3% have some visual disability (W.H.O. criteria best corrected binocular vision 6/24 - 3/60.) Cataract, trachoma/corneal scarring, and glaucoma are the three leading causes of vision Tdss/dlsabitity, and all can be adequately addressed by simple preveNtive and/or therapeutic interventions, if economic and manpower resources are appropriately directed and utilized. The prospects for this happening are not good. Alrred A. Rosenblooa, Y,.A., O.D. Low Vision Care: Positive Approaches to Improving the quality of Llfe 1. Definitions of and Understandings about Aging, -Low Vision, and Low Yision Rehabilitation a. -Dmagraphics- b.. Oef,ining Aging c. What Is TrUe About.The Elderly d. What rs Mot True.About Thi Elderly (myth,s & stereotypes) 2. National and International Programs in Lol{ Vision Care and in Blindness Preventfon a. VOSH (Amigos) , b. Helen Keaier International of the American'Fdn, for the Blind 3. Description and Illustration of Major Types of Low Vision Aids, 4. Selected Highlights of Optometric Research.on Low Vision reoardina Proanosis. Outrnmrs- nnd Follnw-Iln Car. ABSTRACTS 49 _ TIMN 322506
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I 1097 The Door - A Canter of Altecnatives THE 'hiEALTH AWARENESS PROGRAM" OF THE DOOR, NEW YoRK CITY "The Door - A'Center of Alternatives" is the service delivery arm of International Center for Integrative Studies, a private. multiservice for adolescents in lover Manhattan, New York City. In Noveaber 1983, was provided by the W. K. Kellogg Foundation to develop and evaluate health promotion program within the Door's spectrua of other educatic health, and social service programs. The project is designed to shos health behavior of adolescents can be significantly improved through hensive health promotion program that actively involves young people behavioral change. A 10-session curriculYr program is targeted to in adolescents who are at high risk for such problems as substance abuse and nutritional deficiencies. The HAP program vas designed to involve 300 teens in a core program, reach an estimated 1,500 additional teens through supplemental activi MARY YERNON,MO and MICHELE 3GitEN-SPENCER, MPH TEEN-LINK: A HEALTH PROMOTIOt( PROG:JW FOR DISPAYwYTAGED INNER-CITY YOUTH A cam+unity approach to sssist youth in becoming responsible health wise adults has been developed. ihe TEEN-LIl(K project health promotion effor are directored toward reaching youth through the networking of conmunity agencies. The program is designed to taroet inner-city youth ages 10 to years. The components irrlude: a)special activity focused grroups,.e.g, karate, cosmetics and computer literacy, b) psychosocial support groups, stress management, physical fitness and nutrition, sex education, risk- taking behaviors and teenage parenthood, c) ca7tnunity outreach and healt education e.g. Church-Connection and school outreach projects and d) you helpers e.g. youth council,and health educators. Some issues of intervention for TEEN-LINK consist of hiring a conmited endless comnunity presentations, contracting of services with other agen or organizations and developing a network of caring personnel and volunt We will be able to share some results of our 18 month effons including a) ability to develop,an effective interagency network. S) efforts to re cruit youth to the programs, c) strategies for reachinn youth, d) techni for identification of youth at-risk, e) the development of youth council and f) development and impTementation of the Youth Resource Person progr i.e. Peer Health Educators- Beasley, J., M.D. - Bard C'nter; 6rimson, R., PhD.- SUNY, Stonybrook; Bicker, A., PhD. - Bard Center; Steibei, W., Suffolk DPHS; Hibberd, M., M.D., Suffolk DPHS; Faust,I., Bard Center; Heusel,C1_M.p. - Bard Center. SUFFOLK COUNTY TEEN PREGNANCY HEiiLTH PROMOTION PROJECT A demonstration project on the effect of interventions on style and birth outcomes was conducted with pregnant low-i teenagers in Suffolk County, New York. The project was car out within a we11-established public health care clinic sy using a case-manager model. To date, 780 teens (445 study, control) have been admitted to the program at 10 clinic si The project's management information system uncovered a ra factors that influence effective intervention. Clinics dif in relation to ethnicity, trimester of presentation, intak delay, and aainission policies. The teens exhibited a hign transieney rate - 58X moved at least once during 18 months ouved tt+o or more tames. In addition, a separate,computeri birth-trackinp system was developed to enaCie Suffolk to t all births and identify and follow-up high risk infants. I lows cross-analyses of variables (ethnicity, maternal age, birthweight, clinic, etc.), and can be adapted for use by Elnora D. Daniel, Ed.D.; and C'nriscian Jones, M.S., R.H.. F.H.P. _ Hampton University THE INTERDISCIPLINARY NURSINt: CENTER OF RAMPTOtt UNIVERSITY This project establishes for three underserved areas of eastern Virgin nurse-managed clinic and a mobile unit staffed by university faculty a nursing students. Affordable primary health care services are being p to all populations, with special focus on health promotion services fo adolescents and older residents in the areas. A11 clients will be pro• health assessment, including medical histories, physical fitness, nutr: habits, risk appraisal, life stress review, and a lifestyle and habit analysis. Intervention groups are being developed in smoking preventic saoking cessation; nutrition and weight control; stress management; re, alcohol consumption; exercise and physical fitness; adjustment to sexu. saturity; understanding birth control; pragnancy, child growth and devsent; and parenting skills. A follow-up health risk assessment will b to determine whether improved health outcomes have been achieved, and indirect estimates of cost-effectiveness of the health promotion progr will be develope.. 50 ABSTRACTS David H. Gustafson, Ph.D ••vd Kris Bosworth. M.S. Dniversitv of Wisconsin at Madi.sen THE "BODY AWARENESS RESOUKCE nETWORK" (BARN) PROJECT--UNIVERSITY OF W1 AT MADISON This project has created and evaluated two interactive microcomputer p targeted for adolescents on topics of alcohol and drug use, diet and ac smoking, sexuality, and stress management. The objective is co help adolescents idtntify, understand, and avoid or change hazardous behavic The system offers information, behavior change strategies, and referral sources-all easy to follow and portrayed in a game-like manner. In 1982-1983. BARN was field-tested with more than 6,000 adolescents ac families in the rural and urban areas of Wisconsin, using settings sucl high schools, aiddle schools, medical clinic waiting rooms, and 4-H cl Use of the computer system was optional in the test schools: about on of students reported never using BARH, one-third used BARN up to 10 ti and a third used BARN 10 times or more. Middle school students used B more than high school students, and males used it more often than fema In order of popularity, the most popular programs were: (a) body mana (b) human sexuality, and (c) alcohol and other drugs. It is an import finding that the use of a particular BARN_ module was higher in students _  V V NikkTNerman MS Alfred Marcus Ph0• UCLA-JCC Flmbm &~IA(,: €Y L~1 Tf& Zi<'A-GbWITI: SMOKING CESSATION PROGRAM The American Lung Association (ALA) has developed and is currently promoting a state-of-the-art smoking cessation program called Freedom From Sswkin(FF5). This unique program is designed to train clinic ac~TiEa'Eers iA co: uct FFS at their place of work or business. Thus, the underlying assumption of this program is that key individuals recruited within worksites, businesses and community organizations (e.g., hospitals) can be taught to function as smoking cessation facilitators. This study, conducted in Los Angeles County, was designed to provide the first systematic evaluation of the FFS clinic program. Three month, one year and two year follow-up have been completed totaling approximately 500 FFS enrollees. This paper will report estimates of the point prevalence quit rate and sustained quit rate with saliva sample validation for the FFS clinics md compare these to estimates of the spontaneous quit rate derived from previous research and our on-going analysis of national and local data sets. Preliminary tabulations indicate a quit rate of at least 26% for program completers after one year. Analyses will also be reported that identify factors which predict differential FFS clinic success, as defined by the point prevalence and sustained quit rates. These factors have been obtained from a survey of FFS clinic facilitators. Colantonio, A. Yale [Jniversit ARE EMPf.OYEE ASSISTAtdCE PR()GRAFi~i'EFFECTIVE? A REVIEW OF EAp EVAIdFATICNS. There has been a tremendous grovth of employee assistance programs (EAPs) over the past 15 ysars which have traditionally dealt with alcohol and substance abusp amongat employees. The aim of this paper is to exasiine the effectiveness of EAPs by reviewing FAP evaluations published from 1975 to 1986. Each of the evaluations vera analysed according to the following itemss setting, subjects involved, format and type of interventia), research design, variables measured, operational methods and outcomes. The analy4is revealed importaat conceptual and methodological issues: lack of theoretical basis for intervention, unclear definitions of problem behavior leading to referrals, questionable length of follow-up, lack of control groups in study design and little information on operation- alization of variables and on validity and reliability of measures. Although positive outcoaes were reported, these results must thus be interpreted with caution. Recanmendations for improved study design are made for future EAP evaluations. kerri[aa. D.M.. 6d.D., Malsh D C. Fh.D.. Hiwop H.. Sc.D. __ _ os m versi~:SChool of Public Heeith MHZCY DRl/KM DSg AN ffiWLOYgg ASSISTANCZ Pfi008AN AS A GATEWAY INTO TRRA'Jf6l1!! &sploya" assistance paograms are proliferating and most provide an ases~t of an esployaa's problem and referral to treatment. Rising ~O.eltt nsre oests have occasioned interest in case msnegc.ent and tIr tAH potstial for directing asployees into treatseot (conducting oepective mtiliution review). ID>Qloyass follow several p.tbrays into gAP. From sn ongoing study of s lFative treatment strategies, we have cooducted extensive intake inta tetn viww at a blue-collar Joint company-unics LP in one of the natim' larsest corporations. Over a 4 year period, 261 of the gAP's 300 new clients bave cooseated to a faoe-to-face interview, probing lifetime ex- pKiesoa with alcohol yd other drugs, prior help-seekinY, and numsrous fadly, ,)ob amd bealth issues. In this EAp 44% are self-referred, 24% ere referred by supervisors, 33% are brought in by a union ste.ard snd 16t by oororlars. lfsny ocea to the LP's attention after volunteering fo ~ inpatisnt treatsest: 20% enter.d the gAP through this "barJc door" froi traatmmt. The analysis exsaines factors which differentiate those who cor directly to the ZAP frce those who independently seek inpatient treatment and suggests limitations on gAPs as gatekeepers rationing ioea 1 au+ hn- vith t1..4.' ineurwn,w do11aS_s. TIMN 322507
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Dr. Ritva R. Butrum, Ph.D., Diet and Cancer Branch, Division of Cancer vention and Control, National Cancer Institute _ NCI GUIDELINES F03 CANCER PREVENTION c THE FATIONALE AND POLICY I'rMIC TIONS Evidence relating to the role of dietary factors in carcinogenesis come. from both epideaielogical studies and laboratory experiments. The Com- sSttee on Diet, Nutrition and Cancer of the National Research Council 1 1982 conducted a comprehensive evaluation of this evidence and suggestec several associations of dietary intakes of various nutrients, foods and cancer. Based on this study and additional evidence accuswlated since that time, NCI has formulated interim-guidelines which propose a cancer preventive diet. Emphasis is placed on the reduction of dietary fat, a increase of dietary fiber from a variety of fruits and vegetables and f whole grain cereals. A high intake of dietary fat has been correlated with an increase in breast and colon cancer in population studies. The association between breast cancer and fat intake is also supported by cohort and migrant studies. Of tuenty-oae (21) studies of fiber and co cancer that have been reported, seventeen (17) show an inverse correlat between dietary fiber intake and colon cancer incidence. NCI dietary guidelines will be discussed also from the viewpoint of implementation meet Year 2000 objectives. 1045 Wilson Cindy C. Uniformed Services University of the Health Sciences 6 Netting, P. Ellea, Arizona State University. GAMING AS A METHOD POR ETHICAL DECISION-MAKING: A TOOL FOR CONTINUING EDUCATION. Sensitization of professionals to ethical dilemas in long term care involves exposing them to uay scenarios, various health care provid- ers, multidisciplinary data, and professional/personal conflicts in care. The "Ethical Dilem.as" game was developed: (1) to prepare pro- fessionals for potential conflicts within the continuum of long-term care decision-making; (2) to positively facilitate attitude change about the elderly, their families, and their care; (3) to provide a framework of values within which experiences can be organized; and (4) to provide a method for continuing education which can be enjoyable for participants. Inherent in this procesa of sensitization is the development of a better understanding of the roles of 5 professional disciplines and their relationship to health care administrators and their responsibilities in providing long-term care and health care services. This game provides an avenue for frank discussion of the difficult decisions which are often made in the provision of geriatric 1health care. Mildred E. Solomon. B.A., DLp.Ed., Bruce Jennings, M.A., Cheryl Vince, Ed.M., Vivian Guilfoy, M.A. €ORECOING LIPE SUPPORTS. INTERDISCIPLINAtY EDUCATION FOR HEALTH CARE PROFESSIONALS Who sukes the decision to terminate life-sustaining treatment in acute and long-term care settings and under what cireumstances? What guidelines are used In this important decision-making process? Education Development Center, Inc. (-eDC) In Newton, HA and the Hastings Center in Nev York, with funding from the Kellogg Foundation, are developing a new approach to the problem -- an educational program offered to interdisciplinary teass of health care providers at the work sites in hospitals and nursing homes. During the session, we will present the conceptual framework for the program, sumaarize the guidelines, and discuss the issues relevant to developing interdisciplinary prograsu for practicing professionals. Marc D. Hiller, DrPH Uhiversit of New Ham shire• Richard H. Fortinsk an at er ne A. 7~c u re, Umvers t oi ooaths~ a ne ETHICAL ISSUES CCNF.. H N Dl c N(i U NG AUTONOMY FOR ELDERLY In long-tetm care (LTC), ethical dileumas and value conflicts are e: ally salient in the hospital discharge planning process for frail oldei persons. Participants in this decision-making process include the eldE patient, family members, physicians, LTC service providers in the cortaa and hospital discharge planners. This presentation discusses a practicz analytical framework developed to promote a clearer understanding of t effect of the discharge planning process on the autonomy of older pati While discharge planners ideally seek to maximize autonomy, a variety factors often limits the degree of autonomy realized by older patients Hence, discharge planners responsible for post-hospital placement must more aware of all factors which risk compromising patient autonomy in decisionmaking process. In an effort to assure this, a proposed model based on a series of v highlighting actual situatiohs often confronted by discharge planners be discussed. Strategies for testing this framework in a systematic will be offered as well. In addition, the need to include values clari tion exercises in the training of discharge planners as decisionmakers Idiscussed. More emnowered discharge planners should result in incress 1046 0. Hu hes R Chana• G. Blandford P Edelean. R. Slnser and P. ahuette Nultinurpose Arthritis Center. Northwestern University SCULOSHELETAL DISEASE IN THE ELDERLY: PREVALENCE AND ASSOCIATED UNCTIONAL IMPAIRMENT. Prevalence estieates of ausculoskeletal disease !n the elderly range free 20% to 47.5%. Three reporting methods (self-reports. chart abstracts, and physical examinations) have been used by NCHS variebly with different elderly sub-groups and their-relative validity is unkncxn. We have addressed this limitation by using all three report .ethods and comparing their agree.ent across institutionallzed. hoee- bound and ambulatory respondents. Analyses of 221 institutionalized and 290 ambulatory respondents revealed different results by group. Prevalence of disease In both groups on the physical exam was extreaely high at 99%. Sensitivity analyses using the physical exam as the criterion found that chart abstracts were more sensitive than self- reports (probability .93 va. .78) 1n the institutional saaple, but less sensitive than self-reports (probability .6g vs. .a0) In the ambulatory sample. These results indicate that chart abstracts are a sensitive and cost-effective aethod of estimating susculoskeletal disease In an older population (x age 85). whereas self-reports are the sethod of choice in a younger population (x ege 71). Similar data on 4oaebound elderly and functional status data will also be presented. .NONTAGUE, M.; WALRATH, J.; and YOUNG, W.s Pittsburgh Research Institute (xtlKxtBIDITr AND DISEASE CLUSTERING Elderly populations have considerable coeorbidity, yet research on this is scarce. The comorbid population from all adult, inpatient, nondelivery admissions to 80+ western Pennsylvania hospitals for the years 1983-85 (N-1,729,660) is described by Patient Management Categories, which utilize abstract ICD-9-CH diagnosis and procedure codes. Cooorbidity accounts for 39% of the eases. Below are the age/sex-specific coaorbidity rates per 100 admissions. 18-49 Years 50-59 Years 60-69 Years 70-79 Years 280 Years Hales 20.62 35.26 45.49 5-.4 - 62.01 Females 20.91 34.35 43.54 52.81 59.76 I Of the comorbid population, CARDIAC has the highest frequency at 41.0% and is clustered with COPD at a rate of 12.5%, with BONE/JOINT at 11.6%, with GI at 11.3%, and with VASCULAA at 9.1X. Within the CARDIAC COPD cluster, the specific entity of chronic bronchitis-asthma has the highest frequency at 10.9%. Disease clustering is described by both broadly defined disease categories and specific disease entities. @rson, IarJ.l W. snd McCOM, G., tbrthnaetam Qil.o Dhivenitiee Cvllege of Medirine MGM Dffi\DtF1ir AND PHSIGV. DSD18II11Y IN 11€ BMW Phys<ca1 f,,.r.+-aity is a ss)or ose eE s+hfairy and morylity in the a®ed. Cmse serdional utuiiea pmdGad m praviasr 8eenations of elderly people reported the Psevalenoe of veztigo (notly instability) inetne.ed with s8s in all lut tte oldest age gtnup. This n. 3( onsh;' =y not exdst in the aeceot mintt of elderly. iia describe the Revalence of repotted balanee problesn asd their aesodaii.at with saroq lspaitsenc in a tepceaentati.e saple of 1139 oosmity d,elLing elderly penpls intetvieeed in [hdr homes. Qusstims inchaied self tepocb of abfiity to leep balanm fAdle'alldna and self tatsd vlsim (with mttettive leres) a;d lsaring probls. Pnevalence rates of ttese prob]esr vete 24Z, 29%. =d 32S re.pectively. In each case pra.alence inrteasd with sge, indAding the oldest gtoup, t2nee 85 7ieas aad ove. Dtcrall, petws tn report lmrhg ptvbl.as were 2.04 tiss .ots likely to repert balm ptoblmr. Tais effect Wn indepadme of age, adds raties for five year a®s grnaps raged froe 2.08 to 2.48. Sidlaaly. people with viaicn impa(i>tmt sere 2.22 times sose lihe.ly to n-Fatt baLsnoe ptobles. HoURier, yasger elderly people with self teporta! Sapaital vision rete sote likely to neport balatne probls. 'Ds: adds ntios vge 3.93 ani 4.75 for tfie 65-69 and 70-74 yea old aro4s " those for the oLjer a®e gtaups us=e nce sig..ifi_iy diffetesu: fna 1. Khist H. Aung•, MD,MPH and Ellen 1. Sch.idt, M$, OTI - MARYLAND DdPAIT. IL%rr OF HHAiTh AND MIDITAL HYGIENE, PREVENTIVE M6DICINg ADNIMISIYATI011 7f:.IS.IIf-IUE CCleallllTY HEALT6 IIQAIYEU gLDqRI.Y Preseatatibe of a iesesiptive study of 593 questionnaires cosqletDd asd•colleeted over a one-year period..(1985-D6) by nursas-aad,sccial workers from the health ispalred eldarly reslding in the community throughout lfaryland«--SLo..ejor areas were covered by the quflEihsLr nairs.; first, the indiriduat's diagnesis, .edications and functional status; and second, the details surreundisg the ineident and'the resulting iajury;•i£ .ay. This data is.being used to develop praqen-_ tios progrm for this health isipairei-elderly populatien.rreli•inary data analysis -indicaew that over 94% af the iseidents were falls.The activity at the time ef the fall .as wlking 1n 53% of the cases. Dewaver,.gOi of the peeiple dlo fall'aksls requited assistance In a.bu- lation. The rjdrity e2 falls (66Z)oceurred inside the har.Pifteen percest.of the fal3a resulted in,fractu;es, of uhieh, 38% Wre hipp fractures. Aospitalisation occurred nith 13% of,tke people who.fell., It is fe'faastibe '~e sote t1iYt the enrironrntal hasards usually associated vith•falis ia the elderly have not shorn te be signi)nicanteauses of falls In this study popmtation. 30 ABSTRACTS
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DG Rern MD 4OH and NJ Fox MOH, Occupational Health Program, Roger Williams General Hospital, Brown University. LEAD POISONIN6 IN PRECIOUS METALS REFINERY ASSAYERS Lead poisoning in a precious metals assayer prompted a workplace in- vestigation. Heavy metal contamination throughout the refinery was documented secondary to the incineration, grinding and melting of scrap alloys. Air concentrations of Lead, berrylium, nickel, and cadmium - s••iting from these processes were 1-2 times OSHA Peraissible Exposurt Limits (PEL). Air concentrations of silver were 200 times the PEL. The 15 incineration, grinding and melting workers had minimally elevated blood lead levels (28 t 9 ugJdi). In contrast, the refinery's three laboratory assayers had much higher lead levels (48-82 ug/dl). The assayers were found to be using a flux mixture containing finely powdered lead monoxide (litharge). A survey of Rhode Island and Hassachusetts precious metals refineries revealed that although this assaying process has been in general use for decades, there appears to be little appreciation of the associated lead hazard. Strategies were devised to notify assayers in this non-unionized industry of their high risk status and to avoid economically advantaging those companies choosing to ignore the problem. Janie Gordon, Sc.M and Cecile Rose ~M.._D_.t. MPH (IUE Health and Safet) ~taen ca1~.c11~ ol~i ginis. Y(y"MIATIVE CACMIUM SCHEH4- ING P1i0(i7M DeuIQNE9 BY LMCN APD iNRVEH$ITY. in 1981, Cv40A cited a refrigerator coil manufacturing company ia Virginia for over-exposure df 'tlio ubtkforce to cadmium fumes. Subse- quently, a ventilation system was installed to casply with the OSHA cadmium standard, in 1983, a sister plant in Canada demanded ispcov,- ed ventilation and a medical surveillance program for cadmiuo-induced health effects. when the union in Virginia became aware of the ef- forts of the Canadian union, it requested the help of a university Occupational Madicine Clinic in screening 4 representative workers. Pesults showed 3 of the 4 with elevated cadmium body burdens, 2 with significant proteinuria and 1 with lung disease. The union, c and iniversity then arranqed'a'oooperative screening prograa'for'al exposed workers. Despite later withdrawal of support by the , 104 workers were screened. 30% were found to have elevated cac~ body burdens. 12% had caelaiusr-related end-organ damage. Subsequent efforts to obtain workers compensation and to arbitrate for employer support of a medical program ensued. This case illustrates: 1) The importance of inter-union cqen micatien across international,borders; 2. The iaportance of worker notification and medical surveillance; 3. The need for cooperation between clinics and local/international unions; 4. The ce.plexity of responding adequately to widespread rhrnnic oecuoational disease. , • • 1 Handke, J.L., Lce, S., Smaliwood, A.W. and A. DeBord U.S. Znviru.,.ae:.ta1 Protection Agency ( FAILUAEOF OSHA-REQUIRED PERSONAL PROTECTIVE EQUIPNEHT TO PREVENT EXPOSURE TO A CARCINOGEN To evaluate exposure to dichlorobenzidine (DCB), an OSHA-regulated carcinogen, urine samples were collected from 22 workers with potential exposure. Urine DCB levels, quantitated by electron capture detector gas-liquid chromatography, ranged from nondetectable (limit of detec- tion-l0 ppb) to 296 ppb, with 15 workers (68%) showing detectable levels. Samples from 6 unexposed workers were all nondetectable. The highest mean value (136 ppb) was seen in 4 centrifuge operators, the job category where workers wore all 05HA-required personal protective equipment (air-supplied respirators, rubber suits, boots and gloves). A follow-up environmental survey showed the presence of DCB inside the rubber suit. Breathing zone samples for DCB inaidd air-supplied respirators showed values of 1.6, 2.9 and 3.8 ug/![- (HPLC). Wipe samples for DCB in the inside surfaces of personal protective eq2ip- ment indicated contamination levels of 1.2, 1.7 and 8.5 ug/lo0ca (HPLC). Although legally required, personal protective equipment did not prevent exposure to the carcinogen dichlorobenzidine (DCB). s M.S.E.H. (Virginia Department of Labor and Industry) Annette Ph~illip, RE-5-cile Bose M.D., M.P.H. (Medical College of Virginia) P80.9CR21g €14'C~(m.I-~BOUTIt~ RE£RIC€RA1Uft ADD AIR OCeaITICNING l41II7PEZS4NCS. 'ihirty-saven nas:icipel.maintenance tachnicians and helpers developed upper respiratory and eye irritation during confined space welding on ~refrigeratiun and air conditioning units. The work prooess involved draining the refrigerant tubes and coils of fluorocarbon liquid, then soldering, brazing and welding leaks. However, ssiall aanints of liq- uid remained in the refrigerant tubes. Concern arose that the liquids would dacaspose when exposed to the heat generated frea the repair process, producing phosgene. Ptasgene exposure is of particular con- cern because of its severe toxicity, olfactory habituation and the possible delay of sysgtc.s for up to 72 hours after exposure. nn in- dustrial hygiene analysis of the workplace utilized detector tubes to measure the breathing zone concentrations of phosgene.during the re- pair process. Airbornecascentrations were detected at a level of 0.2 ppf. A Miran 1-A portable infrared spectrophot.e.eter was also used to measure phoagene. Finally, a newly-developed laboratory method for srasuring pbosgene was also utilized. This study suggests that pins- gene exposure is a significant problem during refrigeration and air conditioning maintenance. Both adequate respiratory protection and improved ventilation are recosselnded as part of an abatement stratecp.. Cathertne P, Koshland Ph.D, and Barbar L. Materha M S, CIH University of aSf ornia, Berke sv ,CURRENT ISSUl!S IN INDUSTRIAL HY6IEME-SAMPLING OF AERa50LS Industrial hygiene sampling of aerosols (dusts or mists) has sxny.inherent probiens tMat are•not encountered with yas4s-oc 13apori. IIrawing particulates into a sampling devite in such a.ray a€ to 'provide a representative measure of the amount breathed by a 6orxer is,constrained by the physics of particla behavior in a flawing[ 'airstreaU. Freudenbers N. (Hunter College);'Tatua, M.L. a s iver PuB-Li8 Schools); Hassan, &. (BEBASHI). THE POLITICS OF AIDS EDUCATION: HOW TO FUNCTION EFFECTIVELY IN A POLITICAL CLIMATE. - While public health experts agree that education is the most effective tool for the control and prevention of AIDS, AIDS educators have faced serious obstacles in getting the prevention message to all sectors of the population. Opposition to open discussion of drug use and sexual behavior, discrimination against homosexuals and drug users, the per- ception that AIDS in only a gay white disease, and conflict about the costs and benefits of testing for the HIV antibody are among the pro- blems AIDS educators encounter in their daily work. This session will explore how political and social factors influence the practice of AIDS educators and how educators have responded to these challenges. By presenting the findipgs of a national survey of AIDS educators and by examining in depth the development of AIDS education programs in one school district and in a black urban com- munity, the panel will enlist session participants in defining guide- lines for how AIDS educators can function effectively in a political climate. i.• Barbara A. Spradley, School of Public Health, University of Minnesota Gtridelines for Quality Practice in Public Health Nursing In an era of cost contailsunt and other external pressures, how can public health nursing maintain quality services to clients? What are the critical issues confronting public health nursing that influence quality practice? Miat standards of practice should guide public health nursingts decisions about quality? This paper addresses the above questions by first examining such issues as defining public health nssing, the impact of changing population needs on public health nursing practice, health care financial ilmlications, and evaluation and research needs. Second, the paper describes public health nursing standards for practice. It concludes by offering a set of guidelines for quality practice in public health nursing. The guidelines include emphasis on stronger collaboration with other public health disciplines, expanded knowledge and skills in marketing strategies and use of the political process, strengthened research efforts, and strong leadership positions in the cortrmmity. . Hutchison, Ruth Raagan, R.h., C., M.P.H., Setan Hall Universit , h ra~ n e, YTb7tTM and rax n S. I. Zo1ie e or auT10 n y Hea tn Care or aortn ersey. nc., ranoe, N NEW HOME HEALTH rIUR5iN0 PRACTICE STANOARDt: A MODE1 FOR INTRODUCTION', I;dPtEdEYTATIOH AHD EVALUATIOH The ,VIA Council of Caeawnity Health Nurses recently published Standards of Home Health Nursin Prattice which were written by a six person tas orce representative a ve r.ational hone health and .nursing urganications. The Standards include organizatioo of home health services, theory, data co iectien, diagnosis, planning, inter- vention, evaluation, continuity of care, discharge planning, case sunagement, coordination of cor.munity resources, interdisciplinary collaboration, professional develop.r.ent, research and ethics. A cesmunity health nurse educator and a director of patient services discuss the process they developed to introduce, Implement and evaluate the home health standards in a large urban home health agency. Discussion includes methodology for securing clearances, obtaining cooperation, establishing protocols, budgetary considera- tions, time reallocations, inservice education, and conmitment to professional nursing objectives. Supported by the agency's adminis- tration, the process evolved slowly and with eag.r p-tir.ipatinn This papar discusses situations where current wethods-are likely to yield inaccurate assessments of exposures and describes the factors which contribute to the discrepancies. The error involved in sasiplini'°ah aerosoY•with a significant propoPtioe of lafge particles typically leads to an underestimate of the true exposure. A Mripr is,provided of aerosol research aimed at developing sp?e -1 ippropriate sampling techniques, specifically new designs bY'ftltir casutta "fdr personal sampling of inspirable (formerly termed "total") particulates. -- 40 ABSTRACTS
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, Kara as Margaret R., David B. Thomas. Fred Hutchinson Cancer esearc ~enter, att e, CANCER IN ASIAN MIGRANTS TO THE U.S. Compared with U.S. whites, incidence rates in Asfan countries are lower for breast, prostate and colon cancer, but higher for esophageal, liver, stDmach and nasopharyngeal cancer. Differer~Fes in the occurrence of these diseases in Asia, the United Statsay..and among Asian migrants to the-U,S. has presente3'the opportunity to exapline the relative influences of genetic and environmental fitators in the etiologies of these neoplasss. Using published statistics for Asian (Chinese, Japanese, Filipina) and three other selected groups (Puerto Rican, Mexican, Polish) for caRparison, cancer rates relative to U.S. wf_iites were tabulated for residents in each country of origin, sigrants from these countries to the U.S., and thgir offsPring. This information provides clues to the, etiologyof- these neoplasss and is of value in identifying current and future npqdg o'f Asian populations in the U.S. for prevention and treatment of specific cancers. Stephen H. Schvarti"`and David B. T'homaa Pred Hutchinson Cancer Aesearch Center, Seattle, Washincrton. PRO.T&C•PIOtIS OF CANCER IaCIDENCE IN SOOTHPAST ASIAN REFUGEFS IN THE UNITED STATES Over 700,000 Southeast Asian refugees are estimated to be living in the United States at this time. The authors studied the extent to which cancer is likely to be a sajor health eoncern in this population. Based on rates froe other Asian populations, it is estimated that only ahout 700 cases of cancer are currently diagnosed in this cohort each {ear, with the majority being tusors of the lung, stoaach, nasopharynx, land liver. With the exception of lung cancer, the incidence of these major neoplasss is euch higher than found among U.S. vhites. As census data indicate that over 80% of the refugee population is,under 45 'years of age, the number of cases of cancer can ix expected to increase over the next several decades. The likely patterns of cancer incidence in tht.future among Southeast Asian refugees, projected from studies £ mortality among other Asian nigrants to the U.S., are discussed; ith att~ntim to possibilities for prevention of those cancers vhich ow and in the future any occur with relatively high freq~ncy.in this ation. Haitun¢ Kin¢, Natiorsi Cancer Institute and Georgetown University Prances.B. Loc)ce, National Cancer Institute MORTALITY TRANSITIOM AMONG CHINESE h{[CIRANq•S Previous studies of disease transition patterns among Chinese migrants In the U.S. and other areas have been hampered by the lack of comparable date- from the-homeland, with the exception of cancer, the findings of which came from a 1875 national mortality survey in the P1tL;. -Besed otr the- yet to be pubIfsfied' d'ata on non-cancer deaths from that survey, we are able to examine differences In these diseases between mainland Chinese and their counterparts in Hong Kong, Singapore and the United Statts, with particular emphasis on intervention possibilities. 11-01 , aobya Stone, Dr.P.H., and Peter Keaper, Ph.D., Rationai Center for Health Services Research and Health Care Technology Assesament, Rockville, Maryland 20857 CA8IH0 FOR A DISABLED ELDERLY RELATIVL: WHO REARS THE BURDEN? While empirical and anecdotal evidence indicates that families provide the bulk of long-term care to frail elders, little is knovn about the magnitude of this burden in the United States and the factors which influence the decision to provide care within a faail.y. Using data fros the 1984 National Long-Tera Care Survey, this paper presents aa- tional estimates of spouses, ehildren and children-in-lav who have a disabled family saber and calculates rates of caregiving by the type of care provided (i.e., IADL pay, ALDL and ADL) and the characteristics of the potential caregiver network. This paper also presents findings froe a awltivariate analysis which assessed the relative importance of a variety of factors in predicting the decision to provide care to an elderly family member including kin relationship and network character- istics, living arrangements, eaploysent and competing familial obliga- tions as vell as the use of formal servicu by the impaired elder. This paper discusses the laplications of these findings for the design of long-ters ure policies and the developeent of employment and retire sent benefits. _ 52 ABSTRACTS Howard R Kelsan Ph.D. and Cynthia Thomas, Ph.D., Department of Epi- desidloav and Socia' Medicine Hontefiore Medical Canter and Albert Einstein Collese of M dicina Bronx H Y. SOCIAL SUPPORT AHD ZOCIAL POLICY The provision of su;portive health and social services needed by dapen dent elderly persons is related not only to available resources but to prevailing societal values and social policies concerning the legiti- , mate roles and responsibilities of government and the family. Constraint in the provision of formal support has been justified on the basis of projected high costs and by rhetoric - but not data - suggesting it would replace informal family care. In this presentation, we describe the levels and the relationship be- tween formal and informal services and the physical, functional and I social charaeteristics of a representative sample (N-1855) of elderly ~ persons, whose health and vell being is being studied longitudinally. I The findings suggest that these who receive sore informal support do not necessarily obtain less formal support. Therefore, informal sup- port is not likely to be withdrawn if formal support services become more available. Expansion of formal support services by government may have a budgetary impact, but is not likely to undermine the role and importance of informal family support. Shelah Leader Ph.D., American Association of Retired Persons MEETING THE HOME HEALTH CARE NEEDS OF THE AMERICAN ELDE POLICY DILEMMAS ANt) MUDDLING THROUGH Several major new trends in the American health care delivery systen have:combined to creata serious problems for the aged in obtaining needed care. Uncontrolled increases in the cost of hospital care led the U.S. Congress to switch Medicare from a retrospective charge ba payment system to prospective payment on the basis of diagnosis. This new,payment system sharply accelerated an existing trend towar earlier hospital discharge for virtually every medical condition. The financial incentive to shorten ho§pital stays coincided with expansion in home medical technology which theoretically permits the delivery of highly skilled medical treatment outside of institutions. Since Medical covers, skilled nursing in the home, the aged should have accoss to high quality care in the most cost-effective and least threatening environment. This shift in the site of service delivery has posed gra questions about: hospital discharge planning to ensure continuity of care; defining eligibility for home care servicesi defining and monitor the quality of care provided; the cost of high quality services; and t growing burden of care imposed on the patients' family. Rsehel F~oaZ CUNY affiaLtnda A 8leoenthaler HCHSR FINANCING LONG-TERM HELP FOR THE DISABLED ELDERLY The soccese of extending life has increased the prevalence of chronic svedical conditions and long-term functional dis- ability among the elderly. Disabled elderly depend, to a large extent, on the+ftnpaid help of wives and daughters. However, as a greving number of vonen have competing re- Isponsibilities, fewer will be able to provide unpaid help continuously. This paper exawines the financing of paid non-professional services for the frail elderly since the prognosis is that they will have to depend ihcreasingly on paid help. Continuous dependence on others for a long pe- ziod of time is likely to absorb a substantial share of the economic resources of the elderly and may result !n impov- erishsient. The financial risks of long-term functional disability can be predicted in large populations and are thus insurable. Our paper examines to what extent the major proposed long-term care fil'rograam and plans provide protec- tion from financial risk and shield the elderly from 1.mpov- arishawtnt. ve also compare the proposed solutions for the U.S. with the actual policies in foreign countries that have, to a considerable degree, attained such protection. 11~`d/2 eillia. L. e.ery, RpH and Kristine Odle. RSe, Oroup Healtb Cooperative of Puget Snund HEALTR PROROTIOa AND aISK REDOCTION SERVICES FOR THE ELDERLY HRO ENROLLEE AT GR07P HEALTH COOPERATIYE OF PUGET SOUND The groving nuaber pf eiderly and thdr,freQu.nt, cestly uae of aedical serviou has aade eanagiag the cart of elderly enrallees a high sriority In this large, staff aode! HRO. Throe natianal funding sources are assisting in the developeent of a ceqrehensive holth prosotien and risk reduction pregraa for enrollee age 65 and erer. The pregraa .i11 be inttgratat into the eoisting pritary care delivery systeo. The kealtM pneatioe and risk r.duetian s.rvic.s tephasiz. incrtased Physical sativity, reductien of excessivt preseription drug use, reductoa of accidents in the hoe., detectisn of hearing deficits and inereastd uso ef hearing•aids, detection of eatreated vision deficits, and incrund use ef coaauaity reaources far theu uith ancorrectable risioa ispairpests, reduetioa ef eneess aloohol use, oliaination of ssoking habits, enhancaaent of s.atbelt use, isproveeeat in the rate of flu ieeveitation, detectien ef hyperten.ipn and iepravt.tnt ln coepliance rates of hyptitusi.es, and iscreased early dotectiea of brtst eaneer. Th. avaluation vill detereine the ispact of the health preeatiea Rragraa en risk reductien, utilization, and costs.
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Rafaela Robles Ruth Mart~nez, Mildred Vera and Margarita Alegria, Schopl of Public Health, UniversitV of Puerto RLco, .,.... ,..,,... .,..... 'iTi€ INIpACT OF QIADCE IN RFX3ETILY DIVLiBCm 4X:tRFN Puerto Rico has one of the highest divorce rates in the world. Puerto Rican Hispanic and Catholic legacy define the position of divorced wanen as deviant. In this sociocultural envirctment, the divorced wanen have to cope with the strains of this stressful live event. 'ihe present paper aims to investigate the effect of social resources oa paychological well-being of divorced curen. Data were collected from personal iipteivie.rs of a sataple of 300 wanen drawn from the wurtmrnis thtntghout the Island using a stratified random sampling with proportional allocation. Findings demaistrate that social resources available are positively related to the womenn's psydiological well-being. As expected, the various stresses studied are negatively related to the canen's psychologi- ca1 well-being. Daniel R. Jimenez Ph.D. Kaiser Permanente Medical Care Program "ary Ann Jimenez Ph.D. San Diego State University TREATING CHILDHOOD MENTAL DISORDERS: A PROGRAM FOR HIGH RISK INFANTS Increased public attention to child abuse and accelerated intervention efforts by local public agencies have swept increasing numbers of chil- dren into Juvbniie facilities through the court system. Although federal and state laws now require peraatKncy planning for each child, limited r sources are available to provide pucili,atric and medical services to the children after they have been removed from the home. These children have Generally been removed from the home due to physical abuse, neglect, or sexual molestation. Many of them are also suffering from other health oroblems such as alcohol or drug dependency due to the mother's addictioi 4IDS related diseases, or developmental disabilities.This paper will re- port on a model program developed in Los Angeles,County which provides nsychiatric treatment, diagnostic testing and assessment, medical caee, and nurturing by adult volunteers. Children remain for about 3 months in the program. The program only accepts children from birth to 4 years of age. Placement with foster parents or reunification with the family i, part of the plan for each child. Preliminary findings after 6 months of operation will be presented. The Bienvenidos Childrens Center is locater in Hest Covina, California. Ahea_rn Mar Beth The Johns Hopkins University School of Hygiene and Pub ~c He~ th; hntbnn Bruno J. National Institute of fieota7 Health; tlerthamer-4arsson isa, Eaton William N. The Johns Hopkins Un_y chooi of Hygiene and PuS it Health; Hirsky, Allan F. National Institutp of Itental tiealth ATTENTIONAL DYSFUNCTION IN A POPULATION BASED SAMPLE OF SECOND GRADERS nttentional dysfunction has been shown to be associated with learning disabilities, general school performance and later behavioral and emotional problems. However, there are little data on the incidence of neuropsychologically evaluated attentional deficits in population based samples and their relationship to attention, learning and behavibr as evaluated by the classroom teacher. Such data have been gathered in a study of second graders from the Johns Hopkins University/Baltimore City Public Schools Prevention Center Program. The development of an attentional assessment battery tapping the ability to sustain, focus, encode and shift attention and its modification for field use within the public schools will be dis- cussed. Preliminary results examining these different components of attentienal function and teacher ratings will be presented. J. Rolf, PhD L trc:kett PhD C. Alexander, ScD. L_ wulff, ScD, A. Chandra and J. Baldwin-Johns_Mopkins-Sch. of Hygiene and Pub. Health HEALTH CQ-1SEQUEliCE9 OF PUBERTAL DEVEtAPMF3iT FOR FAMILIES OF MILDLY RETAPDED ADOLESCEt1TS Retarded children are reported to be at increased risk for adjustment problems, and their families are at increased risk for psychological stress and decreased sense of well-being. However, very little has been reported about physical and mental health consequences of pubertal devel- opment in families with a mildly retarded, main-streamcd adolescent. The normal biological and social changes of puberty could produce additional stress for the family when it is already burdened with meeting the sgec- ial needs of an atypical child. To access the impact of these develop- mental factors on health and adjustnent of the family, a survey study of families in the greater Baltimore area has been designed. The initial findings of physical health, adjustment, stress on and coping by the parents and the adolscents are reported for sasple of families with mildly retarded, learning disabled or normal adolescents. The relation- ships of these variables to pubertal status and concerns about future problems and service needs are discussed. Michael Blank, MA, University of Virainia Sehool of Nursina Donna Frede inal RN Ph0 Unlversity of Virainia 5chool of Nursin6 ILLEGAL DRUGS: ENDEMIC SUBSTANCE USE IN ADOLESCENTS The access pattern and prevalence of illegal drug use among adolescents are explored in a survey of 2,092 high school students. Findings indicate low levels of reported use of heroin, Inhalants, downers, amphetamines, and cocaine; higher usage levels with marijuana and alcohol within the populatlon=and significant differences in usage across gender and age lines. An ANOVA was carried out to test for age/sex differencesin reported usage of these drugs. Results showed males and older respondents indicating the highest usage of alcohol, marijuana, LSD and cocaine. Females and older respondents indicated significantly higher usage of amphetamines. Older females used barbiturates/tranquilizers more while males used significantly more inhalants. Older respondents have greater access to all drugs. These findings suggest that the use of Illegal drugs by adolescents can be viewed as a complex, age-linked, psychosoclal phenomenon that crosses gender lines. Age and gender differences as well as differences between those ever using illegal drugs and those never using them are discussed. The use of such self-reported information to plan appropriate intervention, education, and prevention measures Is critical; for example, support services for those using or considering using drugs, and use of previous users and peer educatorsforintervention. Barbara Hanlev, MSN, David Hammer, PhD, James Mulick, PhD, Nlsonaer Centc., UAF, The Ohio State University. MEETING 'IIfE MENTAL HEALTH NEEDS OF EDMR CHIZDREN/ADOLESCENTS AND THEIR FAMILIES. The purpose of this paper is to describe the copcept, design and first year results of a three-year project funded by NIMH to develop, implement, evaluate and,disseminate a model curriculum for pre-service professional training in community-based assessment and treatment of children and youth who have behavioral or emotional disturbance in association with mental retardation (EDMR). The project has three major goals; a) to develop a curriculum representing appropriate state-ofi-tke-art evaluation and treatment strategies, b) to foster an enduring'basis for interdisciplinary collaboration among professionals who have the most service contact with this population in the community,,including those who work in mental health, pediatric and educational settings, c) to demonstrate how state-of-the-art evaluation and treatment services can occur in generic mental health/health service agencies. Jacqueline 4iallen, Ph.D. and Nancy B. Lsarow, M.A. THE EFFECTS OF PPS ON TH€ USE OF COMMUNITY HOSPITALS BY PATIENTS WITH MENTAL DISS7nDF]!S The effect of Medicare's Prospective Payaent Syste. (FPS) on the use of short-tarm gaWal hospitals with and without psychiatric units by elderly patfifStts with snttl disorders is examined using pre- and past-PPS data on a national sa.ple of 400 short-term general hospitals and on all Medicare and non-Medieare patients discharged from those hospitals. 'Patisnts in the two ti.e periods are cospared with respect to DBO rsix, severity of illness, length of stay, services used, and discharge destination, taking into account the presence or absence of an inpatient payehiatric unit. The ability to compare Medicare patients to non-Medicare patients as well as patients in hospitals with psychiatric units (psychiatric units in ahort-term general hospitals are, for the sast part, excluded from PPS) to those in hospitals without units is an important strength in the design of this study. Jamea H. Swan, Li.nda BezqtS~old, a,-rr,i i L. FAtms, ins_t_itnte for H@al.th and lk~iix3, Vers tY of Cal , San FranO t12*17lRY IiF2iiFS, Iv"CAIIIH IH RIi$ 1@M OF IIiG I106P1TAL RIMIMURSEMERI! 2he iag:ameritati.on of H.dicars's Diagnosis Relatsd t;tauQ (CAG) pqy- asrst to Yxsapiials has resu_ltad in conidaraisle oonoarn about post_ hospital cars. A,sulteampl.a of 101 oomatity ssntal health centers in nine astxopolitan az.as *+atior++ida wets irr..lrrisd in a sttx;y of lI1G ixgects on six differstst t:ypms of pest-lxspital eoammit.y service Iaovid.ts. Over 70 peresett x.nozt'.ad being affected by CfiCS in arr aatner or another. Rapoxts of fIiG effac.#s that changed eaitar c1iQltRlel YR7 Yti7.al:ed to diCr1NY in the vo7.ua1e of scm center services but incr.ess in t2icw ..zwicas used by the agad. Putia:e analysis will link afC reports of DP6 affactsi to overall oc®atit.y c+a~ and to t3se mxperienea of other o®mmity plwiders. Hudt f2ndings trill be reported in the pegar to be prasented. TIMN 322494 J I rm a ABSTRACTS 37
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1118 Leonard H- Glantz, J.D., Boston University School of Public Health ~S ON THE'POWER OF THE STATE TO QUARANTINE INDIVIDUA S C ~ () ARE HIV POSITIVE q j{{ The increasing Number of individuals who are infected with HIV has to calls for increased coercive governmental action such as mandatory screening of certain groups. While there have been no significant prop for large scale quarantine or isolation of positive individuals, there been suggestions that some positive individuals, such as prostitutes wh continue to engage in at-risk behavior after being informed of their HI positive status, should be separated from the general population. This paper presents both the substantive and procedural constitutional safe- guards that limit the power of the states to use their quarantine autho Issues presented include, the type of hearing one is entitled to, the burden of proof, the role of the least restrictive alternative doctrine and limits on the length of time one can be isolated. Because quaranti is such a drastic measure, it presents a paradigm for the clash between the civil liberties of individuals and the power of the state'to protec public health. endy K- Mariner Narvard School of Public Health OHPULSORY AIDS SCREENING: WHY, WHEN, AND WHO? Yew proposals to scrren groups as diverse as prostitutes and inrsigrants for HIV infection appcar almost monthly. Yet the leaalitv of compulsory screening remains a matter of controversy. The author proooses criteria for analyzing the appropriateness of compulsory screenino in different populations based on (i) the purpose of screening (e.e., to identify persons in need of medical care or information; to collect data for epidemiologic studies; to report results to public or private acencies; to trace contacts; to prevent the patient from transmitting infection); (2) the accuracy of information provided by the screening test; (3) the nature and effectiveness of the means proposed to achieve the intended purpose (e.g., reporting, isolation, eligibility for employment, insuran (4) the effect of the use of the test on the behavior of the persons screened and others; and (5) the characteristics of the oopulation to be screened. George J. Annas, JD, MPH, Utley Professor of Health Lav Boston U School of Public Health AIDS AND PBE:.i:A;:CY: DEVELOPING A POLICY FOa SCREENING AND COUNSELING FOR HIV ANTIBODIES Routine screening for almost all populations is controversial. Perhaps the nost difficult problems arise, however, in regard to screening of pregnant women, and determining what types of counseling should be offered both before and after HIV antibody screening. This paper vEll review the major policy options and exaaine the relevant lessons learned from past screening attempts (e.g. for sickle eall aneaia) on pregnant vomen; and from current genetic screening programs (especially alpha-fetoprotein screening for neural tube defects) with a view toward suggesting the basic principles upon which any RIV screening program for,pregnant women muat be founded. Robert V. Buccini, H.D.-Dept, of Medicine, Univ. of North Carolins~ W(HHA WIDESPREAD HELMET USE DEC&EASE BICYCLIST MORTALITY? Over one ai]tton bicycle safety helmets have beaa w1d in thia country. The ability of this trend to have a noticeable impact on the 1000 U.S. bicycling fatalitisa ohach oeeur-inuwll7 1a-patenabilly iiaited by the prevalence and severity.of hi,cycling nishapa. The current study esa.inea this• peesil.ilityary en-aaalysa--af-tha. iqjury patterns,of all faeally-injured LScycliata.in Dade Covatys FL for the period 1980-1986, performed by review of autopsy and`accident reperta for each case. Data Sneluda de.ographie infaseties, injusies- noted-at autopay, and whether the victim had besn vu.ring-a helmet. Prelif.{naxy results are aa follows: there vere 90 fatalitf.s (84Z sale, 11Z feale; aeaa age 35, aediam age 26). No victim va. weaiIAg a halaet at the tiae of the accident- osly'19i had'ciearly acn-survivable extr.4-cranial injury, whereas 59S had,hefd injury vitimnt otlcar significant injury; 22% had head injury with ~shemrrssit= probabl7-survivablit eitra-craaill injury. IT: 3s conaluded that non-survivable extra-cran.ial bicycling, injuries are relatively infrequent, and therefore that vidrpread• helmet use could decrease.bicycling-usociated mortalityt Patty Molloy M .3... Christine Blaber, B.A., Cheryl Vince, Ed.M„ Education Developsant Center. Inn. ADO[.ESCOiT INJURY DEATHS IN NEW €NGLAND Mortality data for all causes of injury for 15 to 19 year olds were exaained for the five-year period 1979-1983 in six states by the New England Network to Prevent Childhood Injuries. Three major causes of adolescent death emerge: motor vehiole occupant in,iuries, suieide, and homicide. State-apeeifie results are analyzed by gender and eoapared with national data. Motor vehicle occupant deaths account for nearly 50% of all adolescent deaths and ole rates are three tisws that of ferle rates. The rates of motor vehicle occupant death in northern, rural states are twice the rate of the southern, urban states. Suieide accounts for almost 20% of the adolescent injury deaths. Among sales, suicide rates are dramatically high: more than seven times the female rates. Suioide rates are also twice as high in the northern states as in the southern states. The rates of ho®icide in the northern states are comparatively low and no yender differences emerge. In the souther states, the rates of howieide among adolescents are twice the rates of the northern states, and the sale rates are twice the female rates. These findings support the need to target injury prevention efforts toward adolescents in order to reduce the incidence of injury deaths among this age group. I Darr Bertolucci and Mar Dufour National Institute on Alcohol Abuse and Alcoholism, James Col iver, A cohol Epidemio ogic Data System 7ACIAL DIFFERENCES IN ALCOHOL-RELATED TRAFFIC DEATHS FOR THE U.S.: NATCHING OF FATAL ACCIDENT REPORTING SYSTEM (FARS) DATA WITH MULTIPLE CAUSE DEATH (HCD) DATA FARS contains information (including data on alcohol involvement) on all fatal highway accidents; NCD contains information (including con- tributing causes listed on the death certificates) on all deaths in the U.S. A computer algorithm has been developed which matches FARS data ith MCD data. The routine yielded 87.4 percent overall matching. An especially important contribution of this procedure is the' addition of the race variable to the FARS. This makes it possible for the first timf to Investigate racial differences in alcohol-related traffic deaths for the Nation. The proportion of alcohol-related deaths among Blacks was lower than among Whites. Rates for Asip-Americans as a whole were spe- cific subgroups. For Native Americans, rates for men and women were imilar. For all other groups examined, alcohol-related motor vehicle eaths were much more frequent among men than women. Coo Gail; Hurri N.P,H., Patricia of San DTead De artmsnt of Health Sarvices Dfvision of Esasr enc Medical Servi ces SEVERITY OF INJURY AND OUTCOlE ASSOCIATED WITH MOTORCYCLE ACCIDENTS IN A REGIONAL TRAUWI SYSTEM An analysis of treuma .registries submitted by 'desrg n3Lftl' Sa'11'D1eg d County. Traul~ Nospttals was reviewed fdr th8 peribd Augl7at" 1; I989' through July. 31, 198AS Helmet use by drivers and passeWvs,i was studied to, determine differences in severity of' injUYtq:' 1'7myth' o'f hospita.lizatiqn,,,mo,rbidity and mortality among, ti"ie tivb-gpDLpY. Of the population examined, males comprised the sa,iaffty oT M(8'COM• cycle accidenL,..vjctiq+s (91.2%). Almost one-half--(46:6%r o'f "tBe: {Ya- tients were between the ages of 18-25 years. Only 34 percent•,of the total patient group `were wearing helmets at the time of injury. Thia paper will further examine helmet usage comparing length of stay severity of in3ury, operative procedures, and cost of hospttATTtRtt0t between those victiss..wearing helmets and those with h8' head prbtec+a tion device. Andreas Muller, Ph.D., Universitv of Oklahoma Health Science Center, Colleae of Public Health, Oklahoma City, Oklahoma. BUSINESS RECESSION, TRAFFIC SAFETY LAWS AND MOTOR VEHICLE FATALITIES: A TIME SERIES ANALYSIS OF THE OELAH(kfA EXPERIENCE. In 1983, the motor vehicle fatality rate for Oklahoma decreased by 232 and has further decreased since then. Oklahoma traffic safety officials believe that the unprecedented fatality decrease reflects to a large extent the combination of (1) stricter sanctions for drunken drivers, (2) the raising of the legal drinking age to age 21, and (3) the child restraint legislation; all laws were isplemented in 1983. However, a severe business recession which beset the state during the same year may also have contributed to the observed fatality decrease. To determine the relative importance of these factors, monthly fatality data foY the period 1980-85 (n-72) are analyzed by 0LS regression repre- senting seasonal trends by dusay variables. To determine the effective- ness of specific laws, the analyaes are run separately for selected age groups (i.e. 16-20). Dusey variables are used to represent the period in which the laws were effective. Monthly age specific employment data serve as indicators of economic performance of the state for age groups in the labor force. When required, the time series analyses are adjusted for autocorrelation. ABSTRACTS 59 TIMN 322516
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1157 .  William M. Greenberg, M.D.. Albert Einstein College of Medicine Confronting Nuclear Peril: Current Psychological Perspectives For the 42 years that the possibility of a Nuclear Holocaust has been available public knowledge, evidence of individual concern has anifested as brief periods of intense concern, against a backdrop of much longer periois of marked inattention, even as nuclear arms and nuclear- armed nations have steadily proliferated. This dysfunctional pattern is suggestive of our inability to effectively cope with this serious threat. Psycho- logical aspects of our response to this threat are reviewed and explored, including "psychic numbing," denial of personal responsibility, helpless and hopeless- ness.. As the designated therapeutic "agents of behavioral change,' eAbers of the mental health profession may particularly have a professional responsibility to understand and address this problem. Dev Nair, South Shore Mental Health Center, Quincy, MA and Edwin T.-MU , DePaul Univ., Chicago, IL . _ EVALUATION OF A NUCLEAR PSYCffGbDUCATIGHAL PRGGRAM Various authorities have indicated that youth are deeply concerned about the possibility of nuclear war. Scme have advocated nuclear education curricula, whereas others have condetred these approaches as being politically biased and as creating the very fears they are attempting to alleviate. This presentation focuses on the implica- tions for public education of an evaluation of the psychologicaL impact of such a program on ninth grade students. Evaluation of prgram effects revealed an increase in awareness and knowledge of nuclear issues without any impact - neither an increase nor decrease - on fears of nuclear war. Participation in the program increased feelings of empowerment with regrard to nuclear concerns. Other findings will be reported along with a discussion of the implications of the findingsfor social policy. Jaaes A. Ciarlo. Ph.D., University of Denver NUCLEAR ANXIETY AND PSYCHOPATHOLOGT IN THE GENESAL POPULATIOR Although Americans have been quite worried about the possibility of nuclear war, there have been few studies of the amount of anxiety experienced by the population. Nor are there studies that show whether nuclear anxiety is merely another sunifestation of more basic psycho- pathology in persons who suffer from such anxiety. This paper reports a study of nuclear anxiety in the adult general population of a state, as part of a survey of .edical, psychological, and substance abuse problems. A random sample of 4,745 Colorado residents was interviewed, with a response rate of 72x. The presence of psychiatric disorders, including phobia, panic, and generalized anxiety, was determined using the Diagnostic Interview Schedule. Nuclear anxiety was assessed with items covering respondents experiences and attempts to cope with any nuclear war-related distress. About 20% of the saaple had a current diagnosable disorder using DSM-III criteria, and about 25Z had experienced so.e nuclear anxiety or distress. Yet there were few consistent relationships between psycho- pathology and nuclear anziety, and very few persons reported negative effects of such anxiety. These results indicate that nuclear anxiety is not a manifestation of pre-ezistinR psrchopatholonT. Susan_~, University of Wyoming, Laramie, WY and Michael esW sel~, -Bandolph-Macon College, Ashland, VA ENEM1! IMAQES Issues around peace and health often are conceptuali zed using psychological parameters. Increasingly psychological auchanisms under- lying hostile enemy images are being studied and efforts directed toward increasing awareness about the true natienall character of enemy countries, most notably the Soviet Union. Ccemon psychological mechanisms that bolster the enemy image in our unconscious belief system are distorted perceptions, psychological defensiveness, and consensual paranoia. Developing healthier perspectives based upon the art of empathy and realistic husd.lity requires bringing beliefs to conscious awareness and challenging their veracity. Although essential in the production of peacefule international relationships, this process is no less important within the context of human service deliveray systems. This presentation will explore the basis of psychological enemy images, examine the mirror image eff2sct, and explore practical ways to examine our perceptions of enemy countries and help others do the aame. Donna J. Petersen. MHS, L.M. Wulff, RN, MSN, SrD. G.R. Alexander, MPH,.S.eD., C.E._ Miles, BS, The Johns Hovkins School of Hvaiene and .Pyblic Health. Denartment of Maternal & Child Health A NEEDS ASSESSMENT-DRIVEN APPROACH TO COMPREHENSIVE PLANNING OF CONTINUING EDUCATION FOR COMMUNITY HEALTH NURSES ~ A statewide survey of local health department Co#unity Health Nurses (CHN) working in Maternal and Child Health (MCH) programs was conducted to assess comprehensive continuing education (CE) needs. Both supervisory (15%) and staff nurse (85%) responses were elicited to identify areas of perceived competency and educational growth and to develop a long-term education planning agenda. An initial assesament of respondent'characteristics indicates that over 40% are diploma graduates in addition the majority of MCH CHN's are generalists with less than 8X identifying a specialty area. Differences between supervisory and staff perceptions of CE needs were.evident in the finding that while 50% of nurses desire a clinical CE focus, over 752 of supervisors believe the focus should be administrative. Over 2/3 expressed specific CE needs in traditional Public Health areas as well as in evolving specialized MCH technology areas. The findings of this needs assessment represent part of a comprehensive planning effort to develop and model a long-rang. CE program for CNN's in traditional Public Health settings. Cindy NacQuarrie. R.N., M.N. 4ssi~,tant Professor of Nursing Universit5' of Missouri-Hansan City PERSPECTIVES IN GERONTOLOGY: DESIGNING PROGRAMS FOR NURSES The education of health professionals in the field of geriatrics is an important aspect in affecting the care of older adults. Geriatric Education Centers were established to address the needs of faculty learners, who teach those who will ultimately work with older people. The provision of educational programs to those working with older adults offer a means to strengthen and improvs the health status of the elderly. This presentation describes the experience of the Missouri Geriatric Education Center and the implementation of programs for faculty members who are involved in curriculum development for gerontological nursing and nursing students who are enrolled In a graduate program with an emphasis in gerontology. Anderson, Elizabeth T and *cFarlane, Judith M. Texas Wosan's Daiversity, Houston, Texas HEALTH PROMOTION AND DISEASE PREVENTION FOR COHHUNITY HEALTH NURSESs DEVELOPMENT OF A CURRICULUM Health proswtion and d4lease prevention, recognized as a goal for our Nation, represents a special area of nursing knowledge and akill directed towards all persons - infants, children, pregnant women, adults and the aged - regardless of sex, race or ethnicity. This presentation will focus on the curriculum developed to teach coaunity health nurses about health promotion and disease prevention through a continuing education program funded by the Division of Nursing. In addition, preliminary evaluation date - knowledge, attitudes and behavior - from over 100 com.unity health nurses will be presented and discussed. Susan williams, University of Missouri-st. Louis and Sim Williams, Maryville Collage CONTINUING EDUCATION NEEDS OF REGISTERED NURSES IN ROME HEALTH CARE. Maintaining quality of eare for patients receiving home health eare from RN's is critical. Increasing clinical anc anagement skills of nurses is essential if quality of care is to be attained. This study explored the continuing ed- ucation needs of RN's employed in all 240 home health agencies in Missouri. The purpose was to have nurses iden- tify what specific clinical and management skills they needed. Data was collected through a mailed questionnaire. Responses froa over 30 percent of the agencies were re- ceived, supplying data on educational needs of RN's. This paper will focus on the findings of the study which have defined four major content areas for continuing education in hoae health care. Those areas are Community health concepts, physical assessment, advanced technology and anagenent. 72 ABSTRACTS TIMN 322529
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1134 L. Fenster, Ph.D., California Dept. of Health Services and H. Coye, M.D., New Jersey Department of Health BIRTHWEIGHT OF INFANTS gORft TO HISPANIC {70HEN F1IPIDYED,IN AGItICULTURE. A prospective study was carried out to examine tbe•effects of agricultural work on the birthweight of infants of Hispanic women. The study population consisted of 1040 pregnant women enrolled for prenatal care in two rural health centers in California between 1982 and 1984. Eirthweight and gestational age of infants were examined after classifying these women into three groups: 255 mothers doing agricultural work, 134 mothersYorking in non-agricultural jobs, and 651 mothers not working during pregnancy, Stepvise linear regression analyses using forward selection procedures were carted out for a number of aodels to determine whether work category or trimester worked influeneed birthveight after controlling for confounders. The incidence of low birthweight (<2500 graas), mean birthveight, and mean gestational age did not vary significantly with work status. All women had access to prenatal care, nutritional supplementation and had low rates of alcohol and tobacco consumption. This favorable distribution of factors known to influence birthweight may be protective against the stresses of agricultural work. George Friedean-Jimenez M.D. Mt. Sinai Medical Center, Hew York Occupational Diseases Mang Minority Workers Issues for Future Research-,A Clinician's Perspective There is a paucity of data on the incidence and prevalence of occupational diseases, especially among minority workers. However, there is evidence that minority workers are at higher risk for occupational diseases than are White workers. The evidence that Black and Latino workers are at elevated risk for occupational diseases will be reviewed. Areas for future research, frOm.a clinician's perspective, will be outlined. Some of the special problems which arise in caring for and designing preventive strat- egies for Black and Latfno workers will be discussed. Some of the factors which directly or indirectly place minority workers at higher risk for occupational diseases include selective patterns of employenent with overrepresentation of minority workers in bazardous jobs, lack of collective qargaining power, high rates of unemoloyment, inadequate occupational health educational programs (especially for non English-speaking workers) and poor access of minority workers to health care resources. Lela D. Morris, E.N., M.P.H., Continuing Education Coordinator, North- ern California Occupational Health Center, University of California gerkeley. OCCUPATIONAL HEALTH AND SAFETY FOR MINORITY fd0&KERS: PDIICATIOHAL MODELS FOR W08¢ERS, HEALTH PHOVIDERB, AND HEALTH PLANNEBS. According to NIOSH and other recent survey studies, minorities are generally concentrated in high risk; low paying and physically demand- ing jobs. Black vorkers face 37S more risk of occupational illneas and 20Z more risk of death on the I ob than white workers. There have not been consistent programs to reach theae "at risk" workers with informa- tion and training on hazard recognition, control and OSHA regulations. Following on a kay recommendation by NIOSH for addressing these prob- lems, the Northern California Occupational Health Center/Labor Occupa- tional Health Program has developed two prograas: I) Educational Conference - A 2 day training for cosounity health professionals serv- ing minority populations as providers or health planners. A multi- disciplinary approach to occupational disease recognition and control; IL) Coawunity Health Clinic Project - A 2 year program focusing on educational strategies for Latino and Asian workers. This paper will report and assess these pro~i ects, educational materials and their impact on the health and safety of minority workers in Northern California. 1138 ' Deeds, S. (National Amer Red Cross), Kreuter, M. (CDC), Lewis, F.M. (Univ Washington), and Rimer, B.K.,(Fox Chase Cancer Research Center). AP.DOR fHD AUTHORSHIP: PUBLISHING Itl HEALTH EDUCATI011 Four tenets guide the current session: Publication in health educa- tion is possible; publication is an easy extension of ones current activities; publication does not zo,uate with pain; and publication is not an activity for a few academicians. The process of publication is outlined, including the process of carving a piece for a particular ,iournal and the caeran pitfalls authors experience in submitting a manuscript. Available ..ealth education journals are revitwed that- address policy, czanaga ent, program, theory, and research. Knoaing the mission of a,fourr.al is key to correctly targetting your pa;er. Publication is not carried out in a void but is driven by a set of prograr priorities; oie first think, then do, and then write. The panel puts the sequence,into its proper perspective. 1139 Zapka, J. (UHASS); Dawson, L. (UNC): Moen. M. (Hinn DPH); Hauer. K. (Hinn DHS) _ _ PUBLIC HEALTH POLICY AND HEALTH EDUCATION The role of education and educators in the policy process is not only appropriate, but mandatory if rational, social and health policy outcomes are to be achieved. First in this panel, a conceptual framework for the role of health education in public policy will be described. This will include operational definitions, a model of the policy development process, as well as categories of intervention strategies which range from ihdirect influence to direct political involvement. This overview will be followed by three illustrative papers: a) a case study of the Minnesota Plan for Nonsmoking and Health, a template for state action to control smoking; b) a discussion of the education needs for Medicaid eligible consumers in5olved in prepaid services plans; and c) a discussion of industry and the environment and the public right to know. 1140 Violet H. garkauskas, The University of Michigan; Jean Goeppinger, The University of Virginia; Chris Kovner, New York University; and garbara G. Valania, Center for Health Kesearch, Kaiser-Permanence )ETER.KINI:FG AND MEASURING THE OUTCOMES OF PUBLIC HEALTH NURSING SERVICES This solicited session will be conducted as a research seminar. Panelists will discuss conceptual, neasurement, and .ethodological issues related to determining variables appropriate as outcomes of public health nursing (PHN) services and programs, and to choosing and developing tools for the measurement of those variables. Panelists will address varioas categories of variables, including health and cost easures, and their use in research as well as in agency-based prograa evaluation. Half of the session time will be allocated to open discussion between panelists and the audience. 1141 Catherine Malloy, Dr. P.H., Assoc. Prof., HUSC Ches. SC Mary Ann Christ, Fd.D., Profe#apr, MOSC Dorothy D. 3oscinskl, H.S., Hyg. Ass't Prof., HUSC A SURVEY OF THE HOMELESS: HEALTH STATUS AND NEIDS The purpose of this study was to..describe the personal c.haracteristies, health status„and populatiog seeking refuge in an urban Southeaetern shelter. Research.objectives•were:' to describe the_personal characterisNes, the health status and eources of care for this group; to identify utilization of health services; and to acquire knowledge and skills to b} ble to meet their long term health care needs. A non-pro.bability convenience sasple of•50• {+oseless adults vas interviewed Tbe sasple was drawn fros the Crfsis qinistry Shelter and reprepnts..morn.qhan 50% of the Eotal population at the shelter. Trained inSQrviege(:s used the Basic Shelter Inventory as the structured intacvfew tool. Data were analysed by descriptive and analytiq stttistics. The relationship between socio- desagraphid characteristics, health st.tus, and health care providers vas analyzed using the chi-square test, analysis of variance, and Pearson's Correlation Co-efficient. The findings have Smplications for health policy, nursing researe.h, and the use of nurs,ipg c%SnicJ as an intervention strategy. shirley ?hitney,'M:S., Haren Ke.l.ley, M.H.S., and E'.llis Arnstein, M.D., New York City DeQartaent of Health, New York, New York. DEUEZCPbffi,D' PhD Ib2LE6ffNPATICN C€ A PDHLIC HE.ALTfi NUR4IMG PPOGH1Nt ft7R HC4EEEW PAMIL7FS. 74:e Family Health Program of the New York City Dspartnr+nt of Health's HomeIA=s Health initiative serves :mze than 2500 honeless families wto are tenporarily housed in privately operated "t,elfare" hotels. Riie program's majo.r objectives are to improve the health of homelens families through pr+eventive intervention and to docuient their health needs. In tl)e hotels serced, tsw:ty public health nurses, augmonted by crams:ity service aides and tvo consiil.ting sxial uozicers, provide arientatirn, health assesce*+t, individual/grrjup health educatian, referral and follaw-up. Priority is given to pregnant uznan, nevtorns, and fam+L+°= with histoty/evidstx:e of substanze abuse, cliild abuse and neglect, and mental illness. A surveillance and m:nitoring system is directed tusrd decreasing infant :rortality 66 ABSTRACTS
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Nall N. Gottlieb and Alicia Nelson, University of Texas at Austin , A CONpiTITIOi[ APPROACg TO V01¢BITE SNO[ING CRSSATION A quasi-expaiseatal desigs ws asad to test ehs.effeet nf~eti- tlos-.r raareittss8 to a self-Llp ssoking cessatioa progTat and Crest Anerieaa SsokaOut (CA50) In 12 state human se:Hea:dijtai' sation rorksiCes. The criterion for winning was to hase.the highest prapecttoa of esployees sign up either as noa-ssoking sppporteri 6i as parlSolpaata in a self-help steking cessatisn progru. The prist ras a cold turkey buffet for all etployeas at the winning rorksitae on the day=tolloring tbe CASO. dleiu test of proportions sba*ed' sign,ificast difference between sacker supporters (p<.001). ieif~ help piogra: pa=ticipants(p<.001),.and.GASO day only quitters (p<.01). Total.partieipatios of uozksits aployees in the CABO aeB self-help-}rag¢u averaged across the six competition .orksites rar 70% vs 20Z in the aon•cospetitioa sites. Assa.ins e.25Ls.oking rat:, 2iL of.ihe'aspkers In the aospatition rorksites and Sx vf those ih'the non-cosPItition worksites signed up for the:at!l-hrip. progras and another 45X'of the eoepetition worksita e.ekars and 30% of the Don-coepetitiea seokers signed ap for the GASO only. Susan G. Zepeda, Ph.D., Orange County Health Care Agency wORKPLACE POLICIES REGARDING ALCOHOL USE Lost productivity of America's workforce has been identified as one of the sast costly social effects of alcohol misuse. Nationnwide, that cost has been estimated at $61.1 billion. This study reports on a survey of 500 large employers in Southern California, regarding implicit and explicit policies on work-related employee drinking. Its findings serve to identify strategies used by employers to contain the risks associated with worker alcohol misuse on and off the job. Findings also indicate "lost opportunities" for such risk management, which occur when management permits or encourages high risk alcohol use. Recommendations explore the utility of voluntary use nf worksite poli- cies in reducing the social costs of alcohol misuse. 1099 Harold T. Yahr National Institute on Alcohol Abuse and Alcoholism Paul Lichtenstein Health Care Financing Administration 4EOICARE AND MEDICAID ALCOHOLISM TREATMENT DEMONSTRATION/EYALUATION he demonstration involved the granting of waivers by the Health Care Financing Administration (HCFA) to pay for the alcoholism treatment of dicare clients and Medicaid recipients in freestanding, nonhospital based providers located in Michigdn, Illinois, New York, Xew Jersey, nnecticut and Oklahoma. HCFA's current policy is to pay for treat- nt in hospital-based facilities only. Over 100 providers partici- ated in the 4 year demonstration from 1981 to 1985. One of the major research questions of the study which will be reported on concerns demonstration clients. Two years of pre and two to three years of post treatment date were collected for the demonstration clients and data from the same time period were collected from a matched cohort in each state. In prder to obtain additional evidence regarding the effects of alcoholism treatment on health care utilization and costs, n analysis was undertaken of the types of illinessess, including alcohol related illnessess, associated with the trends In health care ~tilization and costs before and after alcoholism treatment. Bachman S.S Datten H.L. Health Policy Center, Brandeis University DAY TREATMENT FOR SUBSTANCE ABUSE: A RANDOMIZED T22AL OF ITS COST- EFFECTIVENESS Few studies provide conclusive evidence that Day Treatment is clfnicall; and financially superior to 24-hour inpatient hospitalization for the treatment of alcohol and drug (eubstance) abuse. And, .ost of these studies were conducted'at private or public psychiatric hospitals. While substance abuse treatsent In coso,mity hospitals has recently become sore cosnoa, there have until nov been no re-evaulations of day treatment in this setting. In this study, patients who met strict eligibility criteria vere randomly usigned to inpatient or day treatment in a coa®unity general hospital. Day-treatnent patients received care similar to inpatients except for participation in morning and afternoon groups to aronitor the home-hospital transition. All patients received individual and family counseling, group therapy and education. Family involvement was stressed in both models of care. Cost and therapeutic effeetiveneas data were gathered from patients during treatment and extended (18 month) follov-up. In this study, ra examine preliminary cost data including hospital, ancillary and cosnnmity service costs as well as initial follow-up information. We hypothesize that day treatment is less expensive and at least as effective as inuatient treatment. Harold T. Yahr National Institute on Alcohol Abuse and Alcoholism p NATIDNAL COMPARISON OF PUBLIC AND PRIVATE SECTOR ALCOHOLISM 7REATMENT DELIVERY SYSTEM CHARACTERISTICS The primary purposes of this study were to: (1) Compare, nationally, alcoholism treatment delivery in the public and private sectors in regard to the economic status of clients served; types of care provided and treatment settings; (2) Investigate the question of the existence of separate public and private sector delivery systems. Data from the 1982 National Federal Census Survey of treatment units were used for the analysis. Profiles of for-profit, nonprofit, State/local and Federal treatment unit ownership categories were constructed, described and compared. The findings support the conclusion that each onwer'ship catergory is associated with a distinct delivery system. Treatment unit ownership trends were also investigated us5ng data from the National Federal Census Surveys conducted in 1979, 1980, 1982 and 1984. The implications of the study findings are discussed. 1e1d, N., Goodspe,.d, R., H. Kleber - CIGNA Corp., CIGN Corp. & Univ. of CT School or Medicine, Yale University School of MediciDe A ROLE FOR PPOs AND >tANAGED CARE IN SUBSTANCE ABUSE SERVICES Analysis of a nationwide insurer/health care deliverer con.tC.act, which specifically covers only substance abuse services, wfis done usi8(# a unique data set drawn from a claims form designed specifiptl.lY fae sub- stance abuse. On a population base of several million=enrollqes~ 2% used the program. Of those utilizing the benefit, there weca 8-1951 ciaimants, average age 35 (slightly older for alcohol 9nd ypusp,ek for drug abuse). Epidemiologically, individuals younger than 20 accounted for 12% of claimants. Two DRGs (435 and 438) accounted for 72% of claimants. Alcohol accounted for 76% of diagnoses with CNS4B.CitWlanta next at 7.8%. Small area variation analyses of facilities J g,n~flted a wide difference in length of stays for both detoxification'ad$ 1'npatient rehabilitation even after preliminary correction for clinicRi+-btatus. A detailed analysis of the clinical and practice pattern irlp"ta,t,(;ions will be provided in the oral presentation. In addition to an extensive research program, the policy response has been to set up PP03.apecifi- cally for substance abuse services. This wi11 include predetermination of detoxification protocols based on research and other means of closer follow-up of clinical outcome and length of stay criteria. Al Wright, J.D., Di.re.Xor. Los Angeles County, Office of Alcohol Pr aas #^ THE CC!lUNITY D100ffi APPROACH7 LOS arr_s..e COONTtf'8 APPLICATIOM OF PUBLIC SlJ1LTH PRIlICIPLWS TO ALCOnOL PA08Le1S The communitp .odel approach to alcohol problea resolution asaurs that alcohol-related problemis are centered in the reciprocal inter- action between individskls and the surrounding ocmmunity. Alcohol- related probler are vieued as being primarily interactional rather than intrapsychic. Successful strategies to reduce alcohol problems .ust be directed toward the total envison.ent surrounding the drinker. In 1984 Los Angeles County funded eight nar prograsr based on this concept. They remain operational vith a total annual budget of 1.4 .illion dollars. The progra.s provide recovery opportunities to individuals with alcohol-related problems (both drinkers and family members) within a context of coommunity action. The prograas promote individual recovery by changing the environ- .ent and blending traditional concepts of treatment, mutual self-help, and prevention. The progras are also active in changing public policies regarding alcohol availability. This paper examines probless in making the progras operational and focuses on the effects thepr oqras have had in reducing alcohol proble.s in their co~unities. 11 IC Gillman, D.E. and Grieve, J. Illinois Department of Public Health. COMPARATIVE ANALYSIS OF MAJOR HEALTH FINDINGS AMONG SOUTHEAST ASIAN, EASTERN EUROPEAN AND AFRICAN REFUCEES'IN ILLIHOI^v. Since 1981, approximately 37,000 refugees have resettled in Illinois. When the refugee health screening program first began, nearly all of the refugees were from Southeast Asia; however, since 1983, there has been a significant increase In the numbers of refu- gees resettling from Eastern Europe and Africa. This trend in new arrivals has generated concern in assuring that culturally appropri- ate medical evaluations are being conducted. This study will compare the results of medical evaluations among Southeast Asian, Eastern European and African refugees to determine if there is a significant difference in the health status among these groups. The results of this analysis will be illustrated in a matrix form. Guidelines and recommendations for tailoring health screening procedures to specific cultural groups will be presented. TIMN 322508 ABSTRACTS 51
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S. Levkoff, T. Wezle, Harvard Division on Aging, F. Coakley, Elue Cross glue Shield of Massachusetts, H. Jordan Hedi0ual Systems, D. uusz ovicz.. ' DSg OF SERVICES g7 AIGH COST ELDLRLT IN AN lOfo It is iaportaot for HHOs to identify elderly at high risk for health care ezpenditures so that they can manage patient care sore lfficiently. HCFA is also interested in ezaaining high cost Medicare beneficiaries in its attempts to adjust Medicare's eapitation formula for HMOs. We rely on a self administered health status questionnaire completed on enrollment into an RHO to predict those elderly at risk for high health care ezpeaditures. The saaple consisted of 895 elderly individuals enrolled at one &iD. Four variables were significantly associated with average annual par capita costs: number of medications a person reported taking (p-.001), number of years since last hospitalization (p-.01), age (p-.01), and allergies to drugs (p-.05). We also compared findings from regression models predicting average annual utilization and cost rates for hospital, physician, referral, nursing home, and home health services use. The implications of these findings for unaged care and for the adiustment of Medicare's capitation formula for 1£fOs is discussed. Gerald Riley, Health Care Financing Administration FER ES $E W N ENR LLEE.S AND COMPARISON GROUPS IN THE DISTRIBUTION OF PRINCIPAL DIAGNOSES ASSOCIATED WITH HOSPITALIZATION Eggers and Prlhoda (1982) have shown that Medicare enrollees In HMO demonstration projects generally used.fewer services prior to enrollment than did fee-for-service comparison groups. This suggests selection of a relatively healthy Medicare population Into these HMOs. This study refines earlier analyses by examining the distribution of principal diagnoses associated with hospital use prior to enrollment in 2 demons'tration HMOs In order to estimate the incidence of chronic illness in the HMO and comparison populations. A lower (higher) Incidence of chronic Illness In the HMO populations would suggest a lesser (greater) need for health services after enrollment, relative to the comparison groups. In addition, diagnoses associated with post enrollment hospitalizations will be analyzed to ascertain incidence of chronic diseases and presence of specific conditions, e.g. cancer and heart disease. A.M.Epstein, J.A.Hall, M. Feldstein,.M. Fretwell, J. Tognetti, J.W. Rowe, B.J. McNeil. Depts. of Medicine, Radiology and Preventive Medicine and Clinical Epidemiology, Brigham and Women's and Beth Israe Hospitals; Institute for Health Research, Harvard Sch. of Public Healt Boston, MA. THE EFFECTIVENESS OF INTERDISCIPLINARY COMPRENENSIYE GERIATRIC ASSESS- MENT FOR AMBULATORY ELOERLY PATIENTS. Previous studies have shown that interdisciplinary geriatric assessmen (IGA) improves the health of hospitalized elderly when compared to traditional care. To examine the effectiveness of IGA for ambulatory patients we randomized 600 elderly from an FMO into 3 groups: 1) IGA and short-term IGA follow-up by a team includingageriatrician and specially trained nurse and social worker; 2) consultation by a "second opinion" internist; or 3) only traditional IttO services (controls). Patients were evaluated prior and 3 months subsequent to intervention by health status instruments measuring: functional status Self-perceived health; Social activity (SOC-ACT)• Emotional well-being (EMO); Cognitive function; and Satisfaction. Initial results showed the IGA had no short term benefits on health status and had adverse effect: on SOC-ACT and EMO. Long term benefits are still possible, botit may b inappropriate to provide IGA for most ambulatory elderly patients. 1103 SHAH, C.P. and COULTER, I.D. Canadian Chiropractic College and Department of Preventive.Piddictne and BiostaTtinstnitces,pRUnTi~v~ersity of TEACHINS'OF-COH4UNITY HEALTH CDUTR~EoRtl°eHIR~PRaCfiC"C9LLEGE. To optimize` paEienf'dSre,'chiropractors like all other haa,lth Professionals need to critically pppraSsti the -TitEratUre a7id be knowledgaltTe in the health-care systes in'i'vfiicli'fi"e hr"3he practice: Td Tacili°£ate this, we have introduced in the fourtn year,of underyraduate education an all-year couF3e toh3Tsting of four modules,_Tt consist-s of a totaT of 3b hburs of Tfttures and or 'semfnsri. The ffrst module deals with research study design, and its strengths _A weaknesse; 'so €fie student can learti to critic'al1,y ippraise the Titera(ture: TW"secanii-oise deal's with the des+ography'and health status of the Canadian population. The third sqdule,deajs,r7ith important health legisiation, health ~ manpower, institd~ions and resources, voluntary hMtfi SonciR§,. reguTstion of hdal'th professionals, and future trends..sad.tssues s in health-cere..systes. The final module deals with'oCctipational $ health. Detail ob,jEdtives of the course with regara to knowledg6 g skills and attitudes wili be discussed. The overall objection of tjiea course is to increase the literacy of the chiropractic student iri thet Joseph C. Keating,Jr., Ph.D., Northwestern College of Chiro~ practic; Karen Larson,BSN,DC, NWCC: Marcia Stephens, MALS I, NWCC; Timothy J. Mick, DC, Los Angeles College of Chiropract, PHE JMPT, 19- . A REVIEW OF TH LITERATURE The Journal of Manipulative and Physiological Therapeutics I (JMPT) is unique among chiropractic publications in North .america in that it meets both criteria for scientific publis'ing: blind-peer-review of manuscripts and indexed in scientific sourceworks (e.g., Index Medicus). Now in its tenth year of publication, the JMPT offers a showcase of chiropractic scientific activities during the past decade. This report provides a bibliographic analysis of the first 9 volumes (1978-1986) of the JMPT. Types of articles, authors" profesxions, institutional affiliations, latencies from sub- mission to publication; and funding sources are noted year b year. The evolution of the chiropractic scientific activity and litorature is reflected in these data. Su7aestions for 'uture development are provided. Instructioa in Chiropraetic Manipulative Technique Sean Horoney, DC, PhD Palmer College of Chiropractic - West Sunnyvale, California A chiropractic student initially begins instruction in manipulative technique with classes on the identification of anatomical landmarks. These classas advance to instruction in regional methods of spinal manipnlationt usually the sequence begins with pelvic and lumbur procedures and continues with the thoracic and cervical spine. Often, a special course is offered in extravertebraL joint manipulation. Joint manipulation is the application of a thrusting force, usually of short duration and high velocity, to a specific skeletal site; the parameters usually reviewed iq a class on technique includes doctor and patient position, manual and skeletal contaot sites, stabilization methods, and direction of thrust. In the ideal curriculum, a course in regional manipulative technique should adopt a biomechanical perspective, depicting for each identifiable "lesion" or "subluxation", the orientation of the corrective force as a vector aligned with a set of orthogonal axes affixed to the patient. This approach would allow for a complete and integrated presentation of all possible styles of manioula t ion. Constantina Skanavis Los Angeles College of Chiropractic THE RELEVANCE OF CLINICAL MICROBIOLOGY IN HEALTH SCIENCES Paper attempts to summarize much of what has been written about improving teaching of Clinical Microbiology in Health related programs!arprescnts data referring to position on th- above subject from a survey done of selected faculty and students at chiropractic colleges. Chnnges in methods of instruction in Health Sciences are covered. Information stresses a broad-ba3ed conceptual framework (set of relevant concepts). The planning of any teaching program should follow a series of straightforward, logical steps. Instruct• or should first consider the end-product of overall course, e.g., a chiropractor, and ask "What knowledge or skills in Microbiology does a student need in order to be a competent chiropractor?^ When this has been defined, the next stage is to consider the most appropriate way to teach each skill or item of knowledgt: Paper asks is the ntrad'itional" teaching method most appropriate? Points out other methods which may be effective. 1104 Kark J Sesal. Ph.D.. Amertcan Medical Association AGENDA-SETTING AND DISEASE PREVENTION: 'IHE POLITICS OF THE SODIUM-HYPERTENSION LINK • How do scientifically driven health issues gain a place on public and governmencal agendas? Hore importantly, what do the answers to this question suggest about prevention strategies that rely on governmenc, interest group, and market activities to alter individual behavior? Sodium has been identified as a causal factor in the development of hypertension, and sodium restriction as a useful approach to the prevention and treatment of hypertension. This paper will address agenda-setting and disease prevention through an examination of the rise of the sodium-hypertension Link as a highly visible public issue. The politics of this issue will be examined in three principal spheres: science, regulation, and the market. Finally, lessons drawn £rom this case will be applied to current prevention efforts. TIMN 322510 ABSTRACTS 53
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Diana J. Mertens, RN, 6NH, 2frH - IL Dept. of Public Health ' SURVEY OF BARRIERS TU rHBHAIAL AND WELL-CHILD CARE The Illinois Depart~n. of Publir Health on a grant from the Governor's Planning Council on uevelopmental Disabllities, surveyed all wom.n dr livering live infants betveem 10/1/86 and 9/30/85 who, according to their birth certificates, received little or no prenatal care. Respon- dents were asked to verify their level nf care and to list any barriers to care they may have encountered., Additionally, they were asked what services they received during their pregnancy. Similar informacion was requested on barriers to and components of child health services for their children. A subsasple of the nonrespondents in areas with rates of infant deaths far in excess of state averages received Public Health nursing home visits to obtain the information while linking them with services in their coodunity as needed. Data are being used to target Department activities in the area of prenatal and well-child services. Additionally, the results have been shared with other state and local agencies involved with the provision of services to childbearing fami- lies. Results of the study indicate that these women overwheld.ngly felt that both prenatal and well-child care were important. Of the barriers to care reported, the most significant included: lack of financial resources, inability to find a physician who would take Pub- lic Aid clients. lack of transportation, family problems. Louise H. Warrick, Dr.P.H. University of Arizona BARRIERS TO PRENATAL CARE J(HONG HISPANIC AND ANOLO WOMfiN IN MARICOPA CDUNTY, ARIZONA Barriers to care among, disadv;ntaged Hispanic (n=165)'and Ang3o (n=161) mothers were identified through a folloW-back . survey of. 1984 births. Subjects were contact2d through telephone and hane interviews and birth certificate data were merged _with questionnaire items for ana)ysis. Fifty-one percent of the respondent mothers reported Income below $9,000; 48% did not graduate from high school; 44% were unmarried; for 32Z it Was thcir first child; for 35% it was their second child. Thirty-eight variables were entered into a discriminant analysis to identify,the predictors of adecuate and inadequate prenatal care,. Adequate prenatal care was defined as registering for care in, the first or second trimester and having 5 or nore prenatal visits. For Anglo mothers, the strongest predictors related• to financial coverage. For Hispanic mothers, the awst•predtctiVb variables related to self perceived need fo,r care and knowledge of wNere to go for care. implications foi `utreach are discussed. Kenneth Keppel, Teri Liss, Gloria Sispson, and Samuel Kessel U.S. Public Health Service NAT..NAL MATERNAL AND INFANT HEALTH SURVEY (HHI1S): BARRIERS TO CARE Barriers to prenatal car= discovered in the 1987 nretest of 600 infant deaths, live births, and stillbirths in Tennessee, Arkansas, Michigan, and Wisconsin will be highlighted. The 1988 NHLNS will include mail, telephone, and personal interview contacts with 60,006 mothers, hospitals, and prenatal care providers associated with 6,000 infant deaths, 4,000 stillbirths, and 10,000 live births (lncludes oversampling of LBW and VLBW Infants). A threefold over- sampling of blacks in all three coeyonents of the HHIHS will coin- cidentally yield more precise estimates for unmarried mothers, who wili be contacted in all of the 52 State and independent registration areas which so permit. Questionnaire content, agency co-sponsorship, and anticipated data uses will be described with slides, brochures, and other handouts. Elsie R. Pamuk, William F. Pratt and MarJorie C. Horn National Center for Health Statistics DET€RNINANTS OF PRENATAL CARE UTILIZATION: DATA FRON THE 1982 NATIONAL SURVEY OF FAMILY GROYTH The 1982 National Survey of Family Growth,is used to examine the relative effect of financial constraints on the likelihood of obtaining early and continuous prenatal care•services, controlling for other factors thought to affect motivation to seek care. Source of payment for delivery is used as a proxy for economic circumstances directly affecting the receipt of medical services during pregnancy. Logistic regression, done separately for whites and blacks, is used to evaluate the effect of payment source relative to mother's age, parity, marital status and rantedness of the pregnancy at the time of conception. Timing and continuity of care is also examined with respect to whether the first prenatal visit was to a clinic or a private doctor. 62 ABSTRACTS SERMEUS, Guy PREGIANCY, DELIVERY, AND MATERNITY HOSPITAL STAY IN BELGIUH Dmring 1986, questionnaires were collected from 22 000 mothers, greatly representative for the Fleaish part of Belgium. The question- naiees were given to the mothers within the first week after they left the suternity hospital, and they were collected one weak after. The data .ut allow an in-depth analysis of the mother's pregnancy- aspects (quantitative and qualitative analysis of pregnancy atti- tudes, health status and medical consumptioa pattern), of the deli- very (period, preparatory aspects, nature, pain stilling methods, qedico-technical interventions,...), and of the stay in the maternity hospital (nature and evaluation of the received services and infoe- a.tioa, contacts with aItmedical and para-medical professions,...). It will be able to link the findings of each of those three different parts. A fourth part enables to differentiate the findings according to the socio-economical status of the mother and her family. Results caa also be differentiated for groups of as well as for separate hospi- tals, ince for each questionnaire, the hospital has been fully ideatified. Susan DeeNarnais, Ph.D., Comsission on Professional and Hospital Activities, Ann Arbor, Yichigan• THB FIRST TWO YLSgS OF PPB: PROGRAY IYPACP AND REGIONAL VARIATIONS Under a grant from the Eeaith Care Financing Administration, the Comaisalon on,ProfesaionaL.+lBd.Poapit;},)letiyities is+mamelorl" changes in the utllizatioA end.qmlitr qf< hpsPitel ca,re using a, data base containing abstracts of hospital discharges for a cohdrt .of 6[e hmspitals form 1980e198s_0:1r y,iodinss sh,ovt_,l'cpqti.nufng decr.ase.iq hospital adsii.asions for,Yedicar4.patieqts.iA 198M8k, AIAS for medical patients hit a plateau from 1984-19gS. Surgical ALOS, which had decreased from 1980-84,., increased slightly in 1988 In all regions except She Kaatr.wheri surgical AIAS decreased even futrther. This is surprising, since surcical AiAB (both pre-opera£fve and po.4yspegstivpl ma; already shortest In the Mest.. Death rates, readmission rates,.consultation rates, and rates oL,tran.fera to- other shbrt-term'hoipitals are all consistent rith'piv-PPS trends. Ho.ever,, a gre}terproportion of Medicare patients .e`r' di8charged to Sls,and Homq Hulth Agencies in,198a, co.pared.ta ths previous patterns, Christapirr Fbgen, Ph.D. (Servioe FeL7aw) and Haama M. Coffey, Ph.D. (Director), Hxpital Studies Progrse, Nationl C!lR.er for Heslth Sevles Research, qHS. ARWRIA1flES5 OF DU3OSIS R3ATED GInIPS FDR IUSa1TN.iZ® MEDICAID RO SLUE CR)SS PONB.ATIO'6 The Medicare D'ffi-based hospitalreirbusee:t system Is being usei as a nDdel for if other aG system fo-~Mad s and Bi~ ~s r~eirtusmaft~.~klt~diarye data ifrns Msrylard for the yeers 1982-1984, we use charges accrved ty tiree pqycrs to test rdetfc pay©s shre the saw set of ORG relative ueights and the same multiplier far ccmertinp those relative nei¢rts to dollars. Ile also exandpe the effect of different seighting sd:ees ov hospttal case-adx indices, ohid: directly affect hospital reilesserents, iksults shor thet the pattern of relative Neights dlffes significantly aa+oss pnyvrs, and, after standardizing for DRG mix, Msiiesid dmryes averege 4% niore and Blue Cross charges lOX -less than Meiicare charyes, State-wida. Within hospitals, ha,ever, Mbdicarc charges vere almst :nifmaly higha• than Madimid rlmrpes after stardaniizing for DRfi mlx, shoring t)st the hioc State-wida charges fcr Madicaid patimts were due to their disprapcrtimate tree4na~ in expefsive hospitals. Hospital-lesel rsse mix indices wre brely affected by a dwge frtm pqyer-spocific weights to a11-pqyer seights. 'Tiarsha Goldfarb, Ph.D. and Kosanna Cottev, Ph.D., NCHSR DETEEMZNANTS UF HOSPITAL CASEMIX CHANGES IN THE 1980S Implementation of PPS has been associated with a large increase in DRG-based css®ix of Medicare patients. Explanations, only some of which can be attributed to PPS, include more outpatient care, adoption f new types of surgery, substitution of surgical for medical proce- duras, population aeing, more accurate/thorough coding of discharge (abstracts, and ^gaming." Among issues meriting attention are (1) how has the cas®ix of non:udicare patients changed over the 1980sY (2) how much of the change in Iiedicare and nonN.edicare casemix can be attributed to the factors:listed aboveY and (3) are trends in casemix using DRGs still present when alternative classification systems are used? We addresi these issues by analyzing 1980-85 discharge abacract data for 300+ hospitals. Descriptive and nultivariape analyses are used to measure trends in both Medicare and nonHedicare casemix; to relate these trends to DRGs, Disease Staging and Patient Management Categories as alternative casemix metries; and to estimate the propor- tion of casemiz changes due to differences in admissions pattarns, treatment style, quality of data, extent of participation in FPS, and other variables. TIMN 322519
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1110 JL Pa _ul Harris, M.D. State University of New York, Health Science Center at Brooklyn. Department of Pediatrics. - -" --- PLUMBISH - A CDNfINUIMG PEDIATRIC PBABLEH The toxic effects of high lead levels have long been recognized. However, more recently, a host of biochemical, neurologic, behavioral and hematologic effects of lead in young children and infants have been recognized at relatively low levels. Levels that were previously thought to be "aafe" are now believed to be deleterious. In addition to ingestion of lead paint in old houses, new sources of lead in the environment have been identified and are contributing to the toxicity to which children are exposed. Thes6 include air, water and maternal lead. This presentation will focus on two major issues a) evidence of toxicity from lead at levels previously considered "acceptable^ and b) evidence of the contribution from new and previously unrecognized sources of lead in the environment. The biologic, practical, economic, social, and politica7l ramifications of Childhood Lead Poisoning from all sources will be diacussed. Margaret T. Clark, M.D „ M.P.H., Paul Harris, M.D., Steven Ail, M.D. State University of New York, Health Science Center at Brooklyn. - Department of Pediatrics. FAILURE TO DE-LEAD CHILDS ENVIBDisSBN'Ca A CLASS ANALYSIS OF CHILDREN BE-EXPOSED TO LEAD. Children who have been admitted for treatment of lead poisoning frequently need to be re-admitted because of recurrent elevations in their blood lead levels. The question of whether this reflects re- exposure or continued mobilization of their initial burden is an important one. We conducted a chart review of children re-admitted to Xings County Hospital for lead poisoning during 1986. In many instances, the child had returned to an environment that still con- tained lead hazards. Two subgroups of children who areatparticularly high risk were identified. Children of undocumented isaigrants, and children whose families own the dwelling. In addition, a large percentage belong to the "classic" group at risk for lead poisoning: poor citizen families who are documented tenants in old apartment buildings. Solutions to the continuing problem of childhood lead poisoning must address the particular needs of each group. • 7%-pF. *:f1fiT_-~ri7!'x 1 Z i t .~, N®a York 10461 19'MIV€ 9e]RRa+ AND liifia 1i171SDfS Pessivaly irbalsd sanla. (also ,mllad sidn-stz+ses car seoaxl-haad saoln) has L•asa sham to be hazaxdaus to c+iih*Um's health. creas-aectLafal cdrxt arzi other sttxiies hava fosid a direct relation batw.an pessive sadtirt7 arfd: (1)a *m+ ciT in birthrw.ight, (2)z..piratory i1L^iss in ttr first two years of life, (3)07.x}a, bztxx3iitis, and pneusrnia, (4)deilancd asl3as, (5)reduation in p,l+r*+exV flsneti.ory and (6)ohilshood cano¢. tkjtor4ptataly meny studiis have suffetsd frcs a.thodologicnl dratcozirrgs. zha.e ineluda the failure tot (1)axttzol for ernfamdiM va,aa}•l•s such as sooiall class arxl other d:ildrsn in the family and (2)callsat data pzOSpeati.vmly at tYsgaret irrt¢vals for active nr<v.illanca in the det.at.ion of ayaptome. 2ha aia of this paper is to facus att.ntion on the effects of passive ®ddnxj on child health and critimll.y raviwv otisting ree.erdi .stablts`i ng a causal relatiawhip lxtwesn passive amoking and child health. This paper will also sarvs aas a stlaxlus for ftu-2her, raseazrli which will pznvl.da infoaBmticn for health profeasionals and ot2mrs irrvolvad with public po.licy. Dou Pierce B.S. R.S. acoma- erce ountv Health Department CONTRIBUTING FACTORS TO HIGH URINARY ARSENIC LEVELS IN CHILDREN LIVING NEAR THE ASARCO SMELTER IN TACGHA, WASHINGTON A 1985 Arsenic Exposure Pathways Study perforsied by the University of Washington identified nineteen (19) children within one-half mile of the Tacoma smelter with high urinary arsenic levels. In order to lower these arsenic levels, environmental and behavioral conditions contri- buting to exposures were identified and behavioral and environmental , modifications were made. This evaluation included the tracking of the children's daily activi- ties and behaviors. Daily urines were collected and analyzed for inorganic arsenic. Controls, representing similar age groups, sex, socioeconowics, etc., and living within the one-half mile radius were evaluated and measured in the same manner. Outdoor play activity and certain play areas appear to be primarily responsible for elevated urinary arsenic levels. Prescriptions for mb dif ed oraclosede being developed and public play areas will be Mirrls Lamrov. !5. R). Teneasee Cttxrbnuk of Hxlth ard Envilarnmt` Fa0] MV1Q:TD•G A+D oI~EAE PFklkNflw - gOJD (374ER0IIJT CUff4RATE WITH FCl7) INX6TRIES IN PriDll:I LABEI.DG AID AMATISD%? N trition labelirg iec}iinrerrts wans zaplensrted by the Feod and Dnq Adninistratim in 197: fortified fcods atl foods for .hich a rutritiasl claim is meda. Thtaujnut the 1980's in 1 aptrne to aznumr de.and, the pwularity of n#rition labeling Ias cntinnd to 7ncraasa, % aary food 3rdetriea wtu:'~.~ily disclasirg the nutrieit mnFsit of their prodsts on the 1i In 1594, an frrnvative ad ca#rowrsial apptbsch to feod labeling was initiated by the Ksl: Coqosny. Kellogg $l.labxated xith the Nbtimal C.rer Instibke in snn adVertiairq csnpdg pranoting All Bran a.real as a rich souas of fiber rhidi mry redte the risk of ca,cer. tho rJi FDA hiatnrial.iy ha3 held a rigid positiai agefrut diaoase-rrlated c1aL a an feod 19 they did riot initiata ary neg.rlatrxy actim aptirat Kellogg. Riis nsw dirxtim in rtksiti( Iabelirg epaed the f]oodptes to cmtivversery ard stisulated mrh d[alag.is armig health ta fe,•aionsls, gwenost and irdstcy officials ard caeumr ad.acstES. `.oe of the q.ieaticrt g3rdtrg the use ad misu+e of diseass-apacific health claims in prodst sndeting vhich haw raised ovcr the past tva years ars: 1) will these hea1tfi clabrs preas * a distated inpreaa of C e relative value of individ, sI fmds? 2) Are feod 1aMlinl srd predct adeertiaing app ate aveus for tte disssmdratim of dixase-relatad nkritiai infonnttim? 3) If health cli in food nar{xting ae dx~ed appropriate, .het 1Lnitatioe slnyld be msds? 4) Can there be r cma s asong haalth {xofessiasls ard apKqx•iate agerriea (e.g. NrI, N4S) to atxitentiete i specific claim? 5) (bea FDA hsw U e remacts to effectively d.welm. manitor and e fotw h 1111 Rita S. Laffey, MSW Katharine H. Hesse, MSW ETHICS AND THE PROFESSION OF SOCIAL WORK The deficit model is an approach frequently utilized by hea. care professionals whereby the emphasis is placed on the prt lema rather than the strengths of the client/patient. The medicalization of health care during the past thirty years I forced a preoccupation with diagnosis and cure of problems, usurping a preventative focus. From a social work perspective, the authors will address the ethical issues of professionals who promote their own career interests by encouraging relkence on providers at the expens of client/patient self-determination. Special attention wil be given to the impact of the model on the emotional and phy ical well-being of the population receiving health care. The NASW Code of Ethics will be analyzed as it applies to th model. Alternative approaches and frameworks will be propos Pamela J. Naraldo, PhD, RN, FAAN, Executive Director, National League for Nur.:ng #k Nursing's Contract with Society: Its Ethical Implications and Cimita ons Describe nursing's contract and then will emphasize the very basic ethical tension in.fmrsing's professional responsibility between what Beauchamp and McCullough (84) call the beneficence model and the autonomy model. The beneficence model defines the providers' (NUs) responsibility in terms of determining and doing what is best for the patient. The autonomy model, more recent and imposed to a significant degree by others outside the profession, defines the providers' responsibility much more as enhancing and respecting the patient's right of self-determination. It is an uphill struggle for nursing, under the beneficence model, given the provider-dominant biomedical enterprise, as it attempts to advocate patient self-determination, more information in the hands of consumers, and inclusion of consumers in developing their plans of care. Edmund H. Ricci, Ph.D. and Nathan Hershey, LLB Department of Health Sc:vicas Adainistration, Graduate School of Public F University of Pittsburgh Ethical Issues in Public Health Policy Ethical principles impinge upon the reeo=endations, decisions and activi of agencies and personnel concerned with the health of populations. In t papar, the discussion is focused upon the conflicts and congruency which develop between public and individual intarasts. Choosing between (1) se authority for compulsory, rather than voluntary mechanisms to promote hee and (2) the public's interest in knowledge and individual privacy in strt turing prograsu, often presents ethical dilesus. These dile®as are plt out in the political arena given the fact that we have limited resources davota to public health programs. TIMN 322512 ABSTRACTS 55 ,
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1128 Jaass Fa_tula Ph.D. and Christina Dohart HPA _ ountY t ap aa2 an- PAOrFAa DEYElAPHQii ISSUES in I)TLEHIMING A aAtAAl'ORY COO1rryAIDE PREPAID HIDICAID DEa0NST8ATI0N TTe Honroe County 7EediCap Plan ('JedSCap") vas avarded Sectioe 1115 waivers by the He.ltb Care Financing Adainlrtratioe to test alternative financing and delivery systess for Hedicaid recipients. HedlCap 1s enrolliog on a aandatory basis in four phases the entire Medfcaid eligible populatioa in Honroe County (about 77,000 individiauls) in prepaid health care plans. Initial enrollaent began in June, 1985 and over 40,000 eligibles have been enrolled. This paper describes 1kdiCap's experlence and lessons laarned is dsiqninq aad Sspiesent(oq the prolect, includinq: the health care envtronaent in the County as the backqround for the effortl provider involvenent7 tbe role of the eounty7 negotiatlcns vitb Nev Torf State over design, prograu, and rate Issl:es; start-up difflcoities7 data isrues, and the eferqing advantages and disadvantagee of havinq a third party agency (HediCap) sanage and broker the prolect, e.g., with reqar to enroli.eot and diseorollaent, grievances, policy disputes, etc. Kathleea Heuer H P g Rabart Msver, B.S. and Deborah aachrach• PHD Minnaota newrtwent of Hu^an Services . ,..... _ .. , , .. . _. .., ,. , ... . MINMESOTA PREPAID REDICA:u DEMDMSTRATI(kl PRDJECT: IMPLElEHTATION EXPEBIENCE TO DATE This paper discusses the rajor issues faced by Yinnesota is i.pleseeating a three county sar.datory prepaid prugras oa a daeoastration project basis. Prvbless and issues unique to AFDC. aged. disabled, oestaliy retarded and nursing hese populations arc addressed as .elt as the State's response to these problees. The folloring operational lssues are covered: Medicaid consmaer eduutios and enroil.eat: probless with healta plan enrollseat lisitatioas; definitios of beaefft coverage; case manage- zat: elscounter data reporting; prepaid info118tioa systes developsent; and political oppositioa to prepaid prograas- David B Laskin MPC and Steven Krivit, MPA Santa Barbara Healt* Z:litiative CHarrsw:cS IN IMPI,EWs1TING A LOC1tLLY-ADMINISTERED ME'DICAID PROGRAN The Santa Barbara Health Initiative was awarded Federal Medicaid Waivers under Section 1115, Social Security Act by the Department of Health s Human Services to enable the State of California to test alternative financing and delivery systems for Medicaid beneficiaries. The Health Initiative, begun in 1983, inscribes on a mandatory basis ail Medicaid eliqibles in this county (approximately 21,000). Extensive development activities were necessary to bring the project to operational status. This paper will discuss several obstacles which had to be overcome to implement the program, includinq: acquisition of planning funds; l~saga of special State legislationl involvement of provider groups in policy formation and governance; recruitment of contracted health eare providers; negotiation of contract terms and rates with the State; co<lversion of beneficiarie to a system in which each selected a case manager; design, selection, and installation of the management inforsution system. Lastly, an administrative staff was hired to perform utilization review, quality assurance, qgrievance resolution, finance and accounting, provider fac.dabyithe He~alth I~nitiative~canialsos be eexpressed as~ssons fores future programs. C otbia R w Hue Y. hF:. and Doriene Yuhs, a5w and Mar2.a atnchell. aA Oe uatY 1 a,~ lan, Ion1K. 1lfDICAID FaROLI417(y Ilt hnt'aa :In: E%PERIENCE OF 11IDICAP PWt The Nooroe Couaty HedlCap ?roject began Sn 1992 !a response to aa RFP released by eCFA for proposals to test eoeyetitiYe sodels of baalth care delivery and financing in the Medicaid Prograe. Hed:Cap `as a frea^_ae of choice eaiver and under Ner rork State statute, a_U Medicaid eligibles is Mooroe County (ieclodlay the aged and disabedi are required t~n De enrolled in PwdiCap. Additionally, aedlCap s benefit packaqe ts eosprehensive - seotal health and looq ten care are iacluded. ltiis paper discu.sses two years of e:perience by the Honroe Coutlty HediCap Plan with sandatory enroli.ent of Medicaid eligibles in prepafd, sanqed care plans. To date, over 10,000 public assistance recipients vader the a.e of 6S han been enrolled in the two participatlaq HMDs. Issues of eorollsent design and process, inclediag disenrolleeats, provider transfers, eaeaqtiaes fron enrollseot and enrotlee lock-isn are analy:ed. aedlCap's role as a neutral Party in the se.ter services/enrollaest fuactioe is evaluated aad 1ts experience as a sedfator betwee the payors, enrotlees and providers is sbued. 1129 Judith Sheard M A M.P H David Sleet, Ph.D., Richard Houah, Ph.D., San Dieao State Univeraitv• Robert Tavlor M.D., California State Dept. of Mental Heelth• Farrokh ALemi• Ph.D., Tulane University DEVELOPMENT OF A MENTAL HEALTH APPRAISAL INSTRUMENT Mental health research efforts have traditionally focused on the identification and treatment of psychopathologies. Less common are methods for identifying and measuring pOsitive mental health charac- teristics that enable people to function optimally. This paper de- scribes the development of a mental health appraisal instrument that assesses emotional risk factors and promotes individual mental health. The inventory is used as a tool for educating the public about the importance of mental health in the context of wellness, motivating and stimulating mental health activities in the community, and promoting personal assessment of inental health strengths and weaknesses. Empha- sis in this paper is placed on the research model used as the frame- work for the development of the instrument. This model includes identi fication of mental health sisk factors, stressors, and coping/life enhancement skills. The group decision making process for inclusion of particular mental health concepts and development of inventory questions will also be discussed. Warren Schonfeld Ph D School of Social Welfare Univ. of CA.Berkeley THE WELTrBEL`.G FiO:ECT: MENTAL HEALTH PROMOTION uY CLIENTS FOR CLIENTS A natural eztenaJ.Bn of the aelf-help'i'ovement'in mental health in for clients themselves to do reeeirch and use the findiags'to plan for adee catioa and carae,_The. Californii Hetwork df Tlental Healtl: CAiasnA,j •jyLa'- cosrpleted a study _fur;dad by_the Stake oE"CaIifornia MenLa1 Health Pro- notien.Braach, to identify factors which promote wellZbeing ahd prevallt problems. Intervievs,with'331_clients,' including a random sample of'6T Network members, suggest that-recognition of-itidiJiduilily'tiEhar,than treatmitt.by stereotype, opportunfties for meaningful po•r& ind activit}il and support for handling problems at an early'stage enhance well-b}kf,gl Half of clients sprveyed can recognize and take care of problema before they bece.e severe and might benefit by working in partnership Nith professiont<ls to da.velop'.ipprooria tepprooriate eare plans.. Yet there is evidepce that the mental hsa,ith.system, by iglloring what clients have to siqya_ is ifostEring personal••devaluition and learned helpledddlds; end the fear• created by the thp446 of involuntary hospitalization J7ws,aauwed-4'I,,j,Q;; clients to avoid seeking,treatment. Alternatives atk`41e8ded. It io importdnf that'tbiB'information is communicated to professionals atUl the general public. Since conducted by clients, the project itsedf serves as a model of IDeatsingful activity to prooate well-bslng, Michelle van ny.., h.P.H•, Robert D. Caplan, Ph. D., Amiram Vinokur, Ph.!l a..•i. P.icharjl,,Price, Ph.D. L7niversity of Michiltan SOCIAL SUPPORT AY.D STRESS INOCULATION TRAINING: A PREVENTIVE INTERVENTION FOR 2H8 UNP.NPLOYaD Long term unemployment and its sequelae have been linked to a variety of negatiwe social,bpsychological and physical health outcomes includ- ing depression. increased child abuse and divorce rates, and decreasee in physical health status. The high cost of unemployment to the indivdual and society createa a clear call for preventive inter- ventions to promote coping with the stressors engendered or aggravated by unemployment. This presentation describes a preventive intervention which applies social support strategies and a cognitive behavior modificatien technique called Stress Inoculation Training in an attemp to promwte re-employment and prevent the negative mental health con- sequences of unmployment. Usa of these intervention strategies to promote coping with other stressful life events will be discussed. Elements of a successful preventive intervention s•1ch as trainer referent power, provision of social support, and transfer of problem solving and stress inoculation techniques will be explored. Downey AM, Loulrtana State University Medical Center, New Orleans, LA THE RELATIONSHIP Of• SELF-DISCLOSURE TO SELF-PERCEIVED HEALTH STATUS IN MIDDLE-AGED MALES The purpose of this study was to determine how self-disclosure was related to self-perceived health status in middle-aged males. A non- probabillty sample of 237 male volunteers between the ages of 40 and 59 was obtainod from various instltutions and organizatlons In the Baltimore-Nashington area. The 237 male participants of which 88.7$ were engaged In professional occupations completed Jourard's Forty-Item Self-Disclosura Questionnalre and two separate measures that were em- ployed to assess self-perceived health status. The flndinqs on both self-health assessments, the composite health score and the Bradburn Affect Balance Scale, revealed a small but statistically slgnifiunt relationship between self-disclosure to one's spouse and self-percelved health status. Results of this study suggest that In a sample of professional middle-aged males, the men who report- ed lower self-disclosure scores also evidenced lower self-perceived levels of health than did those males w(th higher discldsure scores. Further test(ng of this relatlonship Is recommended In a representative sample of middle-aged males. ABSTRACTS 63 TIMN 322520
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June H. Buckle, RN, tLSN and Phoebe D. Sharkey, Ph.D. The Johns Hopkins University, Scbool of Hygiene and Public Health. Department of Health Policy sn.d Hanagemcnt. Baltimore, :farvland 21205 THE IMPACT OF PPS Op DISCHARGE STATUS OF MEDICARF BENEFICIARIBS, The primary criterion by which the impact of the Medicare Prospective Payment System ~,hould be judged is its ability to contain costs while uintaining intended benefits to Medicare beneficiaries. Quality of care for the elderly as well as access are important considerations. This study will assess the impact of the Medicare Prospective Payment Systesi on patient care, specifically the frail elderly. How successful the systea will be in achieving cost savings depends on how effective a DRC payment will be in providing hospitals the proper signals to encourage efficiency. Although there are strong incentives to provide treatsent with cost efficient nethods of production, hospitals may also behave in a less desirable manner by refusing to admit high-cost patients, skiming low-cost patients, or discharging patients early. To assess the effect, patient discharge and financial data from teach- ing and non-teaching hospitals are analyzed for changes in length of stay as measured by the Severity of Illness Index developed at the Center for Hospital Finance and Hanageaent, Johns Hopkins University. V V L Jame.s~A. Mercw~~.~D.. Patrick tr0'Carmll, M.D., M.P.H., Diana R. SflCIc9JCtiCFffC A4O DQ1D3{APHIC BO(RECES CF VARIRTICN IN COlRB'Y HC2'lICIDB RATfS diff i~ t~~ tr~ibi ~bl~t ~eseaidi dhais~tiwlly~ ~t~tihi~do status~SES). Hoxev®r, arisider e debeste rengins over whidi r ~onents of low Sffi are nn~ ly asaooia~ad with the risk qf ciBe. We exol~®d the e sct o a ranne o soc3aecronaniC arx2 aphi~c indicators m inti in co"anty ratas bv 1-~reqrtihesesi~ t ates fgr 980~aiable aty3 y tianicida~ ~l~lat~ ~~ty, to~~,~~fam_ _il~_povart~. ~ d~~~rnr~~ +_4 low t~s ~ o 2 f e ~ ' alrne)ain262 ~ e Th® tsro Ses se ~~~of~~iation +~* t o ~ t.es. Fuz ther reaearrh i s n e a3 sd r a s ta t us ~ ~ o v~ r ~y a ~ ~fe<nsla-'~h cat»1ds wt~iich increase the risk o£huatcids and are potentially amenable to preventive intervention. Steven C. Macdonald, Goldy D. &leinsan, Stanley H. Freeaan, Nancy Hsmmond University of Washington Schools of Medicine and Public Health, Seattle, WA INJUBIBS DUE TO FALLS IN THE CONSTRUCTI08 INDUSTRT Injuries, especially occupational injuries, are not randoaly distri- buted in tiaa and space. We examined Workers Compensation claias data from 1984 for injuries (a-2,404) due to falls from elevation in Wash- ington in: building eoastruction (SIC 15); heavy construction (SIC 16); and special trades contracting (SIC 17). 646 firas, in 13 selected sub-categories, had 1,263 claims. "Bridge, tunnel and elevated high- way" (SIC 1622) had 4.6 clai.s per firm, the highest. The 1,263 claims had a direct cost of $3.5 million, 35% of which vas in "Roofing and sheet metal." For all claims submitted to the state (n-190,104), 12% iavolved z15 days lost from work; for all construction claims (~25,101), the figure was 15%. Examination of 969 construction fall injury claims in &ing County (40% of the claims for the state) showed that 31% of claims overall had 215 days lost. Days lost varied by occupation: 44% of "roofers & slaters" lost 215 days; 41% of painters; 40L of drywall installers. We conclude that injuries due to falls in construction are a major proble., with high cost to society and severe and disabling outcomes. Jess Hraus, UCLA; Gina Aharanoff, Los Angeles County Health Dept.; Shakeh Arzesunian, UCLA; Caren Wiatesute, UC Davis. TRENDS IN FATAL PEDIATRIC IlEERSION B(JUBIES, CALIFLIRNIA, 1960-85 Trend studies of fatal injuries are infrequent but can benefit under- standing of influences on incidence. To evaluate long-tert changes in ia.nrsion deaths in California, information was collected from the state's Master Mortality File for all dravnings among residents who were under the age of 15 between 1960 and 1985. The death certificate was exaainad, and information on physical injuries, exposure site, and times of is,ersion and death were collected and analyzed. California census data and in-ground pool permits were used to calculate rates or ratios. During the 26-year period, 5,725 children drowned-an average annual rate of 4.3 par 100,000. Males had twice the rate as for females with peak rates for .ales aged 1 or 2. Ratios of drovsings per 100,000 in-ground pools shov a steady decline since the early 1970's, but they account for the single greatest exposure source for all pediatric drovnings in the atate. Increases in tub/basin or hot-tub/spa drownings are observed. The proportion of drovnings with a lapse time from is.ersion to deith beyond 3 hours nas increased dramatically in recent years. The implications of these findings for preventive measures are discussed. Uy-ce YanEvera, Anerican Red Cross; Kathryn Scott, University of California at Berkeley Current courses of Aquatic Spinal Cord Injury Due To Diving: Surnary of 43 Case Studies Spinal cord injuries are a major cause of disability in America today. Sports related injuries comprise 14.2% of all spinal cord trauma. Diving was the leading contributory sports related activity with 66% of the injuries within etiology. This study presents an analysis of 43 case studies due to diving obtained through completed victim ques- tionaires. 99 victims treated at New York's Rusk Institute were surveyed with 43(43.3%) responding. All respondees were quadriplegics. Shallow water diving was the most common cause. Sex, age, weiyht, and height within etiology indicates most injuries occur to males (UO%) between the ages of 15 and 30 (88%) with a z height of 5'10" (93% S 5'6") and weighed more than 160 lbs. (57%). The majority of injuries occurred in unguarded areas (8f.4%) primarily in private above or inground pools (53.6%) or oceans (35%). Rescue was not performed by trained personnel, but by a friend (74.4%). Due to the initial manage- ment of the spinal cord injury being provided by untrained people, our study indicates that targeted prevention programs should be developed to increase public awareness of the risks of diving into shallow water. J(ath_leen M. He1sL y. Carey V. AzZara w h trs nenartment of P.hlie Health A STUDY 01' INJURY AND ALCOHOL DIAGNOSES AS CO-MORBID CONDITIONS ;1uch attention has been focused on injury risks associated with spiso- idic alcohol abuse, and little attention has been devoted to injuries 'and chronic alcohol abuse. Metabolic disorders, neoplasms, and mental disorders resulting from long term alcohol misuse may contribute to in- ;jury and poisoning. Injury and alcohol diagnoses separately and as co- morbid conditions were examined using the Hass. 1983 Uniform Hospital Discharge Data Set. Diagnoses related to alcohol accounted for 94,150 discharges for an annual rate of 1641.1/100,000 population. Injury discharges occurred at a rate of 1770.8/100,000, and as co-morbid con- ditions the rate was 156.1/100,000. Those over the age of 60 accounted for 58.8% of the co-morbid conditions with a rate of 524.7/100,000. The co-morbid rate of injury and alcohol £oY,females (168.2/100,000) was higher than that of aales (142.6/100,000). Alcohol as a co-morbid fac- tor was found to be associated more often with certain causes of in- jury; i.e. 9.9% of falls and 15.6% of suicides had a co-morbid alcohol diagnosis. Synergistic effects from alcohol conditions and poisoning injuries are also examined. Implications for future research in injury trol particularly as it relates to other disciplines will be dis- uased. P.J. Saturno M.D. M.P.H. J. A. Msr Ph.D. P.W. 0'Carroll M.D. FFFB(.'P OP LH3AL DRIHICM !G'g Ct( YO(RH SUICIDE AND HQMD:CID€ HATE9 l tuatim and ,rati~ th~e ~i1 of alclatw avi.c]H a~a n[thmtiaide icv -t+m ~ ~ i ~ ~ ~y~nQ dtelh s>= riZn this~~p e t~1I1I1~q~~~a1 Of t11a iani4lda in~ Drinkinq ZI A1)~!n thas r ihk ot guietda 1 , ~ b ( y~S~ar ~ tJ;eir ~~ 1 GMOor liro data from the 8 a~ l ~ tg tT-ati'ra tal Cesrt.er o th~e 1C~svs itirorsatiucs ar so i b a~w ~ lcvlatad ata f St t t ~ ~ehs.tt~ iaaf.rst~os~ () ~~~~poStfatastwith IL1ii at ZO 219~1® but rastrict,adto baer ug;re winer a~ 18 wara~ns as 1.ncreasindy ~oeed~~~ha7d.ssama snalygsi~saxrsas~ perEIt~wa orn~tcreol ~a~i~`aaot ~Ti tw ah~ ai~fricantl t4ts r ita8 wv~itrhI ~iiA> Zal~a ~ iia'k3~f aa n atther of the'c ontrol 0 0041. Noaff ~ ~~aEtw d fqr t t ~ ry an~ysa~Lpy atS ~ ~ 78- ~ e rn ~ s ~ ~ 00~ 5 0 .03 :and toL € ~ f w1h~i 6tge aales ( RR 1 ly-h~i poiTi^1OSWmfoxrt~mSi1tima_(f~ot'~hani~lcvi.l Or~j~yyou~th~ b~ii3cialoin .rrducin4 the risk ot ~ am3nq youth: 1055 Ho_rtensia A.nr'o. Richard DoBwton Universitv School of oClas Ca>€ Medicine Jose Pares_ hita_ke_~ RISg FACTORS ASSOCIATED WITH DEPRESSION AMON9 !4(SXICAN MBERICANS 'I An estimated 13.4% of the participants in the Hispanic HANBS reported sysptor of current depression and 4.2% had a lifetime prevalence of depression. Prolonged feelings of wanting to die, suicidal thoughts and suicide attempts were estisiated to be 9.7%, 8.6% end 3.2%, respectively. Risk factors associated with lifetime prevalence of diagnosable depressi were gender (p<.001), age (p<.002), marital status (p<.001) and esplo status (p<.02). The lifetime prevalence for depression was highest among wosen (6t), those unesq,loyed (5.1X), and those separated (10.2%) or divorced (9.9%). Current depression was associated with gender (p<.001), being US born (p<.001), age (p<.01), marital status (p<.001), e.ploy.ent status (p<.001), inocs (p<.001), and education (p<.001). Groups most at risk for current depression were wo.en (18.3X), young adults (18.6X), those with no education (21.6Y), those une.ployed (18.3%), those with an annual inoes,e of less then $20,000 (15.9%) and the divorced (19.9%) or separated (24.6%). These findings show many cos.on patterns with epidsiological studies of depression aswng non-Hispanics and suggest t aside fro. acculturation, risk factors associated with depression among Mexican Americans saryy be similar to those in other populations. J 34 ABSTRACTS TIMN 322491 ~ ,
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1114 Ajaa S. Friediob and Iames P. Hadle Health Care FinancIn Administration fice o emonstrations and valuat ons, B timore. Maryland EVALUATING THE INFORMATION BROKER CONCEPT: EVIDENCE FROM THE HEALTHCHOICE EXPERIMENT In support of Medicare policies that afford beneficiaries greater choice In coyerage, further research Is needed on the roles that information on the prepaid Medicare concept plays in the enrollment decision. This paper examines the contribution of an "information broker", HealthCholce, Inc. in improving consume welfafe in the purchasing decision. Since February 1983, HeaithChoice has counseled Portland, Oregon Medicare beneficiaries on the availability of prepaid alternatives and has acted, at one time or another, as the sales agent for four Nedicare HMO risk-based contractors. The study ls based on a survey of approximately 1050 Medicare beneficiaries in Multnomah County, Oregon with two-thirds of respondents persons who enrolled in 3 Medicare i•isk-crontracts or tM Kaiser Portland Social/HMO demonstration during the period October 1, 1985- March 1, 1986. The remaining respondents may have considered a prepaid alternative and decided to remain in fee-for-service. The paper examines if these beneficiaries were aware of HealthClwYce and HealthChoice's infltxnce on their health plan decision. The paper concludes by critically examining the value of an information broker In complex, multiple plan competitive Medicare markets. nurses provide essential health swnitoring, early intervention, and coordination of resources to individualize service packages for their elderly neighbors. Utilizing local resources, the BRP balances the potential depersonalized nature of corporate health care. Data froa two years of operation indicate: specific serviee needs, the role of the Block Nurse in ateeting these needs, the cost of ispleweatiag this aodel, and the advantages of a neighborhood based prograa for the elderly. M Brecer. Mult. Co. Public Kealth: S. Will. OBSU School of ltursina TBE BLOCK NURSE PFA)GRAH - USING NEIGHBORHOOD RPSOURCES FOR THE HANAGE- MQBT OF CERONIC DISEASE IN COl4ffitYITY BASED LOt1C TERM CARE Rhis paper describes the Hultno®ah county Block Nurse Program (BNP), a pilot prograa.for delivery of health services to cootmity based elderly. Although pbe corporatization of health care has brought :.:-sc change in the delivery of care, the focus of the system reaains that of treat.ent of acute illness. This focus does not address the pre- dosinant risk factor in the elderly population: health deterioration associated with chronic disease. Focusing on the prevention of this deterioration, the SNP strives to extend the period of ti.e that the co®unity is a viable living setting for the elderly. Beighborhood Ann Huntsman. R.N., M.S.N.; Bruce Beck, M.D., M.P.H., F.C.C.P Barbara Huck, R.N. El Camino Hospi*al, 2500 Grant Road, Mt. View, CA 94040 Pro,lect Trans 1 t ion - Study of a Home Intervent lon for Pat ients - 65 Years or 01der. Purpose: Project Transitlon developed fromconcerns of health care providers at El Camino Hospital, Mt. Vlew, CA. The goal was to determine If traIned volunteers can provlde affective support i n eas i ng the trans I t ton from hosp i tal to home for se t ected patients 65 or older. Dosign- This descraptive study consisted of an axperimental (n=100) t control Cn=100) group.Experimental subjects were visited by a volunteer the day of discharge f called the following 7 days. A11 subjects were interviewed using OARS t recetved a fol lowup phone ca11 2 weeks after discharge. Data Collection: The OARS, fotlowup phone assessment, volun- teer's dal ly"log, discharge planning records, tmedical records were examined. Resul ts: An SPSSX computer programwas used to analyze data. Prel iminary results indicate that women over 65 1 iving alone, without firends t family In the Immediate area a^s the most vulnerable group in need of volunteor services. Final resul ts wi 1 I bo aval labie for presentation May 30, 1987. Phillips, a., MSN, Phils. Corporation for Aging (PCA), Eisenberg, David, PhD (PCA), Eutzik, David, PhD (PCA), Lang, Abigail, HSii, (PCA) POST HOSPITAL C0t4WqITY CABE FOR TBE ELDERLY The period following hospital discharge i critical to the long tara health status of elderly persons. iaafediate intervention with sooial upport and ancillary services can optimize patient recovery and care- giver effectiveness. The Post-Hospital Coam:nity Care Project provides such isssediate support to elderly patients discharged from area hospit- a1s. Adainistered jointly by the Philadelphia Corporation for Aging and the Phila. Center for Older People, the project provides a replie- able swdel for such a program. Using asseasnent and follow-up incer- vievs for 500 participants and comparison group .eabers, the research tests the impact of intervention on both short teras funetionai status and long term client outco.e. Additional data on earegivers will be analysed. The presentation will focus onpreli.inary research findings and the prograamatic model. (funded by AoA Grant #03AH 0217/01) DennisY- Nugent, Prokct Officer, Health Care Ftnanefng Administration Kathy Fllln[tson, Protect Ofticer Heelth Care Finanetotr Administration AN ANALYSIS OF THE AID TO FAMILIES WITH DEPENDENT CHILDREN (AFDC) HO6:EMAKEK/HGM.F HEAITH AIDE DEMONSTRATION- WHAT DID WE LEARN? This paper examines the operational structure, the research methodology, and the evaluation results of the AFDC Demonstration. Funded by the Health Care Financing Administration, this 4-year project was developed to study the effects of training and employing AFDC reclpients to provide home care services to elderly and disabled individuals at risk of Institutionalization. The objectives of the demonstration were to reduce the welfare dependency of the AFDC participants and to prevent or delay the institutional placement of the functionally-impaired clients. The evaluation was designed to produce a comprehensive analysis of the costs and benefit3 of Implementing a program of this type. Client outcome measures discussed include mortality, Institutionalization, health status, and the utilization of medical services and Informal support systems. The impact of the demonstration on the employment and earnings capability of the AFDC recipients is also reviewed. In addition, this paper presents a description of trainee characteristics and an assessment of performance during the subsidized employment period. Bicknell. William i.. M.D.. M.P.H.. Parks. Cind~. P,A.. M.S.. Cashman, Suzanne. Sc.D.. Boston Liniversity Health Policy inct~n~te and S.hool of ubli . He=lth. Boston. Massachusetts Proprietary Walk-Itt (:atterst What is the Reaction from the Traditional Medical C-11111aw. With a comprehensive but in-depth overview of one of the nation's largest investor-owned chains of freestanding ambulatory care centers, thispaper explores local area responses to the advent of ptoprietary ambulatory care. Located in the greater Boston anea, with 34 centers, HealthStop Medical Management, Inc. has developed basic and baseline data on its fast growing delivery system. In addition to a quantitative and qualitative description of the systems and scope of HealthStop's services, the s~tion of the study reported in this paper focuses on the tesults of a survey of the responses to and reactions from private primary care physicians in HealthStop market ateas wh&e other changes in the organization of the ambulatory care delivery system have been minimal. Areas of interest directly probed include advertising, office hours, walk-ins, case and payor mix, and charges for selected conditions. In addition, physicians' qualitative reactions to the addition of a ptnprietary walk-in center in the comraunity are diaeussdd. Rose M. Yunkar, Robert Jono, Abdul Sajid, University of Texas aad.•Br. Walk-In Clinics - Evolutillsn & Diversity Within the Industry Industry projections oL patient volume in walk-in clinics for 1990 range between 82,098,000 - 103,965,000 visits. These clinics continue to evolve as competitors to hospital emergency departmencs for the care o£ patients with minor trauma and to oftice-based physicians for patients with illness complaints. Studies indicate variations in clinic owner- ship, patient-six, tfbGrs, names, staffing and marketing emphases. Specific patient populations targeted by walk-in clinic ownarship in- clude ffi90 enrollees, workaen, military personnel. Medicare, and Nedic-3id patients. A survey of 630 ambulatory patients in three types of primary care sites demonstrates priorities of walk-in clinic patients that are different from those of patients seen in emergency rooau or traditiona7, office practices. Being able to get care without an appointment was sare important to walk-in clinic patients in their choice of visit site' than concerns about continuity or quality of care. Location was a prim factor in selection of visit site for patients of both the walk-in clinics and the emergency departments, but of lesser importance for patients visiting office-based physicians. The volume of workman's compensation patients was associated with higher numbers of males seek- ing care at individual walk-in clinics and emergency departments. 1116 DianeMSil.er-Btazas, pichard Fine, Annoa Lbon San Francisco Gemat.al Hosoits]. EfFDGi CF A FLISPITAL F111AD7CIAL WOGRAt. FCR Mf-DI. __ "1'AFP TRAnMZG As a county Inapital, San Frtutoisco Gerteral Xospitsl is obligated to provide health care to its county residents regardless of the patient's f3z>,ancial status. In recent years, the Hospital has been faced with dilsama of p.=+v+A+ ng quality health care to an increasing numbar of hig risk, t:rsdically ind+9eat patients at a time of decreasing public funds and rising medical costs. in addressing this iswe, the Hospital has looked for ways to not only improve the egficiency of its ssrviccs but also to improve its reveraie genetatint3 ability. Ctte inet2rod being explored is to increase the efficiency of the Hospital's billing system by incmasing the involve ertt of the "edica1 housestaff. A study is being mtt3uot®d to detennine c.fnther ttainincJ andd involving providers ` Hospital's bil).inq andd financial p]amti.ttq oxocesses•will improve the hilli ng systae. It has long been contended that patients aree not fully bi).led >ee"^m their visits are not accurately dccuresit.ed by housestutff. ~Lhis study will ocaaare the levels of billinq before and after *he training program and deternd.tte the inport:attce of inwlviM ygrasestatf i. Hospital Flrm=. TIMN 322514 -J ABSTRACTS 57 I
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1144 QUALITATIVE ISSUES IN HEALTH EDUCATION RESEARCH: AN ALTERNATIVE I PARADIGM a+ll. Assumptions underlying the positivistic paradigm of research are examined and other ways of thinking and knowing are proposed. Empiric research has served us well in addressing those questions which it can answer. But there are unanswered questions which call for new ways of inquiring. The alternative paradigm is referred to as qualitative, naturalistic, ethnographical, phenomenological, as well as by several other designa- tions. There are distinctions among these alternative approaches, but the distinctions are of less import than the similarities of their theoretical premises which are grounded in natural settings. Variations may exist in the assumptions made about the nature of the person, place, thing, or process to be examined, the questions to be explored, and the techniques to be used. Constructed realities and geqeralizations will be examined in relation to context and time as essential to understanding phenomena under study Examples of health related research, both completed and proposed, using a naturalistic approach will be presented. 1145 Richard Gist, PhD, & Q. B. Welch, PhD1 Office,of Research and Analysis. Kansas City, Missouri Health METHODOIAGICAL AMD INTERPRETIVE ISSUES IN CENSUS DATA AND NEEDS ASSESSMENTS RELATING TO HOMELESS POPULaTIONS Increasing attention to hcmelessness from health officials, taSman services agents, policy makers, and the general public has led to a growing and confusing array of statements regarding the magnitude of the population, their various needs, and appropriate responses to meet those needs. The critical application of systematic empirical methods in establishing these data can greatly contribute to the accuracy and the clarity of both the data and the decisions to be smde. To effect this and, a representative sample of published studies and estimates is considered in terms of inethod employed, definitions used, purposes of the inquiry, and strength of the logical and or theoretical link between question, method, data, and conclusion. It is shown that where empirical designs have been employed, results have been surprisingly consistent, where other approaches (key informant, agency contacts, etc.) have been used, such greater and possibly exaggerated estimates have resulted. Both practical and ethical implications for future studies are discussed. Betty Morrell, MS, Philadelphia Health Management Corporat an Sta-n o85, ., an arypat racy, VARIATIONS IN SOCIAL SERVICE NEEDS AMONG A HOMELESS POPULATION There is a growing interest and concern about the specific needs of the homeless population. Preliminary statistics from a data base describing over 1000 clients seen in Philadephia for two years show that almost half of all clients contacted need some type of social service related assistance (e.g., housing, medical benefits, transportation). This paper examines these clients by the type of their social service problem, and the profiles and compares them in terms of their demographic characteristics (i.e. age, sex, race), their pattern of contacts with health professionals (e.g. frequency and/or location of contact), and the other types of medical or social problems identified (e.g. podiatric, vision, drugs). The study findings provide information about the systemic responses needed to address a homeless population with varied needs. ' Rita M. Valade. M.S.W. Johns Hopkins Hospital. Willisa R_. Breakey_, M.D. Johaa Hopkins Dniversity. SOCIAL WORK CONCEPTS IR RELATION TO PSYCHIATRIC SOCIAL GxIRP AMDNG THE HOMELESS MENTALLY ILL This paper reports our experience of providing psychiatrir,_services to the homeless aentally ill in light of three basic Social Work concepts: I)Reginning where the client is; 2)Pereon-in-Situation; and 3)Client's Right to Self-Determiaation. Successful interventions demand accurate assessment of the patient's attitudes, experiences, and receptivity to psychiatric intervention. Furthermore, understanding the personal environment, social mores, lifestyle, and survival tactics of the ho.e- less person is integral in establishing a therapEutic relationship, providing appropriate treatment and enhancing complianca. The relation- ship between the patient"s right to self-determination of life style and treatment compliance is also explored. Case studies will be.used to illustrate the three concepts and some of the diles•as facing the professional in providing psychiatric services to the homeless mentally ill. $. Kleinman,_OTEr S. McKnicLht MNj E. €rank-Regan, MSN; R._ Gia ,~ 2~L~~1e1~.~ Ph4,,, office `of Ri~seai8fi and Analysis, Kansas City, MO Health Department LIFE SKILL ASSESSMENT AND ANALYSIS OF IMPEDIMENTS FACING HOMELESS MEN Ild AN URBAN SHELTER Intensive interviews with residents of an urban shelter :oa homeless men were conducted to assess adaptive living skills and behavior patterns among a probability sample of clients. Rather than seeking evidence of pathology or assigning psychiatric diagnoses (as has been the objective in most prior studies), this approach was concerned with the relationship between current attitudes and behaviors on-the one hand, and the ability of formulate and achieve specific realistic go'als on the other. Where impediments were evident, the design sought to shed light on the ori- gin and nature of those impediments and to suggest practi- cal interventions. Findings are compared to and contrast- ed with a variety of published studies and technical reports to synthesize a more practical view of the majgr homeless populations and their varying needs. INTERAGENCY AIiD INTERGOVERNMENTAL ISSUES IN THE CARE OF THE HOMELESS CHRONIC ALCOHOLIC The reclassification of public inebriation from mis- demeanor to syndrome, coupled with the shift in the expectation of public action from arrest to treatment, required a variety of shifts in public policy. A variety of changes in the systems involved and a resulting com- munity crisis brought into sharp focus weaknesses in the assumptions which directed these shifts. Evidence col- lected raises the hypothesis that, while chronic inebri- ates may represent a minority of the total homeless pop- ulation, they may be the most prevalent chronic members. The need to develop procedures for the involuntary detention and more appropriate treqtment of these persons requires the interaction of mental health, public health, police, and court systems, along with redesigned approaches to coordination of services between public, private, and charitable human service entities. 1146 J Okta Ph0 Uaiversit of Mar land and J Mamon PhD L Bon® MPH M Fa ev H D SLeinwachs h0 00 of H oiene and ub ic ea th Johns Ho kins Universit . DISCHARGE PLANNING: W T DO SOCIAL WORKERS REALLY Do? While NASW and the AHA have set standards for discharge planning (oP) for Social Work (SW), very little is known about what actually takes place "in the trenches." Ase the standards even realistic considering the context in which discharge planning actually takes place? This paper describes the OP activities performed by SWs of 1100 ran- domly selected elderly patients discharged home from 5 hospitals in Bal• tiaare. SWS completed forms on 98%. About 25% received social work service/assessment. SW cases were identified via admission sheets (25%: rounded (20%) and referrals from other professionals (50%) For 30% of the cases, SW activities were concentrated in the last 48 hours. Results show that while a broad array of social work activities are involved (e.g. education, counseling, referrals) the majority of cases received very little SW time (less than 2 hours) and were felt to be un- probiematic. Of cases opened by SW, referrals were made for home healtt care (85%), equipment (24%), psychosocial (5%) and social services (27%) Characteristics of the more difficult cases are described in detail. Implications for social work are discussed. Dr. Susan B1umPnfield, Mount Sinai Medical Center Dr. Andrew Fleissman, Mount Sinai Medical Center Dr. Gerard T. Reardon, Mount Sinai Medical Center PATIENTS, HOSPITALS AND COMMUNITY RESOURCES: WHERE PATIENTS GO AFTEL HOSPITALIZATION AND iJITH WHAT SERVICE The changes in the health care environment, specifically those relating to health care delivery, reimbursement and quality assurance, have forced social work departments to examine more closely, the outcomes of their discharge planning programs. A pilot study was done at an urban academic medical center to determine where patients from the medical-surgical services go upon discharge from the hospital. The services that were put in place for those patient upon discharge wns also examined. Staff, supervisors, and managers developed and refined a data collection instrument over a three month period. Findings will be reported on data collected for the following year. Implications of this methodology for other areas of the hospital, quality assurance and other institutions are dis- cusaed. Recotmtendations will be given for further study, program development and directions for social work education.l 68 ABSTRACTS
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Terreace L. Hay and Deborah K. Williams Health Care Financir-g Adainistration, aaitiaore, Maryland Explaining Fge Differences Asong Physicians Wide variations in physician fee levels have been reported in the literature. These findings have attracted considerable public debate as to whether these differences are justified in terms of "raasonable" practice costs. In this study we analyzed differencas in physician fees for office visits, hospital vtsits and other selected high volume procedures. Thesa relationships vere studied using a nationally represeatitiva saaple of 2303 physicians from the 1983-84 Physicians' Practf:e Coats and Iacoee Survey. Regression results confirm that practice costs and area cost of living are significant predictors of physiciin fee levels. The role of other important factors such a: physician experience and demographic characteristics, practice voluae, time spent with patients, and competition are also exaained. Implications for policy development by third ;.arty payers are also discussed. arr JK, Empire BOBS, Pink R, NY Medical College, oloabotos J, Columbia U, Schachter M, Empire BCHS HYSICIANS' DECISION MA.l1IN0: EFFECTS OF HM0 MODEL TYPE AND CHARACTERISTICS OB MEDICAL PRACTICE ON UTILIZATION ata from a national study of 167 HMOS were analyzed to learn how organizational conditions of practice and payment echanism may affect physicians' practice decisions. Fac- tors such as physician staffing patterns, practice arrange- ments, and quality review mechanisms, In addition to mcde f reimbursement and type of HMO model, are hypothesized tc act as internal constraints and incentives which influence physician behavior. The data show that IPAS are distinctly different from other HMO models: more physicians in solo practice, reimbursed by fee-for-service, and seeing a snall roportion (<15%) of HMO enrollees in their practices. Also IPAs are characterized by more fully developed quality as- surance programs and m6re financial risk for individual phy icians (39AG vs. <15% of staff, group, and network HMOs). IPAs tend to have higher hospital admission rates (94/1000) nd lower office visit rates (3.0/member) than staff and etwork HMOs, but the patterns are inconsistent. Multivar- iate analvsis is used to c}arify other sources of variatior. Steven F. .1n+nka, Mii, tSH, Deborah 1C. Williams, ttS, John C. Lang- enbrunner, ADD; u.S. Health Care Financing Administration (HCFA) Predictors of Phssiciaa Income: Iaplications for Policy Reform Expenditures on physician services has been a policy issue for sore than a decade. Using the most recent HCFA-sponeored national survey data on office-based private practice physicians, the authors have developed an econometric model to examine patterns of physician income in relation to s•aeh factors as practice style, work effort, productivity, training and credentials, gander, and payer six. Results both reinforce and dispute previous policy research and evidence on physician erviees and fees. For example, solo practice is inversely related to higher income levels only for non-surgical specialties. In addition, fammile physicians (medical and surgical specialties) continue to earq,less than their sale counterparts - perhapi due to discrimination - though the historic gap is narrowing. Overall, the range of findings are reviewed and discussed, especially in the context of current physician payment policies and proposed reforms. 1117 ~ Lavrence H Walker Ph.D. Graduate Program in Health and Medical Services Administration, Widener University, Chester, PA. ,..." ....,.."." .,.,. ...a,c......,~„: ,. vc.rrv n.aveara.n.rTnr nvTrnws USING STaATEGIC ADAPTATIUN NDDSLS Health Care institutions and programs, especially hospitals, are seek- ing to diversify their service aiz in an effort to cushion the per- ceived impact of new third party payment mechanisms and changed econo- sie structures and conditions. However, relatively little is known about which factors influence diversification and perhaps even less about how to go about its iaplesentation once a decision has been aade to carry it out. Since one of the nain reasons institutions change over time is to utilize resources sore profitably and efficiently given a changing de- sand structure for their products, strategic adaptation models, devel- oped to help better understand how corporations in a business environ- sant adapt and change over tiae, aay provide a useful theory base for understanding how health care institutions handle diversificatiop as well. Several key strategic adaptation models are presented and dis- cussed together with short case studies illustrating their use in a health care environment. 58 ABSTRACTS Jeffrey A. Alexander, Ph.D. (U• of Alabama at Birmingham) and Laura L. Morlock, Ph.D. (Johns Hopkins Univ.). CORPORATE RESTRUCTURING AND HOSPITAL POLICY MAKING, This. study examines the effects of corporate restructuring by non profit cor.munity-hospitals on the 9tructure, composi•tion and 'rdTe of hospi.tai•govehning boards:•-Ne expect that the policy making function of the hospital. wil.7 change to refTect the multi-corporate structure implemented under.corporate restructuring, the over:•lapping boards and di•vewsifled'business responsibilities of the new corporate wtfty. Speci€ically, we hypothestze that the hospital board under corporate restKucturing will more reflect the "corporate" model found in the priviEe --busi,ness sector and-less the "philanthropfc" model comeon to most communlSyc hospitals to date. The analysis utilizes survey data on 1037 hoapitals imdergoing corporate restructuring fFOm 1979 1985 and 1883 non-corporately restructured hospitals. Findings are discussed in termi of the blurring distinctions between for profit and non profit activity in the health care sector as well, the implications for institutional and cormunity accountability. Deborah A. rlan Ph.D. Emor Universit School of Hedictne Ue t. o Communit McFaHealthdHPH Pro ram 3 Gatewoo Rd, t anta 3 4 STRATEGIC RESPOIiSES TO COMPETITIVE FORCES It1' THE HOSPITAL IIIOUSTRY: A STUDY IN STRATEGIC GROUPS The hospital industry in Tennessee, comprised of 1/3 not-for-profit private; 1/3 not-for-profit public and 1/3 for-profit hospitals, offers a unique opportunity.to study the strategic responses of hospitals of d€ffering ownership status to changes in the industry s competitive envirornent. Porter's model of..forces driving industry competition was used to identify changes in the canpptitive enviroment of the hospital industry in Tennessee from 1980,1984. Seven strategic responses-diver-• sification, innovation, growth ire narket share, brand identification, quality, cost and use of financial.l'everage- were measured for each hospital as of December, 1985. •A cluster analysis using the'seven stra- tegic responses as cluster.ing"vaYiables was•performed'to identify stra- foribetweensgrouphdifferences insownershipustatus, size,olocat€on,tandEt multihospital system group membership. The only signifiyanE difference n~ificant,~indicatingcthat hospitalsz@regardless ofsownership,naresig- resDonding strategically in similar ways to changes in the comp. envir. Warner, Lora H., Mgd., and.$egun, James W., PhD., Department of Health Administration, Virginia #pimanwealth University. CONTROL OF STRATEGY-MAKING WITHIN SMALL MULIT-HOSPITAL SYSTEMS Hospitals are foieing,cultihospital systems,(FtliSs) with growing frequency. About 80% of MHSs are small, composed of 2-7 hospitals. An €mportant policy and manftement issue in NHSs, whether small or large, is the extent td which member hospitals surrender autonomy and authority over their own strategic tlirections. Using a contingency framework, the present study uses both system•and hospital.level var- iables to explain the extent to which hospital members of MHSs con= trol their own strategy-making. Survey.and secondary data from 272 mesber hospitals of 62 small multihospital systems (size.2-7 hospi- tals) are analyzed. System dispersion, size, ownership, strategic type, and stage of development along with hospital performance, size, distance from corporate headquarters,.relatienship to the corporate entity, length of inembership, and market factors are determinants of the locus of hospital strategy-making within MHSs. Pratical impli- cations for management in small°multi-hospital systems are discussed. Ellen M MorrisOn, MA, Center for Health Services & Policy Research, r es ern versCi:y: ~ ep en orfeTl-P @ o9g aUUdL@ JCnOC! 07 managemen~. Mn uieeate University STRATEGIC MANAGEMENT IN INVESTOR-OWNED AND NOT-FOR-PROFIT MULTI- HOSPITAL SYSTEMS: RESULTS OF A THREE YEAR STUDY The process, content and implementation of strategic planning in eight multihospital systems will be presented. Over 100 top corporate executives in three investor-owned and five not-for-profit systems were interviewed in depth in 1985. The eight systems represent approximately 600 owned and contract managed hospitals located in 43 states. Follow-up telephone interviews with approximately 40 top executives are currently in progress. Interview topics focused on strategic reaction and proaction to the Medicare Prospective Payment System and private third party payor cost containment efforts of the early and mid 1980s. Analysis of 1985 data reveals varying levels of strategic sophistication among the systems, and entry into health care financing, diversification and non-health lines of business. Qualitative interview analysis will be supplemented by findings from 1985 and 1987 surveys completed by corporate staff and hospital administrators. Similarities, differences and overall industry -.ie .ai 11 hn ii -,een,l TIMN 322515
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Casiille Claymon. PhD, and Miriam Dinerman, PhD, School 0 ocia'T-7orfc; R-uf-g-ers University ew BrunswicK-.-WT- VARIATIONS IN THE DISCHARGE PLANNING PROCESS Effective adaptation of discharge planning to prospective pricing is necessary to assure continuity of care and efficient use of health care resources. Provision of discharge planning services has been found to reduce length of stay and to account for major portions of hospital social worker time. On the other hand, there is evidence that neither screening criteria nor discharge planning services are currently meeting post hospital'needs. No systematic study of the discharge planning process has been undertaken previously. This paper is a report of the developmental research methodology and preliminary findings in a study designed to map the discharge planning process and to determine the extent to which it varies in conjunction with organization, discharge planner, patient, and resource characteristics. A.E. aain 140. and Pamela Hanes Spolm, M.S.H., Institutn for Heal and Aairg Ativetsity of ~g~atr TiE CiiANCIIiG = O€ RfM SOC91I. 1iORKEL IN 48E li6PP1AL DIgcRhrcz PIPt8027G PADCM.S The role of hospital disdan7a plamitg is imtnesing in impoztanoe as nldarly pntiarts ara being released frzs hospitals aooner and with high.r aatity lnve7.s. Sina the flill iag)ementat,ion of Msdicazs's Pccspactiv. palmnt syaf= (PF5) for hospitals in 1984, there haa been a rnkabls redutictt in let gttrof-sGay aaorlg elderly Medicarn patients and an in-ro+•.e in the need for tisnly and appropr+ate poet-3:eapita7, cars pleusting. A reoettt s.uvey of 200 ran3aly selnc,-t.d arut~ cat a hcspitais in five statns suggssts t2tat post-InspiYal patisnt - platnltrT is being initiated auch soaysr, that mesters' level sodal worlaers are ixrseasircfly invo].ved in t2lese activities, and that the autatay and de-i.icru„Nng muthrity of the social wortt dischatt,)e plamar have bnan expanied. At the same tian, issuss of phyaician authority, lxagtontatiat, and service nvaiirt,ii ity eorttinun to core0tr.i,n the effectivarss of dis$ratgn platnezs. 1147 Howard S. Berliner and Robb K. Burlage, Columbia University, New York, N.Y. METROPOLITAN ACADEMIC MEDICAL CENTERS: RESPONSES TO A FOR-PROFIT ENVIRONMENT This paper will examine the social, organizational and financial environment the metropolitan Academic Medical Center currently inhabits. Increasingly, the AMC must contend with forces and institutioni which promote the for-profit model of health care delivery, as well as proprietary forms of medical research and technology generation. By examining the responses of AMCs in 4 major metropolitan areas (New York City, Chicago, Houston, and Los Angeles) we will report on how different centers are responding to this new challenge to their structure and mission. Alonzo L. Plough, Ph.D., M.P.E., Tufts University, Medfora, MA. FOR-PROFIT DIALYSIS CLINICS AND TAE ACADEMIC MFDICAL CENTER: IMPLICATIONS FOR THE ORCANI7ATION OF HIGH-TECH MEDICINE The profit:-making dialysis industry largely emerged from a base in Academic Medical Centers in the late 1960's. A "revolving door" between Academic Medical Centers and for-profit dialysis cenrers characterizes the current relationship. Nephrologists can wear two hats; as attending physicians in the Medical Center and as a staff member or director of a profit-making clinic. This paper will present findings from an empirical study of the case-mix differences between profit-making dialysis clinics and Academic Medical Centers. The greater patient severity of Academic Medical Center patients is often related to the "revolving door" phenomenon. There are implicationa of this practice for other high-technology procndurea in the academic medical setting.crhere.clin_ie entrepreneurs control the flow of patients. Fain, Oliver, M.D., College of Physicians and Surgeons, Columb,ia Uniyersity, New York, N.Y. FOR-PROFIT ACTIVITIES OF ACADEMIC MEDICAL CENTERS: A CASE STUDY Over the last decade, Academic Medical Centers, in spite of their non-profit status, have undertaken a variety of for-profit initiatives. This paper will examine descriptively the for-profit activity of one metropolitan Academic Medical Center. The range of activity from the establishment of food services to the creation of consulting firms will be examined. The reasons for the choice of particular activities and the relative importance of each will be explored. Comparisons to other medical centers will be made. Louise H. Warrick, Cs.P.H. University of.Arizona 9JURCFS OF RBPORTED ERfOR ON THE ARIZOhA BIRTH CERTIFICATE A follaw-back survey of 1984 births in Maricopa County, Arizona of disadvantaged mothers was conducted by telephone and home inverview (n-339). There were four items on the birth certificate which were validated with the nuther at the sutvey: Hispanic origin, cesarean birth, nurber of prenata].visits, and month prenatal care began. Using the mother's report as a standard, the level of agreement be- txeen the birth certificate and mothers' report was examined. 'L1n greatest discrepancy between the birth certificate and nnthera' report aas nurber of prenatal visits and timing of prenatal care. In this case, 56% of the birth certificates were misclassified with the mother usually reporting nnra eare than the official record. A systenntic error in reporting waa discwered related to the inplennn- tation of the State Medicaid dennnstration program (AHCCCS). Review of procedures for filling out the birth certificate at one hospital indicated lack of srrn,i,,.ds, uplications for quality assurance of vital records are discussed by the types of errors found and their source. Ellen M. Naor t Donald R. Lemieux, Maine Department of Human Services , THE ACCURACY OF PARENTAL wOR*wISTORY DATA ON THE BIRTH CERTIFICATE In 1983, the Maine birth certificate was revised to Include infonoa- tion on the usual occupation and Industry of each parent during the 12 nonths preceding the birth. This information is valuable for detecting and monitoring potential workplace hazards adversely affecting pregnarr cy outcome. This paper tyports the results of a followback survey to determine the accuracy of the data. The sample data suggest that occupation S industry are reported some- what more accurately for the father than for the mother. Specific pro- blems include 1) the reporting of the most recent, rather than the usudi, occupation s industry, & 2) the reporting of "housewlfe" for occupation when the mother had been employed for wages. The completenest of reporting was acceptable; approximately 90$ of the certificates sampled had codable entries for both mother's & father's occupations. The results of this study are being used to identify changes needed in the hospital worksheet for preparation of the birth record and to plan educational programs for individuals filling out certificates. 9itit-Fn H.atr 133.w3 F. N3a }fodt BtefE CNtatast Hmlth . Alte[N. CY 17137. H3lPIHdB pRQE IN'tEF:'S O? aS>11~SAL Pr'~BII.IIY Pte.ala2 cets hs. 7ag ts:n used as a stanJftd mssaze for the hsslth-zelated xe- sss.dh. prm- mnerl by noaccreepXim3 or ndssags cP Revelam mte, tc&aner, or stilll te fand in neaty actldeks. A mmrn eettr, ard the foaa of thia psps, is fai3hae to crnlLtiam m'a36.ait NOCiables'. 'Ee,lc.ait vsl8ilas' irrhxis asPling achs , mxlimll irisEa.y, or arotis risk fed~ fx the dL~ese ucts {^se."{^„'i^'. Me premsta+i•*+ wi11 be fan-foY3s first, eenp7es w1]1 be gLan thst d3tonslxafe the nooessitY aE ,.,rtsr;,,,i 9, aadsti, fmnilae w211 be dedced u-der the ozrlitimsll ad •,•,,ts*i.*.+t asu:ptias, third, c++-t'm{^s zetindwith^+Airion+l ad .=%>'r;s,a mtss aos the seee arlr only Nacy •M*r+'+i'.e aasuiptlan. 9isse assu:ptiag wd71 bs disnmed aul crt;••rt- 1b:atty amiilts wi11, ts extadad to 4rifl- d3~ sabe. TIMN 322526 ABSTRACTS 69 I ~i
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I John E. Helzer. M.D., Washington University School of Medicine PREVALENCE AND PREDICTIVE VALIDITY OF DL4 DIAGNOSIS IN GENERAL POPULATIONS Diagnosis In psychiatry has benefited greatyrfrom the development of highly specified criteria and structured interviews based on them. The Diagnostic Interview Schedule (DIS) was developed specially for the Epidemiologic Catchment Area (ECA) Survey. Because it is based on Ik4Bf-IH, because it can be given by lay interviewers and scored by computer, and because of its use In the ECA survey, the DIS has becolne popular for epidemiologic and eiinieal work. Drawing upon epidemioiogic data for DSSId-DI alcohol abuse end dependence in several study sites (U.S. and Puerto Rico, Canada and Taiwan), prevalence and predictive validity data are presented. Raul Caetano M.D., Ph.D., Alcohol Research Group, Berkeley, California DISCUSSANT - P fte 5( DdR Besides discussing the results and implications of the papers In the session, this presentation will also focus on the proposed changes in DSM-IB concept of alcohol dependence, Its advantages and shortcomings. Indian Health Service Task Force Parity Funding Requirements For The Indian Health Service This report exaaines the parity coneept by cosQarison the Indian Health Service and U. 8. populations in terms of health status and the availability and use of health services. Smith, Ellen ?t., Office of Technology Assessnent U.S. Congress __ CLINICAL STAF?'_`.IC 114 THE INDIAN HEALTH SERVICE: ISS:JES, GPTIOHS, ACTIONS The Federal andian Health Service (IHS) has been dependent on phy- sician recruits frc= the 'Tational Health Service Corps (iTHSC) to staff its hospitals and clinics in the 1980s. The `7IISC is being phased out, however, and after 19RR few physicians will be available to IRS. IHS has not been able to fill its vacancies with voluntary recruits. This imminent staffing crisis has prompted expansion of voluntary physician recruiting activities in IHS, as veil as concerns in Congress about its effects on the ability of IHS to deliver services. The congressional Office of Technology Assesiment analyzed the IHS staffing situation and presented issues and options for action in a report and hearings in spring 1987. The present paper sunanarizes those issues and options, and reports on IHS and congress- Lonal actions in response to then during the first session of the 100th Congress. 74 ABSTRACTS 2005 Williaa A. Knaua, Dou laa P. Wa ner, Elizabeth Ika sr ICU Research UnLt, Georga Washington Univsraity Hedieal Cenier Was Sngton DC EXPLAINING VARIATIONS IN OUTCOME WITHIN CRITICAL CARE UNITS: THE VALUE OF CASE MIX ADJUSTMENT. Substantial effort in devising improved case aix adjustuenta for neonatea and adults treated within critical care unita are beginning to yield benefits as variations in patient outcome are linked to dif- ferences in treatment policies. A recent co>,parison of outcoae rong eight tertiary care neonatal ICUS uncovered inportant variations in the incidence of low birth sur- vivora who had chronic lung disease. The significantly lower Snc1- depce in one center was attributed to a unique, coordinated, non- intrusive method for treating neonates with acute respiratory prob- less. A risk-adjusted study of adults with acute burns linked the probability of survival to the speed of burn grafting. A detailed comparison of outcome from adult intensive care in 13 major uedical centers linked variations In tha number of patients surviving to the coordination of physician and nursing care. These studies uncovered new insights that could have important S.plications for the treatment of future patients. Hulrv Krakauer bD PhDOffice of Medical itevle:+. Hlth Care Fin Pdn CASE NIX ADJfFaL'^B.' IN R4EE ASSF5mw CF T11P: EEFIDLLTIVFPIFSS OF b'FDICAL PHTCtZCES. Tye asrett re.,e..,^-isibilities of the Office of Nedical Review, WhiG1 Ralages the Peer RevieW Organizations (PPas) incluft the mxlito:ing of the effectiveness of the care retldered to M®dicare beneficiaries, asseessmalt of the performerlCe of hospit.als, and the developmerlt of standards for the review of inedica.t practices. In each instancc, 31e allocrdnce aaist be nede for patient characteristics, i.e. case mix. 7]us, in amitoring secular trerds in the oatco:ms of hospitalization by meaz:s of the a8ninistrative data available to HCFA, it has becana apparen* that t2ns sutast~tial increa.se in po;st-a3nission nurtality rates froa 1984 to 1985 aId the lesser increase from 1985 to 1986 are due, in substantial part, to c31anges in the case mix of hospitalized patients. Similarly, the rankings of hospitals based on post-admission anrtality rates are significantly affected by case nix, nearly half of the interlnspital variations in this lneasure being aocaa[Ced for by a limited array of diagnostic predictive factors. 4tlet alternative approadles to the marlagement of a eondition are assessed, various t®Qniques for case mix adjustmmt are available aIri will be illustrated. Mark Hoskovitz and Liaa IezzonL Boston University Medical Center HEflISGROUPS: AN ANAL1rfIC ASSFSSXENT Mumsrous case aaix systas have besn developed to improve and modify the DRG system for payment and quality assessment. Using a data set of 54,112 Medicare cases for 28 of the most frequent DRGS in 24 U.S. hospitals, we evaluated tMe ability of one of these systeas, HedisGroups, to explain cost. rbr untri.aed data, URGs explain 23% of the cost variation. ldding within-ORG MedisGroups scores increases the explanatory pover to 27%. Within individual DRGS, the ability of the HedisGroups score to explain costs ranged from 2% to 23%. For length of stay outliers, HedisGroups i.provad the explained cost from 2Qi to 26%. A set of tvelve eore physiologic variablea from Hedisgroups improved the explanatory pover of DRGs from 23% to 27%. @br DRG 127, reweighting of the HedisGroups clinical variables resulted in the explained variability in costs increasing from 4.4% for the original system to 15.3% using the reveighted clinical variables. Raweighting of the HadisGroups system eay improve its explanatory power and awy, in turn, be used as a risk adjuster for health care outcoses. Stehhat F. Jenc7s, M7. 6PH. Office of Rs:e<+ch. Hlth Care Fin Adn USIIIM C7tiSE PIIR 52•'eS[RII~FSTP 'i9 ASSE^i.4 HOSPrIAL C0.4P3 ADD QifALI1Y CE' C412E Ca.se mix aeaa:.u,rlnt al>d severity Rrasurement systms for hospital inpatients have received most attesltion for hospital p?dVmalt arri bu~ing, althazgl some were developed for assessing risk. bbre recerltly, houever, case mix mea.,^ur®rnnt has been perceived as a tool for msasaurilynd quality of care by coaparing risk-adjusted outmres across hospitals. Refirleaerits to the IFG system that inprovd the ability of IPGs to predict costs for individual cases provide mz91 smalier impcovetenMs in the prediction of average cost per case at the hospitall level. Bq contrast, refir>emalts that iaQrove prediction of likelihood of death at the case level provide substmltial isfcovements in prediction of death rates for hospitals. This data surdgests tY>ak case mix variation that is laareasur®d by systare such as rn['s plays ority a modest role in variation in hospital cost per case Idiiie umeasur®d case sdx variation aa:y play a more faportant role in variaticn in hospitall death rates. 'II1ese findilzls suggest that propos®d u7G refilleserlts as>st be jlriged separately for their ability to ispzrove payslalt and for paymatt purposes.
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Ian Rockett William Hollinshead Ellice Lieberman. Rhode Island partment o Hea t MOTOR VEHICLE INJURIES IN RHODE ISLAND: 'AN EMERGENCY DEPART'iENT STUDY This paper profiles motor vehicle traffic injuries among Rhode Island residents for the period 1984-1985. The principal data source is a statewide hospital emergency department surveillance system, which incorporates all non-ptychiatric, civilian hospitals in Rhode Island with an acute care emergency department. The resulting population- based data are supplemented by mortality data froto the Division of Vital Statistics at the Rhode•Island Department of Health. . InJury cases are differentiated by age, sex, road use status, and level of. care. Epidemiologic measures include incidence rates, case-admission ratios, and case-fatality ratios. The respective-annual average• numbers of motor, vehicle traffic emergency department case's; admi's= sions, and fatalities over the observation period were approximately 11 600, 940 and 92. The paper concludes with a discussion of 11ata deficiencies. Rafa+l_aa I(oblas, Rutll Msrtlnez Mildted Vera aad' Mst®rita A1ssr4a Sdx+ol of Pob).ic Mealth (kuvernitv c= Puerto Rim HEAL74i SHNICYS AMD WOMW 3ffitIISZATTLN IN R&82U RICO Puerto Rico has one of the highsst rates of fas.le stsrilizatias in the wcrld. Howevar, thsn is no informatim of the type of lf~.aith oc hea].th ptefeasicna.is that Puerto Rican w®sn go what aiztzarta at$ ~t Ft iat~~~. 2his pspsr iimeetic)ates undsr type of ssrviws Puerto gicart wuesl utiliza fca- this amth0d of fertility crntrol. 11xs data were ob- tainad fzts p.rsonai, intarviews of 3,175 woara throughout the Island using that ~nt ~~-te saaQl.ing• d~ign. The resu.tts private systa of care (51.310 for their steriliuti.al than the public systam (40.8%). Level of aduca- ti.an, avai)ability of services, uztan zesidanoe, and lower fertility wers aerng the variables related to the utilizatial of the Irivate aysta of cara. Joss s. eacerra, tl.D. and Jack C taith MSDivision of Raprod~ctiva H< 1 b Centers for Dir.aa Control aRRAM-PREDIt6 PATTRRns II PU[RTO RICO We used data froa the 1982 Puerto Rico Fertility and TaeLLly Plenaing Assessaent to ascertain the incidence of breast-feeding in Puerto Rico and to ducribe so.e of its detarainants. Among th. 5,884 births in the sazqle (delivared between 1946 and 19a2), 37.2% were ever breast-fed, havins a aran duration (!®) of lactation of 5.6 sonths. The proportion of infants ever breast-fed ras highest (59.3%) for births occurring before 1960 (M3.7.i nonths), dropped to 25.1% froa 1970 to 1974 (lID.1.9 months), and rose to 38.3% for births delivered froa 1980 to 1982 (iD.3.1 months). Infants of women raised in Puerto Rico (f.5,325) rere aore likely to be breast-fed (39.4%) than infants of wn.en raised in iw York City (17.2%) or in other parts of the United statss (25.8%). The sasr tias trends ar. maintained in these three sroups and are in contrast with the decreasing trend reported in the literature for Hezican-AOericans from 1971 to 1979. The 38.3% of infants ever breast-fed in Puerto Rico in 1980 is below the 74% to 97% reported in Latin-Aaeriea. This study provides baseline data for any future intervention strategies. I Carlos A. Munoz, Ph.D. HEALIH CARE SEFLIING PRUCffiS ANONO PUBR'19 RICARS This peper aiss to determine vhat are the most significant factors affecting the decision to use health care services in an illness episode. A demand model is e.ployed in which the outcome is defined as choice of provider. This choice is determined by out-of-poeket coat of treatment, proximity to a health care facility and the socioeconomic characteristics of the individual. Tlu data used in the estimation was collected from a household seaple of 750 dwellings through the Mester Sasple of Puerto Rico's Depert- .ent of Health. Logit estisations show the significance of ti.e and monetary costs and the role of health insurance in the patient's decision to seek health care from a general practitioner or a apecialist. Arrwbelle Irizarry, Ph,O. and PMlbs SfncMr-Ayfndez, Ph.O. U.P.R., M.S.C., Schml of P,blic FMalth TF€ SUPPQiT SYSTEM OF TFE PIERTO RICAM ELOEm-Yt AN ISLAlq-VIOE OVERVIEW Soeial a.Gport systsr are eritieal for elderly fuxtioning and ad.ptation. Ths objective of this study ws to ids,tify the support systw end satisfaction rith this sysfw of si isisnd wide saGPls of non-institutiarlizsd Puerto Rican elderly rsspordnts. Thia study is the first islud-uide study of agsd Puerto Ricans, A 31 Pa9e qu.stian.ire concerning the socisl-dsogrephic st.tus of this popuiation wes used In the larger project. The qusstions pertaining to the specific topic of suWport syst..s oozpcise nine ite+s about b.ckgrourxl infor.ation and eight 4uestions pertaining to support systw and satisfaction with the systas.. StructurW intazviews were carrisd out fres Septa,ber 1903 to 3aptsaber 1985. The tests of sig,ifieance .ere those of Kendall's Tau e and C and trse.r's V. 1h. a•3or aWort systen for r.spcrdents acs fadly s.,Wrs .M live with or sport froo thr• 3ocio-scoxs.ic oomiderations.mere fand to be an importnt influance for satisfaction with the support systes. Chamberlin, R.W., M.D., New Hampshire State Health Dept.; Gershenson, Harold, Ph.D., Ounce of Prevention Program, Illinois; Larson, Gharles, M.D., McGil1 Dept. of Pediatrics COMMUMITY WIDE APPROACHES TO PREVENTION/PROMOTION IN MATERNAL CHILD HEALTH The most successful disease prevention health promotion programs in Maternal Child Health in other countries have combined primary care with combinations of coemunity based programs involving paid maternity and child care leaves, homs visitors, parent drop in centers, quality preschool and day care programs, and social services. This 90 minute invited participant presentation will compare country wide approaches in Dereoark, Finland and Sweden based on a recent visit there by Dr. Chanberlin, with two community wide approaches in this continent. The first will be a State wide approach in Illinois (The Ounce of Prevention Program, Harold Gershenson) combiTling home visitors, parent drop in centers and quality child care programs in 35 conmunities and the second will be a look at an attempt to establish a city wide home visitors program in Montreal (Dr. Charles Larson). These three 20 minute presentations will be followed by 30 minutes of discussion about how community wide approaches might be established and maintained in the United States. Janet C. Lenart RN MN c o urs no, n versi'tv of Alashinaton A MATERNAL AND CHILD'HEALTH EDUCATION MODEL IN INDONESIA: APPLICABILITY TO THE UNITED STATES Chiidren of the poor and ethnic minorities are not making prbgress toward Health for All by the4rear 2000; as are other Amerjcan children. Developing countries, such•as Indonesia, in,which there are multfpT§ ethnic groups and many dialects spoken, have effective systems ,for reaching such populations. The purpose of this study is to•describa a national maternal and chiad health education program in Indpnesia that utilizes a national women's group, the Aenbinaan Kese,)ahti.*aan:,j(eluarga, to•ddsse.inate information to,villege women. The program incl,u,des,.a, 10-point'philosophy that addregses many.facets of health, incZud.ing income generation, agriculture, home and family •life. Thropg.n,lnt~r•' views o€ 88 individuals and participanf observation of Zb eVents, information was obtained about the program. Features of the 'FnGoneqtan approach, including planning froa the bottom-up,*training inaTgends, health irorkers, creating a sense of teamwork, and working from•a broad definition of health'would address some of the difficultifei in improving health for low-income and inmigrant families in the:U:S. Foltz, A-N. Earvard Institute for International Developaent, Cambridge, MA IRBTITDTIOnALIZATIOf AND PR6CtffiITATION OF 7!C$ SERVICES IN T9IRDifORLD CCDlrPRIES Proeotion of MCE serviees is a major 6oa1 for third-rorld countries. Such activities require additional ruources which are often provided by bilateral, aultilateral, or private donors. Dsin; the caae of Chad, this paper argues that the .ultiplicity of MC@ prograss and stratesies encouraged by these donors saY prove counterproductive because recipient countries may not be able to inte;rate and institutionalize thee within their ezistinR administrative structures. Moreover, without such strong institutional bases, these pro`raas risk becosiuR eospetetive with one another for the limited nsourcea available. This fragmentation of NCE services eEfected by the generosity of donor countries like the United States, is ezaained in light of the U.S.'s own struERle to overcoae the tyranny of categorical MCA prof(raas. 60 ABSTRACTS
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2006 Mark C. Nornbrook Ph.D. Mer n R. Greenlick Ph.D. ~[ or e enne , M. ., P e[te A. La anae. 3 ser' -~r.anen e cen er or ea Researc , Poc an , 7ZI5 axsR ADJUSTORS FOR TS= AAPCC HA$sD O3I Aa1 H74O'$ SZPlCRIElfcs In 19®0, the Northwest Region of Kaiser Peraanents began enrollaent of Medicare beneficiaries on a risk basis as part of HCFA's Prospective Payment Demonstration Project. This created a natural experiment to examine selectivity and selection bias in Medicare HMO enrollment. Three HMO Medicare beneficiary sub-groups were created: (1) HMO cost beneficiaries not electing to convert to risk; (2) FF8 beneficiaries who elected to join; }+nd (3) existing HMO ae.bers who converted to a risk-basis. Prior research has demonstrated biased selection among these three groups. The relative performance of four alternative risk- adjustaent models is examined in accounting for the dfferences in annual per capita cost: the existing AAPCC aithod (age, sex, welfare status, beneficiary status); prior use; prior chronic hospital episodes; and dynamic prior use (classification of expense trajectories over a previous n-year period). This analysis will exaaine the question of what constitutes a good risk-adjustaent model. Ph.D IMPLICATIONS OF GEOGRAPHIC VARIATION IN THE AAPCC Several commentators have expressed concern with the substantial variation in AAPCC rates even for counties located in the same Metropolitan Area. This study docu- ments that variation and explores the implications of administering the AAPCC over MSAS and State rural areas rather than counties. Such a change would lead to a potentially large redistribution of reimbursement between counties and change the incentives for at-risk health plans to locate in particular counties. The effect on the distribution of county AAPCC rates of a fully implemented Prospective Payment System with 100% national rates for most hospitals is simulated. The sources of variation in Part A AAPCC rates are decom- posed into the shares due to differences in discharge rates, in casemix and in cost per standard case. The simulation and decomposition of variance is based on a file of Medicare reimbursement records for all hospital stays and other Part A services paid during 1984. Joaeph P. Newhouse, Willard G. Hanning, Jr., and Emeatt B. Lneler The RAND Corporation RISR ADJUSTERS DEVELOPED FROM THE HEALTH INSURANCE EXPERIMENT: WHAT WDRBS 9ESTY There has been much criticisa of the Average Adjusted Per Capita Cost, the formula Medicare uses to pay organizations a capitation rate. The most serious criticism is that the AAPCC explains only around 1 percent of the variance in annual expenditure; thus, considerable heterogeneity within categories remains. To the extent that groups differ in other ways, there suy be windfall profits on adverae selection using the AAPCC. One should seek to explain variation in expected expenditure rather than actual expenditure; we measure unexplained variation in expected expenditure by the portion of variance accounted for by a person-specific, time-invariant variance component. Using data from the RAND Health Insurance Experiment, we determine hew auch of the expected variation in annual expenditure by adults can be explained by a) variables analogous to those in the current AAPCC, namely, age, sex, location, and welfare status; b) objective or physiologic measures of health such as blood pressure; c) subjective measures of health such as mental health; and d) measures of prior utilization. 2007 Alan K. Palmer, Fsq., Morrison and Foerster, Washington, D.C. . A NEW ASSES9ME.'dT Ct' HCSPITAL 10'0)GiRS: A LF7GAL PIIiSQDLTIVE Federal anti-merger enforcement during the Regan Advi.nistration has been attacked by many as not aggressive. Hut with increased hospital mergers and a heightened focus by the Department of Justice and the Federal T=de Camiission on the health care industry, hospital aoquisitieosv and mergers have received- and will continue to receive- considerable atten- tion fran the antitrust agencies. This paper will discuss the most re- cent actions by the agencies and the courts in this area, as well as the developing set of principles :mder which hospital mergers will be analy- zed. John Pisarkiewicz, Jr., Ph.D., Robert•R. Nathan Associates A NEW ASSE5,94•2JP uF ALLIED HEAhTH PHCFESSICf(AI3: AN ECX=IC PERSPECI'IVE This paper will focus on the market for nurse anesthetists and the crnpetition difficultied they face as revealed in several recent antitrus cases. Topics which will be developed include the product and geo- graphical markets in which nurse anesthetists•function, the canpetitive difficulties nurse anesthetists encounter in dealing with hospitals and anesthesiologists, and the likely impact of a fourtheaning change in status for nurse anesthetists under Medicare. The antitrust cases which will be examined involve ccrnpetitive probl€ms nurses anesthetists faced in Montana, Colorado and Mississippi. Warren Greenberg, Ph.D., The George Washington University and Lawrence Go-dbErg, Ph.D., University of Miami A NEW ASSESSMENT OF ~HIRD PARTY PAYERS: THE INDIANA FEDERATION OF DENTISTS During the last dacade, the private sector has become in- creasingly involved in efforts to curb the rising cost of health care. Private insurance comFanies as well as corpor- ations financing health care benefits of employees have real ized that they must take an active part in efforts to contro excess utilization by providers. our study shows how these recent developments affect the proper economic analysis of health insurance and also discusses a recent case decided by the Supreme Court which affirms the right of insurers to at- tempt cost control even though it impinges upon providers. Economists usually assume that health insurers passively pay physician and hospital bills without taking an active roll in cost containment, thus leading to the moral hazard problei In this paper, we illustrate the new aggressive behavior of the private sector from a Supreme Court decision and other developments and infer that this requires a new treatment of health insurance in the economic literature. 20 (1+endetyn Iris Butler Ni111ams Executive Director Connectional Heatt~ Lonm sS On c TEEN SUICIDE PREVENTION (7)E SILENT EPIDEMIC) After reviewing the statistics and demographics for the State of Louisiana, this presentation shall provide an overview of the realities of suicide, bWnning with the facts and the myths, and ending with the legal implications surrounding suictde. The signs and syndromes will be explored, combined with a brief look at depression and stress in children. Differentiation between the suicidal person and the suicide attempter shall be undertaken. Lastly, reconmendations shall be made for preven- tion in the school system and the identification of the role of the school nurse, teachers and counselors. Saundra Barnet-Re s MD. H hin s Ps hi n a 5 NY Wynetta Devore, Ed.D., Associate Professor. Svracuse Univers tv 00 of a work, Brockwav Hall, Svracuse NY A MODEL FOR MAINTENANCE OF PROGRESS WITH DEPRESSED, AOOICTED,YDONG BLACK MALES Practice experience tells us that young Black males with the dual diagnosis of addiction (alcohol or drugs) and depression can find success in treatment. The difficulty lies in maintaining the success. This paper presents a model for maintenance which focuses on the family unit. Components of the model include education of the patient and family, the conmitment to outreach which includes hame visits and phone calls and the creative use of leisure tirtae by the family. This activity provides an alternative to addictive behavior and strengthens the family. The model demands considerable activity on the part of the practitioner who must be free to move about the conmunity, be aware of its social services as well as recreational resources that are of modest cost or free, many of these farilies have limited financial resources. The goal is good rental health for the entire family. TIMN 322532 ABSTRACTS 75
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1123 Ruch-Ross, Holly S. (Harvard School of Public Health), Gorbach, Judith A. (Massachusetts Department of Public Health), Walker, Deborah Klein (HSPH) and Shapiro, Karen B. (MDPH). ONE YEAR POSTPARTUM OUTCOFII:S OF SCHOOL-AGE MOTLD:RS. This paper reports one year post-delivery outoo.es of 1069 schOol-age anthers and their infants who participated in the Massachusetts ~ Adolescent Pregnant and Parenting Study adatinistered by FIDPH. The isseunization rate for the one year olds is 90t) however, 33% have visited the emergency roo at least once and 9.5% have been hospital- ized. Early intervention programs serve 5.5%. Approximately 4% had been reported as being at risk of abuse and neglect. At 1 year, 30% of participants are in school and another 22% have graduated high school or received their G.E.D. One quarter of the young snthers are enployed) 38% of those e®ployed work aore than 30 hours per week. Licensed day care arrangements are utilized by only 11% of the participants. The level of governmental support is high; the proport ion receiving AFDC is 70%, Medicaid is 74%, wIC is 60%, and ebod Stasps is 40%. At one year post-delivery birth control is used by 77% of the participants with 17% reporting a repeat pregnancy. Dou0las L Pipar Wisconsin Division of Haalth and D, Paul Woberg, University of N(aconsin-Cantar to, Health Policy and Proqrae &aluation - _ _ EVALUATIRI FI)DINGS ON PNO.)ECr NOOEL HEALTH A thorough aveluation of Project Moda1 Haelth (RH) indicates thst it is a proaisin0 health proaotion progrr for aiddla school studants. The proyram vas an intensive. in-school intarvantion (32-37 hours par saaesteN for atb praders cc.bining sevaral proeising aducational end pravantion strategies for changing the health bahevior of adolescents. The evaluation lncludad ao axtansiv., qualitativa process waluatioo nwininq tM actual fapiaaantation of the proyrae as wall as a lonqitudinal, quasiaxparl- •ental outccea evaiuation. la+ila the Ia.adiate post-tast shored only inoonsistent rasults. a 20 aonth follov-up survey of first yenr studants rswlted In claar positiva outco..s for studants In the axperi..ntal schools on .aesures of ci9aratte sacking and lsprovad tood choices. end sa.avhat a.biguous positive outcosas in rates of sexual intarcoursa end sariJuana use. Plf1 as delivered by college students ws prohibitivaly labor intansiw. To investiset. a aore afficiant aaens of dalivary the second year students rara renda.ly assigned to eit)rr: (a) R4( lad by college student taeas or (b) PIM led by a classroom teachar. Students preferred college-a0a instructors to repular teachars. end in perticuler identified rith the sar-sas a..a++r of the Snstnu:tor tsea. Walker, D.K. (Harvard School of Public Health), Mitchell, A.k. (Southwest Regional Laboratories), Ruch-Ross, H., and Sobol, A. (Harvard School of Public Health) TWO YEAR pOSTDELIVERY OUTCOMES FOR TEEN MOTHERS Iffi PRENATAL AND PARENTING PROORAMS OF THE TOO-EARLY-CHILDBPAAING NETWORK Four programs In the Too-Early-Childbearing Network have been using a longitudinal follow-up evaluation sodel to assess pr ogram impacts in several areas: e.g., completion of high school, repeat births, employment, Christi, TX welfare use. Prenatal programs included are in Corpus (90% Hispanic), and Sarasota, FL (71Z Black); post de- livery programs are in Boston, MA (83% Black) and Rochester, NY (76% Black). Data for program participants and local comparison groups collected at intake, birth, one and two years after the birth of the baby will be presented in this paper. At two years post delivery, in school or graduation co.pletion rates (Boston - 77%, - 39%, Rochester - 56%, Sarasota - 78%) were higher th Corpus Christi an those re- ported in other intervention studies (i.e., Project Re direction). The percentage of program participants with a repeat birth at two years were: Boston - 14.52- Corpus Christi - 18.4%; Rochester -24.7z and Sarasota - 22.0%. Nolan, C.B. Hale B., Little, J., Davidson, E., , , Drawhorn-Dansay, L. ~ Hale and Drawhorn, Univeirsity of Alabama at Birmingham School of Public Herlth) Charles Henderson Child Health Center A Reassessment o f the Risks for Low Birthweight in Adolescent Mothers ' Between October and 1, 1982 September+ 30, 1986, 119 pregnant women und er the age of 20 received prenatal and labor and deliver y care through an intensive progran. The mean birthweight of first-order births was 3142.1 gms +/-497t the mean birthwdight of second and subsequent order births was 305 9.9•gm +/-533. Mean birthweight for 32 low birthweight i nfants (1500-2499 gms.) was 2152.2 gm +/-265j only two infants were very low birthweight (<1500 gms). These rates are' lower than expected. These findings sug gest age may not be an independent risk factor for low birthweight. The effects of program elements are examined and the implications for public programs and policies are discussed. M.S. Lee Strunin, Ph.D., Ralph HingaeSc.D., Hath H. Berlin, Boaton University Scheo a Pub ic Hea t. AIDS AND ADOLESCENTS: r;ENDER DIFFERENCES IN I@lOWLEDGE AND BEHAVIORS. Adolescents are a grouu at hiRh risk for exposure to AIDS. In a random of 860 16-19 year olda in Massachusetts 74% of males and e y rv l e su samp 66% of females reported being sexually active (having sexual intercourse nt of saxually r ce an pa year. T t) within the past l contac or other sexua , active males and 7% of active females did not know that AIDS is transmitted by heterosexual sexual intercourse. Only 8x of males and 7% of females reported changing their sexual behavior because of AIDS and only 11% of males and 9% of females who changed their behavior used effective methods. Sexually active females know significantly more about AIDS transmission and sexual behavior than sexually active malee. Fourteen per cent of sules and 12% of females used psychoactive drugs with 1% injecting drugs. Of those drug users 8% of males and 5% of females did not know that AIDS can be transmitted by injecting drugs. Hence many adolescents do not know what sexual and drug precautions are needed to orevent transmission of the virus. School systems and health care providers should systematically educate this population about AIDS to counter the atisinformation and confusion. eresa Scho 1, Laurie Miller, Ruth Salmon, Peter Vasilanko, University of Medicine & Dentistry of NJ-Sch of Osteopathic Medicine WEIGHT GAIN AND ADOLESCENT PREGNANCY OUTCOME Prospective data from 696 adolescents who delivered after 36 weeks gestation were analyzed to determine 1) factors associated with weight gain during pregnancy and 2) effects of pregnancy gains on birthweight, and other outcomes of pregnancy. Pregnancy weight gain was found to be associated with the following factors: mother's athnicity, length of gestation, parity and presence of pregnancy related hypertension. Maternal weight gain during pregnancy markedly increased infant birth- weight. The risk of a low-birthweight infant was reduced seven-fold (OR- .14 CL 0.1-0.2) and the risk of a macrosomic infant 13.1 times higher (OR- 13.1 CL 8.9 - 19.2) in adolescents gaining > 20 kilos. There was no increased risk for Caesarean section, fetal/neonatal death or NICU admission based on maternal weigkt gain. No effect of prepregnant relative weight on maternal weight gain was detected. The effect of weight gain on birthweight was also independent of the maternal pra- pregnant relative weight. 1124 POLITICAL STRATEGIES TO IMPROVE MATERNAL & CHILD HEALTH: National/Regional/Stag/Local Efforts To improve maternal and child health, leadership is needed from policymakers who will take 1fCH issues and move them forward in the public arena. Public healtJl professionals will be interested to learn about the role that national/state/regional/lcoal policymakers can play in improving mateftal and child health. By knoing what political strategies are possible, actions and results become probabl}. Leading political figures who have worked to promote mater nal and child health care will discuss political atrate- gies which can work on various levels and what public health professionals can do to strengthen those efforts. Most importatly, the panel members will explain how their giCH work fits into the bigger political picture of competing demands and diminishing resources. 1125 Sarah Johnson, Ellen Gibbs, Michael Kogan, Christina Knapp, and J.ff Hanson, of tha Massachusetts Denartaent of Public Health BaNNIEAS 70 PRENATAL CARE REPORTED IN THE 1996 MILSSACIS)SETTS PNEN/ITAL CARE 50((VEY: IMPLIG17Id( FOR OUTRE/ld( STRATEGIES The prieury objective of the 1986 Massachusetts Prenatal Gre Survey (MCPS), a fotlow-badc survey of 25BS postpartua aosen that ovenaapled inadequate or non-utilizers of prenatal care, was to identify factors related to prenatal can utilizition. Mean nu6er of self-reported barriers (i.e., financial, sociu-psycholo9iul, and institutional) for inadaquate utilizen was 2.1 for Nhites, 2.2 for slacks, 3.5 for Hispanics. (/(dequate utilizers In general had .46 barriers.)According to age stratification of inadequate utilizers, teens (<l9) and .vsn 20-24 had the highest sean nu.6er of barriers (2.5 and 2.6, respectively). sivariate analysis nvealed that saae self-reported barriers (e.s., financial barrien) were signifiuntly associated with adeqoaq across all race, a0e, and regional subgroyls. Howerer, there were alse differences In barrien anlg subqroups of inadequate utilizen. Policies and proqrass aimed at ieprovin0 prenatal csre utilization should retognize these differences. Also, the types and .:ltipllcity of barriers faced by waaen suggest the need far outreach strategies that take public health .orkers into the day-to-day lives of pregnant wanen. Exaqles of the plannin0 and ispiwentation of two cosaunity-based projects In Massaclwsetts that take into account these differences are presented. ABSTRACTS 61 TIMN 322518
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E G Gay J.J. Kroaenfeld School of Public Health, University of South Carolina ` RETRENCHMENT IN TRE FPAIL ELDERLY SERVICE HARRET: A DRG RESPONSE DRCs, passed to promote coet containment, have resulted in unintended consequences as frail elderly face retrenchment in services available within the inpatient market. Under DRGs, hospitals must find a way to influence physicians practices. This study lools at how SC hospitals tried to change physicians' behavior with potentially resource in- tensive patients, the frail elderly. Patients admitted from nursing homes, whose bill was Medicare reinbursed, were chosen to represent this population. Using the 2,338 discharge abstracts from 68 of SC's 71 short-term, acute care hospitals, changing reimbursement altered practice patterns for frail hospitalized elderly. Admissions signifi- cantly dropped between 1981 and 1984, while the overall Medicare popu- lation's admissions increased. LOS decreased by 11.1Z (no change in LOS for the nonHedicare cohort). Changes in care within special care units indicate increased screening on admission. The proportion who died increased significantly between 1981 and 1984 (16.55 to 21.4%) while the overall Medicare population's rate remained similar, probably due to admitting only the sickest of the nursing home cohort. costs have DRCa implemented as an effort to reduce inpatient Medicare reeulted in retrenchment in services available to the frail elderlv. BovlyoW, Joyte E., Assistant Professor, Dept of Community Health, University of KentucEy Aed Ctr Hospitals and Nursing Hones: Utilization and Per- tormance Before and After DRC's Relationships between acute and long cera care have become very visible due to the great pressures on hospital performance. Nursing homes have ostens- ibly felt the push of earlier discharges, although little systematic data link the two levels of care. This paper reports on a county-level analysis of all hospitals and nursing home in Kentucky in 1983 and 1985. Data on utilization of services, costs per.day, occupancy, and length of stay are analyzed to correlate changes in one level of care with changes in the ocher. Counties with shifts in acute and long term care are characterized with respect to their population demographics, income level, growth rate and ocher social indicators. Esther Hing, National Center for Health Statistics IHPACT OF THE PROSPECTIVE PAYMENT SYSTEM DN NURSING HONE CARE: EVIDENCE FROM THE 1985 NATIDNAL NURSING HOME SURVEY This paper examines the impact of Medicare's Prospective Payment System (PPS) on the utilization characteristics of nursing home residents. Data for the study are from the current resident survey of the 1985 National Nursing Home Survey, a national sample survey of nursing homes, their residents and staff. Characteristics examined in this paper include: age, sex, marital status, length of stay since admission, functional status (dependency In the activities of daily living), diagnoses and selected DRGs. Comparisons of these characteristics will be made for elderly Medicare and non-Medicare residents transferred from short-stay hospitals and comparisons will also be made with comparable data from the 1977 National Nursing Home Survey to assess change in utilization characteristics since the implementation of PPS in 1983. Conrad Kendon J. Pk.D. Northvestern University and the Veterans Administration• Hughes Susan L. D.S.w., and Campionc, Patricia F.,. Ph.D., Northwestern University. ADULT DAY CARE: STATE OF THE ART AND A PROCEDURE FCft ASSESSING QUALITY This paper has two objectives: (1) to describe the state of the art of Adult Day Care (ADC) in the United States and (2) to describe the Adult Day Care Assessment Procedure (ADCAP), a set of instruamnts useful in evaluation research and quality assurance. Previously, there were no empirically derived, quantitative .ethods available for classifying ADC programs, evaluating them, or assessing their quality. The ADCAP, a dense, 24 page questionnaire, was sent to the entire population of ADC programs in the U.S. with a response of 78% (948 centers). Structure scales include Physical Environment, Policy and Prograa Information, and Staffing Information. Population scales included Client Description and Discharge Information. Process scales include Social Environment and Services and Activities. In addition to national norns, regional, state, and program profiles are presented and their use in quality assurance is described. The ADC survey resulted in the aost comprehensive and complete data base on ADC that has ever been constructed. The ADCAP represents an innovative approach to quality assurance and program evaluation that has important implications in these fields. Nsgx 3rQSfitgC lOB !!s 4Cgg9YlGb 4C®MO 9D1YIC$IIYa ?C9Y1aSOt.la 8s1s THE IMPACT OF PACS ON NURSINB HOME DUTCOMES The affectivena.s of the Federal survey and certlfication process to assess tt.e quality of nursing hases •has been questioned.`The process, by ident;fying drficienries inthe environeent and care prnvided, should improve ovwrall care and resident qgtcoees. A new process /PaCSI was piloted and is being ieplcaented nationally. This paper reporti the results of a post test only randoaized trial of the impact of PaeS an resident outcoaes. Medicaid cfrtified nursing hoaes in Rhode Island in=1031 were randoaized into two qroups: those hoaes surveyed by both a PaCS teas and a traditional teaa, and hoaes sur- veyed by only the traditional teas. Experteental hoaes received defi- cieaty citations froa the PaCS teas. Residents were tiso assessed by nurses at the tiae of the initial survey and again six sonths later. Data an 3,025 residents were aggregated to the facility level. Out- coaes aeasured at tiae 2 included nuaber of aedications, sehtal and physical function, iaaobility, continence, and activities. Coaparing experzaentals with controls, no Significant differences ware found for arginal distributions of key variables at Time i,-or difrerential attrition due to discharge or death. No eeaninqful, sigqificant outcoae differences were found. The paper discusses how the survey can oe i.oroved to better affect outcomes. D. 8. TPertheimer and L. S. Kleinman. University of Maryland School of M e ne. IfdPL8M8NTATION OF INTERDISCIPLINARY DISCHARGE PLANNING in most hospitals, there is little communication between medical teams and other health professionals with regard to the development of cohesive end viable medical discharge plane aimed at maintaining patients outside the hospital. in this paper we describe the implementation and evaluation of mandatory discharge planning rounds with an emphasis on timely intervention by an interdisciplinary team. Participants include representatives from floor nursing, psychiatry, social work, dietary, rehabilitative therapies, quality ass:rance, community liaison nursing and a geriatrician. Thia team meets weekly with the medical ward teams (attendings, housestaff, students) to disc+Ls mental, physical and social functioning, comprehensive outpatient services and plans for smooth transitions to home or other facilities of all medical inpatients. The majority of discuaaipp time is spent on frail elderly patients because of their many functional deficits. A pretest poattest control group evaluation has been conducted to determine whether these interdisciplinary rounds decrease readmissiona or length of stay, increase housestaff comprehension of functional deficits, or increase timely referrals to other services. Results from this evaluation will be presented. Janice Mayer, R.N., Evanston Health Department HANDAT'cD QUALITY A$SURANCE IN NG TERM CARE FACILITIES The Evanston Health Department (EHD) is.responsible for the reffulA- tion and licensure of the thirteen Long Terw.Care (LTC) facilities that fall within the city boundar.ies---In 3986, the Evanston•City Council passed legislatioQ4mandating each'LTC facility to establish and implement a Quality Assurance (Q.A_) program. Although Q.A. programs have been a requirement fon.hosp.ital certtficstion by the. Joint Caraission on Accreditation of Hospitals (JCAH) since 1972. their use in LTC have been infrequent at best. This presentation will review the EHD's role in the legislative and .regulatory processes In regard to Q.A. programs in LTC facilities. The EHO assumed a role in assuring the establishment andAoplemen- tation of Q.A. programs by conducting inservices to.,fa~,iliarize staff with the purpo9e and process of implementing a Q.A. program. The effectiveness of mandated Q.A. programs in LTC will.tle'evaluated after programs have'been in effect six months. Evaluation will include both LTC's perception of impact on their ability to provide care, and compliance with standards and regulations. Thomas J. Walsh, Walsh and Assaciates CQST AND GPIALII'P RELATIGNSXIPS IN LONG TERM CARE The quality of long term care has long been of tnterest to public policy makers. In the absence of empirical measures of quality, it has often been assuswsd that higher cost care is better care. This assumption provides a poor basis for policy, however, because tt tsplies incospatibility of cost containment and good care without any empirical basis. The paper wi11 empirically examine relationships between mat and quality of care in long term care sites, using audited expenditure data aad recently developed quality measures. Ouality measures will include the Illinois QUIP data and measures of the adeqnacy of care provided by facility staff. Relationships betwo°n total expenditures and quality level and between specific expenditures such as nursing cost and quality are estimated for all facilities in a sample and for a subset identified as highly efficient facilities. Policy impli- cattons of the results are explored. ABSTRACTS 79 TIMN 322536
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Ann Pollinger Haas, Ph.D., Lehman College. City University of New Yon1 THE PSYCHOLOGICAL AITEBHATH OF LIFE-THREATENING E%PE&IENCESe PRIVATE TROUBLES AND PUBLIC HEALTH ISSUES The author's intensive study of civilian victims of life-threatening experiences (e.g. assaults, rape, vehicular accidents) establishes that a high percentage develop persistent symptoms of posttraumatic stress disorder (PTSD). As these experiences touch the lives of increasing numbers of people especially within large urban afeas', their consequences in tersu of individual psychological responses have an expanded impact on society as a whole. By contradting those who develop PISD with those who do not, factors are idantified that help protect some against the psychological consequences of trauma while leiving others particularly vulnerable. Hecomendations are made for appropriate postraumstic intervention strategies, emphasizing the role of the me.dical practitioner, peer support groups, and short-term psychotherapy. Shelley Neiderbach, PhD Crime Victims' Counseling Services Crime Victimization: A National Mental Health Crisis This session will ad8ress the nature, depth, and breadth of the national mental health crisis resulting from violent crime. Briefly, "victim trauma syndrome" (or,. Post-Traumatic Stress Disorder, DSM-Iii) is the common emotional aftermath of vinlent crime, domestic and non- domestic. This includes sexual and nonsexual violence done. to children, adults, and the elderly, the handicapped, lesbians and gays, hostages, holocaust survivors, and others who have been overpovered by those who•covertly or overt,ly threaten or act Out physl,cal abuse and/or homicide. A group-therapeutic intervention has been developed by Dr. Shelley Neiderbach and Crime Victims' Counseling Services, Inc.,-Brooklyn, New York, U.S.A. Dr. Naiderbacn, author of Invisible Wounds: will describe methods Of dealing with fear, anyer, guilt and helplessness. Other forms of emotional trauma, including anxiety, depression, lactik of trust, self doubt, civil disaffection and thee resulting unraveling of the social fabric which results, vill be presented. B. Lfma, ND, HPH, H. Santacruz, HII, J. Lozano, !ID, J. Luna, ND, and Pal. Departments of Psychiatry, Johns Hopkins Univeraity and __ University Javeriana, Colombia, and Tolima Health Secretariat, Colombia MENTAL HEALTH PROBLEMS OF DISASTER VICTIMS Seven.months after the volcanic eruption that descroyed Armero, Colombia, 200 victims were screened for emotional problems. The total prevalence rate of emotional probleas was 55%. Victims socio- demographic characteristics (e.g. living alone and being unemployed), and experience at the emergency shelters were significantly relatad to emotional disturbance. Host victims reported concurrent physical and emotional complaints, for sihich they perceived the need to receive both medical and psychological care. Implications of these findings for the identification of victims at risk for developing emotionai distress, the management of emergency shelter environment, and the delivery of primary health care services are discussed. ~ 24 Marilyn Seide, PhD, Associate Director, North Central Bronx pitalt Nancy Ray, Director, Polidy Bureau, NYS Commission or Quality of Care7 Paul Stavis, Counsel, NYS COC ISSUES AFFECTING ACCESS TO MEDICAL CARE FOR THE MENTALLY DIS, LEGAL BARRIERS, CLINICAL/ADMINISTRATIVE CONFLICTS, AND REIMBURSEMENT ISSUES 1. "Clinical and administrative concerns and conflicts regar medical services for the mentally ill." Marilyn Seide, PhD 2. "Impact of DRG's on the mentally disabled." Nancy Ray, Ed 3. "Legal issues affecting the provision of medical care to mentally ill patients." Clarence Sundram Stanley W. Eller JD MS, Schlichtmann, Conway & CrowLey Esqs. AN OCCUPATIONAL HEALTH LEGISLATIVE AGENDA This session will focus on discussion bf a Legislative agend: occupational health and safety issues. Topics to be addresset include: New Directions Programs in Occupational Safety and I The Enforcement of Occupational Safety and Health Standards; Revising Occupational Health Standards; Preventing Occupatiot Disease Through Reportingt Workplace Health Promotion; Workez Compensation; Reproductive Hazard Policy; Strengthening WorkE Community Right-to-Know; The Role of OMB in Occupational Hea, Research; and otners George A Silver ND, Yale University THE LIABILITY CRISIS:HEDICAL MALPRACTICE IN CONTEXT While the licbility crisis includes the problem of rising premiums I ieal malpract:ce as well, the roots of the medical malpractice crisis, uch it is, go deeper, and arise from many sources in addition to the ur,ll urrent liability crisis sources. Medical malpractice has its roots in tl ailure of the medical profession to police itself, allowing incompetent a d physicians to practice at will; lack of effective policing by state lic ards and the lack of a strong and effective national effort at promotinf tate efforts. in the process also, is the reluctance of doctors and hosp o take strong measures for control of m.lpractitioners. On top of this, machinations of insurance companies have compounded the problem in many the liability crisis, if you will, which derives from greed and profitee Beyond this, too, is the lack of accountability of the medical professio together, failure to share inform.tion ano education in medical practice the public, which would increase confidence, reduce the suspicions and o ism that foster litigation, and restore balance to doctor/patient relatl While American law is in part responsible, in that suits are promoted by contingency fee leeway, this also enables many otherwise hobbled injured to seek recompense. Efforts to eliminate the "crisis" by sddifications o law, reducing awards, or hampering the litigants are doomed to failure. 044 Glen Bennett.l1.P.H.. Hichaeline Silverstein. B.S.. Sherry Read. B.A. Don A in T P P i i H PUBLIC KNOWLEDGE OF THE RISK FACTORS AND WARNING SIGNS OF STROKE This paper descrlbes#ihe results or a community program to Increase public awareness about stroke. A baseline survey of 953 residents of metropolitan Baltimore was conducted in October, 1986. It showed that only 65X (557i of those over age 65) knew that stroke affects the brain. Over 25R would not seek immediate care if they suffered a TIA. Only 35R and 43X knew that stroke cause more deaths than accidents or murders respectively. A multi-component educatialal Intervention wili be conducted by the AHA. The post intervention survey will be conducted in July, 1987. Any change in public awareness will be discussed. Glen Bennett.l4P.H. and Brenda Palmer, B.S.. American Heart Association SUPPORT GROUPS FOR STROKE PATIENTS This paper describes the findings from three surveys of the strokeclubs in the U.S. They were conducted between January, 1986 and April, 1987. The surveys were done to construct a national database and published a directory. The clubs regularly receive the latest information on stroke care and tips in performing ADL. The AHA maintains the only national listing of strokeclubs. In 1986, 434 stroke clubs were identified. Seventeen (3.9%) clubs failed during 1986. However, 70 new clubs were Identified bring the total number of clubs formaily identified to 487. The clubs are sponsored by the Easter Seal Society, hospitals, and the AHA. Several are self-sponsored. Factors contributing to club survival will be discussed ABSTRACTS 89 TIMN 322546
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p.'MU11oo1 U. M. McFariand 0. K. Freeborn C. R. Yo and Jy Kaiser ernanen nter or Rea th searc ort an re n RLY MEkDERS OF A HEALTH NYIINTENANCE oRGANIZATION TNe,study population was 312 adD'tts t69°yearr of age aThGV1Ver) whe had be,en~mbers of~Ksffer'~riianenie, l(Grth++q~ Region for,ths ftye c7msd- cutiwe yeirs TD70-1974. These~~peaple were rendolsTy'3elecTdd fPeai the t~~nterr vi`extotaJ a>erabershfp'iri,TTl6~or psrticiPatien'tn aii exi'ensive "Nolice* hoid~nterrvi`e xnterrvi`ex Su~rvey." fEe`spo`n'se's fo the survey were used to conff'ru2C StsndeR•aieisure4 Af psc¢oleg~cal distrsss sucT'a's the'Lanjner indsk y and q elvse apProximation ~o tTie DSK-TII diagnosEfc'criteria foc>l.afor depres~ve.disbrder: 6asea'o'n fheir ~consumpt•torkof resourSes pver' fNe next five years; 17% were classified as cons~isten£~y bi'h users,•PGL lox, a'ii`d" tlie i~emaiding 63X"Weiti :fxed~nsers of •qqic4 v~~eons~syentlx , care, Comparing the consistently high with the consistently low we found that tTie:fo'rffi`dEr'ly(Qxluch higher levels of psychological distrvss than-did the lattar,,,.A®qng the consistently Ftigh ulws¢m.otiano prob were second •only ~to chronic medical conditions in ft!•- ting ~ eennte9`s'1~ ;leultir care providers. . Multivariage diser~-ain:Aio anaiXsis feitaatad.Sh}t.psycholopical distres~-~i°s?iiw~St impq~aet factor dfstinqdtsfl'iRd•consistently high from Cloneistently,loH users. We also discuss the'emental health treatment provided aitNTn•thr 1lID for these elderly beneficiaries. 1130 Susan M Andersen & Barbara H Harthorn Univ of Cai can BaN+ara DIAGNDSIS fWD TREA7MENT OF MENTqL ILLN€SS 8Y PRIlW:Y cARE PHYSICIAttB This study examined the diagnostic knowledge and treatment practices of a sample of prieary care physicians (P'CPs) as compared with a sample of mental health professionals (M16s). A diagnostic knowtedge inventory was employed that included case vignettes, diagnostic responses choices, and treatment options. Unsurprisingly, PCPs were most accurate in identifying medically related disorders and identified the affective disorders, anxiety disorders, and personality disorders less accurately then did MHSs. Both PCPs and lff8s were poor in identifying Major Depression and PCPs were particularly poor in identifying Dysthymic Disorder. Both agreed that antidepressants should be prescribed in primary care for Major Depression and for Major Depression with Psychotic Features. PCPS, however, were significantly more likely than MHSs to recommend antidepressants in primary care for Dysthymic Disorder, Adjustment Disorder-Mxious, uncomplicated bereavement, marital difficulties, and a simple medical problem. Both PCPS and MH4s agreed that anxioiytics were most appropriately utilized in primary care for all the anxiety disorders,, even though antidepressants are the treatment of choice for two. Data on psychological treatments in primary care and referrals to I1iSs will also be reported. Barrett JE, Oxman TE, Barrett JA, Gerber PD. Dartmouth Medical School DEPRESSIVE DISORDEtti AND THEIR CORRELATES IN A PRIMARY CARE PRACTICE Study goals were to determine prevalence of apecific depressive dis- orders in a primary care practice aad to aseees outcome over a two year period. Patients (1,646) were first screeued by a self-report easure; 308 patirnts, those above a cut-score and a sample below, were assessedfurther by a diagnostic interview (SADS) for specific disorders. 8.85 had a specific depressive disorder diagnosis (epi- sodic depression, chronic depression, depressive personality disorder), and 5.3X had a specific diagnosis other than depression. Another 10.5% of patients at clinical interview were felt to have significant depression present but did not meet criteria for a specific depressive disorder. Of these patients there were two larga groups; one (6.4% of patients) was labeled "euspected^ (masked) depression and the other (4.iX) "mixed anxiety-depression", For these depressive disorder groups, demographic correlates and se- lected outcome data (number of doctor visits; functional status) over a two year period will be presented. One focus will be the need for diagnostic eategories of relevance to management in primary care. K. Magruder-Habib, W.W.K. Zung, J.R. Feussner Duke University Medical Center LMPROVINC RHCOGNIrION AND TREATMENT OF D€PRESSION IR PRIMARY CARE In a randomized clinical trial designed to Improve recognition and treatment of depression, 100 previously unrecognized depressed asbulatory patients enrolled in a VA Medical Clinic were randomly assigned to: Group A, experimental group with the priury care physician inforsed of depression screening results; or Group B, natural history group with the physician not Snforeed of depression screening results. Recognition was defined as notation of depression in the medical record, significant listing of depressive symptoms, or referral to mental health services. Treatment vas defined as an antidepressant prescription, sental health clinle visit, or mental health consultation. At the index visit 33.3x of patients in Group A were recognized by their physicians as depressed, compared to 11.5% In Group B RR-2.9). At this same time 20.8% of Group A patients were being treated for depression compared to 3.9x In Group B(RR-5.4), Although the cumulative levels of recognition increased over time (37.5Z at 6 aks and 41 JS at 3 sos for Group A; 19.65 at 6 vW and 23.5% at 3 ws for Group B), the effect of the intervention as judged by the risk ratio, while still positive, tended to erode: 6 wdcs RR-1.9; 3®os RR-1.8. Similar trends are evident for treatment. 64 ABSTRACTS Jane Zich, Ph.D. G C. Clifford Attkisson Ph.D. - Univeraity of California, San Francisco USE OF THE CES-D AND BDI FOR DEPP,D.=SION SCREENING IN PRIMARY CARE To examine the utility of depression screening instruments in primary care, 475 patients from a university medical clinic were randomly selected to be given either the Beck Depression Inventory (BDI) or the Centea for Epideaiological Studies-Depression (CES-D)SCale. It was predicted that for medical patients, better screening accuracy would be achieved if stringent rather than standard cut-off scores were used. The NI14i Diagnostic Interview Schedule (DIS) was administered to a subsample (N=65) of the patients and served as the criterion measure for diagncsable depressive disorders. The CES-D and BDI cortectiy identified all patients the DIS had identified as clinically depressed, regardless of whether standard or stringent cut-off scores were applied. Use of stringent cut-off seores, however, reduced the number of false positives and improved overall accuracy of the screen- ing instruments. Neither acreen'ing instrut<ent proved superior in terms of accuracy or patient acceptance. Overall, the study supports the use of stringent cut-off scores for acreening with nadical clinie patients. The CES-D end BDI response patterns of patients were exam- ined factor analytically to determine if a briefer scale could improve screening specificity without loss of sensitivitv. Hichael S. Goldstein, Ph.D „ Emil Berkanovic, Ph.D „ ' V irRiai. Clark, Ph.D„ Margo Eurvicz Ph.D. John Land'sverk Ph D James Iubben. D, S. W. . LIFE EVENTS, STRAIN A1D) DEPRESSION AMONG ELDERLY USERS OF AN 1L"10 This research .e3casiaas tha.ralationship,.bsevesn lifa eudt., life, strain and dbpression.among l,OZS eldacly (65+) enroll,ees in f large Southern California 1DM, Depression is measured using the CanterTor Epids.]alogi.c Studisa,.Daprusion.Scala (CES-D) as a continuoudf variable,. CES-D scoree ara.positively asaociated with the number,of , life events experienced in the past six months, specific events, general lifa straiq, financial attaia, and marital strain. Boaevsz many of thes& variablas ar& strongly relatad,to each othtL.as„5L*11 as vith the respondents level of existing chr'odic hdalth problems and p.rcaived health status. Controlling fpr these relationships is well•asfor a~sasge-of•sscio-demographic varAables through multi- variate analysis fadicatei that specific financier and marital - striins are key.psid3ctors of CES-D a®ong this popu-IiMn. Tba, importance of au.iadng this relationship among individuals reporting stsdlai levals of physical illness7*is,'atressed. 1131 Jaaes A. Ciarlo Ph.D. and Dan L. Tweed Ph,D. Univ, ot uenver and David L. Shero, Ph.D., Colorado vision of Mental Health. MEHTAL HEALTH, SUBSTANCE ABUSE, AND SERVLCE USE IN COLORADO MINORITIES This presentation focuses on the mental disorders, substance abuse patterns, and functioning isp airwnts that are found to differentiate surveyed probability sample/eof Colorado's Hispanic (N-588) and black (N-3o2) residents from the white majority (N-3788) of residents. Associated demographic and residential variables, such as education, incoee, and type of neighborhood, are also presented to generate a more complete "picture" of differential need for services of these ethnic minority groups. As peraitted by the available data, environmental and specific demographic factors (e.g., education, income) will be statis- tically controlled to generate results that suy be ,wre fundamental to ethnic, cultural, and social factors than area of residence and social history. Even sharper differences between these groups are expected in terms of use of nedical, mental health, substance abuse, and other human services. While some of these riy be attributable to differences in area of residence, incoma, and similar "accessibility" variables, other factors are also expected to operate, including the willingness to seek formal and inforsul help for such problems. Dan L. Tveed, Ph.D. and Lee A. Kirkoatrick H A Univ of Denver SPECIAL MENTAL REALTR NEEDS OF THE ELDERLY POPULATION The elderly constitute one of the fastest growing components of the American population. In this presentation we will examine the unique mental health needs of a large sample (N - 817) of elderlv per- sons in Colorado. The presentation proceeds in tvo parts. In the first part we vill estimate the prevalence of various mental health probleau among the elderly. These estimates will be compared with those of other age groups. Differences in lifestyle (socioeconomic status, living arrange.ents, etc J and exposure to streesful life events (physical illness, retirement, loss of spouse, etc.) will Qso be examined as factors affecting the mental well-being of the elderly. In the second part we will focus upon the demand for, and utiliza- tion of, .ental health services by the elderly. The roles of various earsgivars will be examined--vith a special concern for the roles of informal support systems, and the general medical sector in the provi- siom of mental health care. The implications of the results for the planning of services will be discussed. TIMN 322521
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s  I The Ad Hoc Group Against Crisa's Bo•icide Task Force, Mark A. • Mitchell, M.D.,MPE, Sansas City, Missouri Aealth Departw,t EIJcCK CCi4MDNITY MODILIZATIOI! TO DECREASE BOMICIDE IN R7,fISAS CITY With the urging and cooperation of the Health Depart'ent and other local agencies in Kansas City, Nissouri, a black casani.ty anti-crima group perforz.d a eosprehensive study of hoaicide in the city and sade recoaendations to decrease black-on-black hoeicide. The study covesed hoeicides ccsssitted during the years 1981 to 1986. It consisted of review of police and county prosecutor's records of hoeicide victims and suspects for dasograpbiG descriptive, and sit- uational factors contributin9 to the hawitide. There ws also a review of services available to potential and actual boiicide victims and perpetrators. There was also an assessment of major problsas in the ccaeunity/lav enfores:ent/justice aysta. A survey of 16 families of homicide victims was conducted and there were 12 reewmeendations selected out of over 100 considered with the objective of decreasing hoaicide. Reccammendations inelude proposals for novel awareness and education- al campaigns, community and individual witness responsibility, justice systee responsiver,ess and .qu ity, programs teaching conflict resolutior and sel£ este® to high risk youth. These are swu being iz<plmmented. . Gar Linn Ph D Tenn State U'• Baaar A Pusaini Ph.D.. Jenn State D• Bictard ahitten-Stovall N.D.. V.A. tiedical Ctr.~ williaw B. Ne..^er, Ph.D. Maharry Medical College, and Hershall warren, J.D., Meharry MedicaEo ege ALTERNATIVE PERSPECTIVES ON THE RELATIONSHIDS I1hONG RACE, SOCIAL STATUS, AND PSYCHOLOGICAL DEPRESSION IN THE SOUTH A series of eom®unity studies over the past decade have concluded that the long observed relationship between race and sental distress can be accounted for by the effects of social class. This analysis tests an alternative model and finds that race has a sizeable effect on psychological depression among lower-class individuals. Poverty appears to heighten the effect of racial discrimination on nental distress. The data includes a rural Tennessee sample of 398 blacks and 645 whites and a Metro Nashville sample of 326 blacks and 375 whites. The dependent variable, psychological depression, was measured by the CESD. Theresa J. Gro.ala, D.C. University of wisconsin-Madison Heuroeusculoskelatal (NNS) Health Pro.otion in a wisconsin Industr7 Utilizing the International Academy of Chiropractic Industrial Consultants' Injury Survayand their methodology of ergonomic analysis, a preventive health program was designed to meet the specific needs of cheese industry workers. The needs assessment provided data regarding who, what, vhen, and where injuries occurred. Insurance cost data was correlated with injury frequency and incidence. An ergonoeic analysis of production line workers was completed using video to tudy aation. Froa these sources and a continuous dialogue with sanaagement, a three- fold educational program was designed to address cusul.ative trauma and repetitive motion problems. First, supervisors were trained to recog- nize and prevent hazards, and give "first aid" for *iS injurief or potential injuries at the vorksite. Second, lOSS literature was design- ed and provided .onthly to all wrkers; also, one in-house educational program on NHS injury prevention and self-care was eade available to all workers. :Third, a video was developed for "new starts" to teach then safety aspects, preventive ezercises and conditioning. Finally, a follow-up study will evaluate this health promotion program. Charles E. Sawyer, D.C. Northwestern College of Chiropractic, Bloomington, MN and William Meeker, D.C. Palmer College of Chiropractic-West Sunnyvale CA HEALTH,PROMOTION'ATTITUDES OF CHIROPRACTIC PHYSICIANS Although d number of health promotion behaviors have been linked to reductions in disease prevalence, little is known about the extent to which physicians acknowledge the,im- portance of healthy behavior or how often they attempt to influence patients under their care to make changes in health promotion behaviors. We surveyed a group of chiro- practic physicians to determine their health promotion beliefs and practices. The extent to which chiropractors exhibit an interest in health promotion is of interest in light of the conservative nature of chiropractic therapy and disease-prevention orientation of the profession. 76 ABSTRACTS Trina Stacey, B.A., Los Angeles College of Chiropractic 16200_ Amber Valley Drive, Whittier, CA 90609 OSTEOPOROSIS: EXERCISE THERAPYI PRE AND POST DIAGNOSIS The idiopathic, accelerated phase of bone loss associated with postmenopausal and surgically menopausal women is rapidly becoming a large public health problem due to the great expense involved in caring for those with vertebral, hip and distal radial fractures. The method of therapy with the least incidence of ill effects is physical exer- cise. This is a valid, appropriate alternative, however ft is the most overlooked and unappreciated form of treat- ment. Studies have shown that bone mineral content can be increased, not just maintained as with the other forms of therapy. The question may then be asked: what about exer- cise therapy for women already clinically diagnosed? Would exercise increase their risk of fracture, and if not what forms of exercise would be the most effective? A review of the literature will address this conservative, noninvasive approach to preventative and ongoing treatment of involutional osteoporosis. Herbert J.. Vear nE FCCS. President Emeritus Western Sta es Chiropract o Co ege, port an , Oregon. A SCOPE 0! PRACTICR STATEMENT FOR•CHIROPRACTIC EDUCATION Scope of chiropractic practice continues to-be..a conundrum, created.by the legal complexity, language and definition confusion of 50 atate chiropractic pri8tice acts. - This has resulted in uneven and inequitable patient care throughout the United States. The Council on Chiropractic Education (CCE) has prescr4bed educational standards for all aspects of education, including policy/position papers for diagnosis, treatment, referral, adjunctive therapy, and a host of other.aupportive policies. It may not be appropiate for CCE to randate• -ecope of practice, because, of acadeiaic frebddm..Agreesent by the colleges, howevere could influence greater uniforwity in practice acts, resear.Rh, educa'ti•ona•1 -oiSjectives and practide mobility fbr chiropractic physicians. Michael H Biles D C Canadian Memorial ChiXopracti_c College HEALTH RISK OF SHOCING AND DRINKINGz AN ANALYSIS O.F THE RISK ASSOCIITSD WIT3 VAR2ING AMOUNTS OF SMOKING AND DRINKIMG IN CdHEINATION The Canadian "Evaluiife Prograa" data bank was used to analyze the total health risk associated with smoking and drinking in combination. (The "Evalulife Prograa" is a widely used risk appraisal service of the Canadian Government's Health Promotion Directorate.) Rielq profiles were obtained for a hypothetical 38 year o18,patient with all health datasconstant except for smoking and drinking habits. A risk mstrix far drinking (0,3,6,9 and 12 drinks per veak) and smoking (0, 1, and 2 packs per day) is presented and diseuised. The costs of thesa habits are estimated and correlated with overall health risk (i°-0.A98, P<0.o1) and`pradictad reduction of lifa expectancy (r-0.984, P<0.o1). The data indicate that the health risks from smoking are the more significant factor in determining overall risk to health. 2011 Susan Nolthy Allyson R. Davies, and Harris Alleni The RAND Corporation, Santa Monica, CA EXPLAINING CHILDREN'S DENTAL UTILIZATION Using prospective data €rom the RAND Health Insurance Experiment, we examined a variety of factors that predict children's dental utilization. The saaple includpd 1311 children ages 4-14 whose families vere randomly assigned to one of severaL lnsurance plans that varied in the amount of cost sharing. Explanatory variables measured at the beginning of the year were-tested in mil tivarlate mudela to predict subsequent utilization. Results replicated prior findings related to income and education: higher family incume nnd higher education level of parents was associated uLth a,greater probability of use. In addition, we found that children living in single-head households and those whose mothers work are at risk for non-use of dental services, even when controlling for Insurance coverage. Other explanatory factors included children's oral health statua, parent's satisfaction with dental care, their attitudes toward medical care, perceptions of their own health, and perceptions of thcir children's health.
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t Ir Keith H. Horxenlander, HFH, LNHA, HCA Psychiatric Coapaay; Frank A. SSLva, HD, Parkland Hospital; Devra E. Greenvald, HPA, Creater Baton Rouge Health Care Alliance. PROVIDING A CONTINUUM 0€ MENTAL HEALTH SERVICES FOR THE ELDERLY: THE PARKLAND HOSPITAL HODEL Major advances have occurred in the delivery of a continuu of inedical rehabilitative and long ter care servicea for the eldarlp. Unfortunately, the development and implf- entation of a continuum of ental health services has not occurred in a similar anner. One component of this trend has been a reluctance on the pert of private psychfatric hospitals to work vithin the limitations of Medicare and Hedicaid to provide services. 'Parkland Hospital has over- come many of these limitations, and is providing the elderly of the Baton Rouge area with a spectrum of appro- priate mental health services. This paper will discuss the organization and delivery of inpatient, partial hospi- tal, outpatient, assessment, educational and consultative services within the framework of a"for-profit" psychiatrie hospital, An assessment of clinical outcomes and cost/- effectiveness will be presented in this regard. nacalle Saens-Ericsson, ra.U., Unly. of Uenyerl ana Uayid L. Snare, Ph.D., Colorado Div. of Mental Health. - 3ENDER DIFFERENCEg IN MENTAL HEALTH AND UTILIZATION OF SERVICES Researchers traditionally have reported higher rates of mental ill- ness for women than those for men. These differential rates may result from utilization samples and from restricted definitions of mental ill- ness favoring lower rates in males. In our presentation we will diseus gender differences (males-2041, £eules-2736) in the rates of mental illness froa a statewide epide.io- Logiul survey of Colorado. In the survey we used the Diagnostic In- terviev Schedule (DIS) to determine DSM-III diagnosis for individuals with mantal illness. In addition to DSH-III diagnosis, our research in- cluded eight cales that assessed problems in everyday functioning as a: additional indicator of mental health status. In preliminary analyses we have found no gender differences in the surveyed rates of DSM-III diagnoses or in problems with coarunity functioning. However, we did find gender differences for the rates of specific disorders. In addition, we included extensive measures of the utilization of treatsent services. We will discuss gender differences in the use of services and how these differences relate to diagnoses, functional ispsirsxnt, and demographic characteristics.   " T(errry D., Robi(ailie, P., hiassing, K., Orapa de radmrccha-action an bbloq(a du (rau(), Unhrorsl~ da Oudbec it tlarirbel, QP. 8888, &a.c. A, YfDnts'dei, OtaSbx. Capde H30 3P8. Dtias a hml hywnr'kareffs:( es(st fo' tar birthwektl( ? A reill:M-act1Dn eDOr9at9L pafbc tepislaticn proridea that prsqmrk women winse worktnq osrditkns prerK a hmith risk for Uhemetr)ves or thsir fetus heve a ri¢d to ctenqe Jobs or to keave wlth ps,r for tha durat(on d thme rfaks. This Iegfs)et(on (s basad m the tlwory Ulat rspradueths aulcornewiH be (mProrobby sHch a isa+re. ftwsaer, aane rexarch has glovm (het woRnH who do rat wDrk dur(rq pre;nency, hne worse raprodtc(h+e su(maa then Otoee who do. Th(s mn be aHrEbu(ed ia ths'hee(Uy warker effed: the fact that thework(rg populettm is qenerol)y ma'e tR tl+m tM non-workinq popDiation, strra the is(ter may haus hatdiops tr utrrsen whtdt ksep firm sut of the workforw. In a r)uestfarn)ra sttdy of repradct(ve atlcaee asag haapftall wa'kers (H=600), we haw informd(on which permtts trs to cammParetwMnnes far warkars whs did roi work durirg the praqvwy with thmts who kMt the wtrkp(ace afka• (hs the fkat, astad, ar thin trimmlor or pr'a;wxY. This eliminMes the need to ktdc at a qsns'al Populatim mnfrod (rel{ wtme hee(th sta(us mey bear little rasembtasce (s the that o£ the workar populattm PreHminny results thmonstrate that meen b(rthweigit was lower meong dlik9nn of wmwt wis wtrked at ksas( ane tr(mestr of their preqimty then for wmron who (ook a kseve d& far the whole perSod (3.30 kqvs. 3.43 kg p=.07). For first prsgtatcies, nm-smokinq womst wh warked only the f(rst trimes(ar hard offspr'irq with the lowest birthsaiqM (3.18, p•.06).4W -1 ~ e ~work hasad~etrimaFtaOed tu(mne In thlshtmogdtau wtrkar DCW~~• Neil Haizlish Umiversit of California (Berkele ) Ja Beaumont (UC MORTALITY AMONG CALIFORNIA HIGHWAY WORKERS Standardized proportional mortality ratios PHR) were computed for a population of highway workers including ma ntenance workers, enfi- neers, administrators and oflice workers. Hazards of hlghway ma nte- nance work include po~ential exposures to solvents asphalt and welding fumes, asbestos, abrasive dusts, hazardous materia~ spills, and moving aotor vehicles. Underlyin cause of death was obtained for 1570 workers who separated from the Ca~ifornia Department of Transportation betweea 1970 and 1983 and who died in California between 1970 and 1983 (inclu- sive). Among 1260 white males there were sftCnificantl elevated (p C.n05) eancers of the lo1on (P~-143k skin (PHRr218)~ ~rain (PHR-162)i 11 phopoietic Cancer p~ -157 beniga neopIasms (PfAt-343) motot v he ¢ e accidents PMR-14 ) aad au;cide (PMR- 154). Non-vhite aales (H-I18) experienced statistically significant excessqs of ciacer of the ddiges- tive organs (PMR-190) lymphopoietic cancer (PlR-372), and arterioscle- rotic heart disease (1?!flt-149). Amonx 168 white feules deaths from lung cancer (PHR-189) and .ui.cide (PMR-215) were signf~icantl' ale- vated Non-vhite fe.ales (H-24) also experienced ezcess mortality due to suicides (PHR-1271). Further epidemiologic studies are needed to confirm the apGarent excess wrtality. However, reduction of recognized hazards awng highway maintenance workera is a prudent precaution. `Hawar~ iGnen, M.ll. M.P.H, t Ruth lifs M.D. +: Yuunosuke Suzuk( M.D.+: Jose Vatciuku PhD. : trrinr Serwtr M.D. • UMDNJ•RW Jul:asoa Medical School, Department of EmiroameMrl and Community Medicine + Mount Sinai School of Medicine, P.nvironmeMal Sciences Laborstory, New York GM1TATiONS OF RADIOGRAPHIC EVALUATION FORTHE DIAGNOSIS OF A,9DE,41•()SI3 Wh;7eclearakeriaforthediagnusSsot.sbestos•relaleddiseasedocxisl,theacnsilivityandapec}'~dy of the various d•mgnostic modafa'ies arc not perfectly established. We undertook a study to determine the relrtkmahip belween radiogr.phis and hido(ngic manifestations of pulmonary asbesleais (tnterstkiat rwask) in Insulation workers who died o( (ung cancer. Of 430 eonOrmed lung cancer deMhs as of September 1963 we were able to oblaia a chest x-ray suitable for determination of evidence ot paeumoconiosia in 219. 138 of these cases also had a tiasue specimen submiued which was suiuhk for histological study for ddennination of the extent of librnsia. Hixudogk etidence of interstitial fbnsia was evieknt in all 138 casea, however In 25 (18%) there was no radiographic evidence of pnrenchymal (%xosu, and in 10 (7%) IxKh parenchymal and pleural disease was undetectable on the chest x-ray. This data will be discussed with iliustralive rad(ographs, and consideralkm will be giren to the raemia( magnitude and impaY of this problem on the campensad(un systems, as wep as to potentially more sensitive rnt/iographic modalities such u(.T sosnning. Ma(tk Di Catlin, Alaska Health Pro ect and John M, nooker, University oE Alaska-Fairbanks EVALUATION OF A STATE CIItTIPIFD ASDES2CIB ABATt?fENT•TRAPNINO PROGRAM The State of Alaska enacted an asHastdY abatement ce;tifieation prograa in October 1985. All peridhr'perfozming, directly sup:r- vising or monitoring asbestos abatement work in Alaska must success- fully complete a minimum 32 hour t>•airiing program approved by tha• Alaska Department of Labor. Thesi gtbqrams must in'clude hands-on,~ practice of work procedu=es. This paper presents an ovarview of- the state requirements and a prelimidary evaluation of the approv}d training program of the Alaska Lkborers Union Traininty Trust. Sur- vey results from 100 (46%) Laborer union members completingthe asbestos abatement class one year after their initial training will ba discassed. Union mesbers were surveyed for knowledge of health and regulatory_issues, proper work proceduras and~personal protec- tive equipment. Workers were also asked to assess the.training program and actna.l,cepc{itions at abatementprojscts. Johnson, Jeffrcy V., Johns Hopkins School of Hygienel Public Health Theorell, Tores, Swedish Institute of Psychosocial Factors & Health THE EFFECT OF WOR3( STRAIN AND ISOIATI061 ON CARDIOVASCULAR DISEASE RISK This study addressed the etiologic importance of the organization of work in the development of cardiovascular disease (CVD). The relation- ship between certainiiqspects of the psychosocial work enviroraoent and CVD prevalence and mortality incidence was examined cross-sectionally and during a seven year follow-up of a random sanq:le of the Swedish work force, n=13,779. Psychological job demands, work control, and work-related social support were found to interact mul.tiplicatively in relation to CVD prevalence risk. A single measure# termed Iso-Strain, was constructed to model this combined effect. High and low Iso-Strain groups were canpared using a logistic analysis of age trends for CVD prevalence and mortality incidence. It was found that workers in the high Iso-Strain group developed CVD earlier and had a significantly higher risk of dying at a younger age. This pattern was most pronounced for the blue collar male workers. These findings support the hypothesis that prolonged exposure to adverse work organization contributes to cardiovascular pathophysiology and amy ultimately lead to premature death. Gail C. Farr.s)., Dr.P.H. and Pamela L. Davidson, B.S. Dept. of Health Science, Cal-State University Long Beach ARE THE EFFECTS OF STRESSFUL WORKING CONDI'fIONS ON HYPERTENSION MITIGATED BY PERSONAL HEALTH PRACTICES? In the recent years, there has been an increased awareness that the workplace contributes significantly to hypertension and other cardiovascular diseases. This research examined the following: Do persons experiencing psychosocial forms of job stress and/or exposure to hazardous work conditions exhibit hypertension? Do such health practices as exercise, weight loss, and reduced consumption of coffee, alcohol, salt, to- bacco, and red meat reduce high blood pressure under condi- tions of high job stress? Does the existance of social sup- port buffer the effects of stressful job conditions on hypertension? The data come from a probability sample of US adults (N- 2436). This longitudinal survey consistec) of two waves. The reaults of the analysis indicate that job stress re- mains a significant predictor of hypertension independent of modification of personal health habits and social support. The implications for workaite risk factor reduction programs ,are discussed. ABSTRACTS 65 TIMN 322522

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