Day hospital and residential addiction treatment: Randomized and nonrandomized managed care clients.

Male and female managed care clients randomized to day hospital (n=154) or community residential treatment (n=139) were compared on substance use outcomes at 6 and 12 months. To address possible bias in naturalistic studies, outcomes were also examined for clients who self-selected day hospital (n=321) and for clients excluded from randomization and directed to residential treatment because of high environmental risk (n=82). American Society of Addiction Medicine criteria defined study and randomization eligibility. More than 50% of followed clients reported past-30-day abstinence at follow-ups (unadjusted rates, not significant between groups). Despite differing baseline severities, randomized, self-selecting, and directed clients displayed similar abstinence outcomes in multivariate longitudinal models. Index treatment days and 12-step attendance were associated with abstinence (p     

Family characteristics of subjects with panic attacks

OBJECTIVE: Patients with panic symptoms are heavy users of the health care system, although many do not seek care specifically for those symptoms. This study documents utilization of various sources of health care of subjects with panic symptoms, including those who met criteria for panic disorder and those with infrequent panic, distinguishing between use specifically for panic symptoms and use for reasons not related to panic. METHODS: This community-based sample, predominantly Mexican American and female, included 97 subjects with panic symptoms and 97 matched control subjects with no panic symptoms. Data were collected on two-month utilization of various sources of health care both within and outside the mainstream health care system, barriers to access to care, and levels of medical insurance coverage. RESULTS: Subjects with panic symptoms had higher utilization rates for the services of psychiatrists and psychologists and for ambulance services than control subjects. Subjects who met criteria for panic disorder and who sought care specifically for panic symptoms generally accounted for the differences between the group with panic symptoms and the control group. The two groups differed little in barriers to access, but the control group reported that their medical insurance covered more types of services. CONCLUSIONS: Compared with control subjects, subjects with panic symptoms reported higher rates of health care utilization despite having less insurance coverage and experiencing similar barriers to access. The higher rate was due to increased utilization of health care by subjects who met criteria for panic disorder and to help seeking specifically for symptoms of panic.     

Dimensions of care in five United States nursing homes: identifying invisible work in care-giving

OBJECTIVE: We recently reported that acupuncture treatment of stroke patients in the subacute stage gave additive therapeutic benefit. The purpose of the present study was to determine, approximately one year after discharge from the rehabilitation hospital, whether the group differences still remained. DESIGN: The patients were randomized into two groups: one acupuncture group and one control group, considering gender and side of hemispheral localization of lesion. With regard to the main parameters the groups were comparable at baseline. SETTING: Initially, 45 stroke patients admitted to Sunnaas Rehabilitation Hospital were included in the study: median 40 days post stroke. SUBJECTS: Forty-one of the patients were available one year after the treatment period: 21 patients in the acupuncture group and 20 controls. INTERVENTION: All subjects received an individually adapted, multidisciplinary rehabilitation programme. The acupuncture group received additional treatment with classical acupuncture for 30 min three to four times weekly for six weeks. MAIN OUTCOME MEASURES: The patients were evaluated at inclusion, after six weeks and approximately 12 months after discharge from the rehabilitation hospital. The Motor Assessment Scale (MAS) for stroke patients, Sunnaas Index of Activity of Daily Living (ADL) and Nottingham Health Profile (NHP) were used. In addition, the social situations of the patients were recorded at one year follow-up. RESULTS: The results show that the acupuncture group improved significantly more than the controls, both during the treatment period of six weeks, and even more during the following year, both according to MAS, ADL, NHP and the social situation. CONCLUSION: Although the mechanism of the effects is debatable, there seems to be a positive long-term effect of acupuncture given in the subacute stage post stroke.     

Acupuncture in stroke

In 1995 we reported that acupuncture treatment of stroke patients in the subacute stage resulted in added therapeutic benefit. The purpose of the present study was to determine, one year after discharge from the rehabilitation centre, whether the treatment continued to have effect. Initially, 45 stroke patients were included in the study; median 40 days post stroke. The patients were randomized into two groups; one acupuncture group and one control group, taking into considering the patients' sex and the actual site of the lesion. All subjects received an individually adapted, multidisciplinary rehabilitation programme. The acupuncture group received additional treatment with classical acupuncture for six weeks. The patients were thereafter given individual treatment at the rehabilitation centre and then under the primary health care service. 41 of the patients were available for further study one year after treatment ended; 21 patients from the acupuncture group and 20 from the control group. The results show that there was a significantly greater improvement in the acupuncture group than in the control group, both during the six-week treatment period, and even more so during the following year. These assessments were based on the Motor Assessment Scale, the Sunnaas Index of Daily Living (ADL), the Nottingham Health Profile and the patients' social circumstances.     

Comparative costs to the Medicare program of seven prepaid group practices and controls

This research was conducted in order to compare costs to the Medicare program for providing health care service to old people enrolled in two forms of health delivery organization: open market and prepaid group practice (pgp). Two data sources were employed: cost data provided by the Social Security Administration for seven prepaid group practices in five SMSAs and northern California and interviews conducted with administrators of the prepaid groups to determine: organizational sponsorship, incentive structure, pattern of selectivity of patients, and resource availability. Major findings are: (1) Enrollees in prepaid groups incur higher physician costs. This includes services provided by practitioners in and outside the plans. (2) Overall, prepaid groups demonstrate savings to the Medicare program in provider-initiated services- in hospital care and extended care facility services, but not in home health care. (3) Reduced spending in the hospital component does not imply reduction in the extended care facility or home service. (4) Outpatient costs in the hospital are generally higher in the open market modes, probably because this mode of care is viewed as an alternative to physician visits. (5) The greatest cost savings to the Medicare program are demonstrated by groups which are relatively small, yet hospital-based.     

Recombinant erythropoietin and blood transfusions in cancer chemotherapy-induced anemia

BACKGROUND: We examined the relationship between religious attendance, religious affiliation, and use of acute hospital services by older medical patients. METHODS: Religious affiliation (n = 542) and church attendance (n = 455) were examined in a consecutive sample of medical patients aged 60 or older admitted to Duke University Medical Center. Information on use of acute hospital services during the year before admission and length of the current hospital stay was collected. Frequency of church attendance and religious affiliation were examined as predictors of hospital service use, controlling for age, sex, race, education, social support, depressive symptoms, physical functioning, and severity of medical illness as covariates using logistic regression. RESULTS: Patients who attended church weekly or more often were significantly less likely in the previous year to have been admitted to the hospital, had fewer hospital admissions, and spent fewer days in the hospital than those attending less often; these associations retained their significance after controlling for covariates. Patients unaffiliated with a religious community, while not using more acute hospital services in the year before admission, had significantly longer index hospital stays than those affiliated. Unaffiliated patients spent an average of 25 days in the hospital, compared with 11 days for affiliated patients; this association strengthened when physical health and other covariates were controlled. CONCLUSIONS: Participation in and affiliation with a religious community is associated with lower use of hospital services by medically ill older adults, a population of high users of health care services. Possible reasons for this association and its implications are discussed.     

Prospective payment: Its impact on psychology's role in health care.

Describes the new Medicare payment system based on diagnosis-related groups (DRGs) and its impact on professional psychology. DRGs represent medically oriented notions about how many inpatient days a physician needs to effectively treat a patient who suffers from a specified disease. It is argued that for the most part, DRGs ignore the behavioral variables that moderate entry into the tertiary care system and the subsequent use of hospital resources. Under DRGs, the development and use of behavioral treatments for somatic disorders could be discouraged. For example, many newer behavioral medicine techniques may be more time-consuming and/or expensive than traditional treatment options and thus not fall within the time period allotted for such disorder, regardless of comparative effectiveness. Also, under the new system, psychologists can no longer bill separately for their inpatient services. It is concluded that the framers of health care policies should recognize and support psychologists because many of their techniques can reduce the cost of health care by reducing behavioral risk factors, increasing compliance with medical regimens, and preparing patients psychologically for stressful medical procedures. (18 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Health care reform in Croatia: the consumers' perspective

AIM: Assessment of the Croatian health care system (under the reform) from the perspective of the users of health care services. We analyzed the consumers' satisfaction with health care system, health care expenses and access, and described the consumers' attitudes toward health reform, examining the differences among sociodemographic groups. METHODS: The study is based on a data set collected in 1994 through the interviews with randomly selected adults in two major cities of Croatia: Zagreb and Split. RESULTS: A great proportion of respondents were dissatisfied with the current health care services, quality of health care facilities and equipment, and encountered difficulties in access. The elderly, women, and those with lower socioeconomic status were more likely to be dissatisfied and to consider out-of-pocket payments for health services as a problem. A great number of the respondents believed that the reform would either fail or would not achieve significant results. Compared to the younger and higher socio-economic group, the older and lower socioeconomic groups were more likely to evaluate the health care reform negatively. CONCLUSION: Croatian government decided to rationalize the health care system without taking much account of the impact of health reform on the consumers. Revealed dissatisfaction with the health care services might be linked with the expressed doubts in health care reform and concern that changes could worsen the consumers' position as patients.     

Caring for the caregivers

The relationship between disabled elderly veteran care receivers' functional status and their in-home family caregivers' strain was examined in this study. The convenience sample was composed of 93 dyads. Data were obtained from care receivers' health care records and included the Folstein Mini-Mental State Examination (MMS), Activities of Daily Living (ADL), Instrumental Activities of Daily Living (ADL), and Robinson's Caregiver Strain Index (CSI). Major findings were: 52% of caregivers experienced significant strain; 59% of care receivers were cognitively impaired to some extent and were severely impaired in IADL and ADL; and the relationships between care receivers' functional status (cognitive, ADL and IADL) and caregiver strain were statistically significant.     

Randomised controlled trial to evaluate early discharge scheme for patients with stroke

OBJECTIVE: To assess the clinical effectiveness of an early discharge policy for patients with stroke by using a community based rehabilitation team. DESIGN: Randomised controlled trial to compare conventional care with an early discharge policy. SETTING: Two teaching hospitals in inner London. SUBJECTS: 331 medically stable patients with stroke (mean age 71) who lived alone and were able to transfer independently or who lived with a resident carer and were able to transfer with help. INTERVENTIONS: 167 patients received specialist community rehabilitation for up to 3 months after randomisation. 164 patients continued with conventional hospital and community care. MAIN OUTCOME MEASURES: Barthel score at 12 months. Secondary outcomes measured impairment with motoricity index, minimental state examination, and Frenchay aphasia screening test; disability with the Rivermead activity of daily living scales, hospital anxiety and depression scale, and 5 m walk; handicap with the Nottingham health profile; carer stress with caregiver strain index and patient and carer satisfaction. The main process measure was length of stay after randomisation. RESULTS: One year after randomisation no significant differences in clinical outcomes were found apart from increased satisfaction with hospital care in the community therapy group. Length of stay after randomisation in the community therapy group was significantly reduced (12 v 18 days; P < 0.0001). Patients with impairments were more likely to receive treatment in the community therapy group. CONCLUSIONS: Early discharge with specialist community rehabilitation after stroke is feasible, as clinically effective as conventional care, and acceptable to patients. Considerable reductions in use of hospital beds are achievable.     

Effects and generalizability of communally oriented HIV-AIDS prevention versus general health promotion groups for single, inner-city women in urban clinics.

A primary prevention, behavioral intervention designed to reduce HIV risk behavior was tested in a randomized, controlled trial with single, inner-city women. A total of 935 women were randomly assigned to 1 of 3 conditions: a small group, 6-session communally oriented HIV prevention intervention; a yoked general health promotion intervention control; or a standard care control. Both interventions involved the interactive use of videotapes by live group leaders. The HIV prevention intervention, in particular, resulted in significant positive effects on self-reported and behaviorally assessed safer-sex behavior. Women in the HIV prevention group showed reduced point prevalences of medically tested sexually transmitted diseases at follow-up in some comparisons. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Follow-up studies of psychotic patients receiving inpatient treatment or alternative forms of psychiatric care

An analysis of populations treated in the III Department of Psychiatry indicates that 12 years since the transformation of the organizational model of care for patients from sub-regionalized catchment area, inpatient treatment continues to be of major importance, as it was provided to over half of all referrals. Intermediate forms of care, replacing a half of the former number of psychiatric beds, were offered mainly to schizophrenic patients, with the exclusion of those with a marked agitation, psychomotor retardation, or aggressive, presenting imminent danger to self or others. At one-year follow-up J.E. Overall's scale was used to examine 39 schizophrenic patients treated at the inpatient ward, day hospital, or by a community treatment team. Patients treated at the day hospital providing an intense therapeutic program manifested a significantly more marked improvement in respect of 6 symptoms: autism, affective bluntness, guilt feelings, tension, suspiciousness, and bizarre thoughts. No significant differences were found between the compared forms of care as regards the degree of other symptoms amelioration. Thus, the day hospital turned out to be a more effective form of care in case of schizophrenic patients manifesting the cluster of symptoms listed above.     

A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke

BACKGROUND and PURPOSE: Many stroke survivors have minimal to moderate neurological deficits but are physically deconditioned and have a high prevalence of cardiovascular problems; all of these are potentially modifiable with exercise. The purposes of this randomized, controlled pilot study were (1) to develop a home-based balance, strength, and endurance program; (2) to evaluate the ability to recruit and retain stroke subjects; and (3) to assess the effects of the interventions used. METHODS: Twenty minimally and moderately impaired stroke patients who had completed inpatient rehabilitation and who were 30 to 90 days after stroke onset were randomized to a control group or to an experimental group that received a therapist-supervised, 8-week, 3-times-per-week, home-based exercise program. The control group received usual care as prescribed by the patients' physicians. Baseline and postintervention assessments included the Fugl-Meyer Motor Assessment, the Barthel Index of Activities of Daily Living (ADL), the Lawton Scale of Instrumental ADL, and the Medical Outcomes Study-36 Health Status Measurement. Functional assessments of balance and gait included a 10-m walk, 6-Minute Walk, and the Berg Balance Scale. Upper extremity function was evaluated by the Jebsen Test of Hand Function. RESULTS: Of 22 patients who met study criteria, 20 completed the study and 2 refused to participate. The experimental group tended to improve more than the control group in motor function (Fugl-Meyer Upper Extremity: mean change in score, 8. 4 versus 2.2; Fugl-Meyer Lower Extremity: 4.7 versus -0.9; gait velocity: median change, 0.25 versus .09 m/s; 6-Minute Walk: 195 versus 114 ft; Berg Balance Score: 7.8 versus 5; and Medical Outcomes Study-36 Health Status Measurement of Physical Function: 15. 5 versus 9). There were no trends in differences in change scores by the Jebsen Test of Hand Function, Barthel Index, and Lawton Instrumental ADL Scale. CONCLUSIONS:This study demonstrated that a randomized, controlled clinical trial of a poststroke exercise program is feasible. Measures of neurological impairments and lower extremity function showed the most benefit. Effects of the intervention on upper extremity dexterity and functional health status were equivocal. The lasting effects of the intervention were not assessed.     

Characterizations of elderly recipient of home-care and their caregivers. A questionnaire survey of elderly members of a health insurance union

The characteristics of elderly being cared for at home and their caregivers were analyzed based on a questionnaire about health and care for the elderly. We also assessed the problems of home care in view of activities of daily living (ADL) of the home-care recipient. Subjects were members of a health insurance union or their families and ages were more than 65 years old. Results were as follows; 1. The total number of released questionnaires was 5,472, of which responses totally 2,567 (46.9%) were received. Frequencies of the elderly at home without care, at home with care, and in hospitals or nursing home were 86.3%, 9.6% and 4.1%, respectively. 2. We categorized the home care recipient according to their ADL and analyzed their status. The frequency of using health care equipment for home care was significantly higher in the low ADL groups than in the high ADL groups. Caregivers in low ADL groups felt much more care burden than those in high ADL groups. 3. There was a tendency for differences in the use of community welfare services such as visiting nurses or short-stay between the home care recipient with dementia (group D) and the bedfast home care recipient (group C). Approximately 30% of caregivers in group D wanted to transfer the care of the elderly to hospitals or nursing home. 4. In Tokyo and nearby prefectures, there was a highly frequency that main caregivers were recipients' children. In the rural prefecture it was more frequent that the main caregiver was recipients' wife or husband only.     

An introduction to psychologists treating medically ill patients: Competent practice and seeking credentials in organized health care settings for routine or incidental practice.

Psychology has been recognized as a health care science and profession, and psychologists have been working clinically with medically ill patients and within organized health care settings and hospitals for decades. The potentially daunting environment of organized health care should be seen by psychology as an opportunity to further develop and expand its scope of practice. With knowledge of that environment's rules, regulations, ethics, bylaws, and traditions, the clinically competent psychologist who is first seeking to practice in hospitals should succeed alongside psychologists with busy practices who are already exclusively or occasionally within an organized health care setting or medical facility. This article reviews issues of competency, credentialing, privileges, bylaws, and practice expansion to guide psychologists toward a successful hospital practice with medically ill patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Medical crisis counseling in a health maintenance organization: Preventive intervention.

Mental health clinicians can play a cost-effective role in reducing distressing psychological symptoms accompanying diagnosis of chronic illness. Medical crisis counseling (MCC) is a focal short-term intervention directly addressing illness-related psychosocial problems. A randomized clinical trial tested the effectiveness of MCC. Counseling was offered to patients who had cancer that was newly diagnosed, 1st heart attacks, or adult-onset diabetes and was contrasted with a control group receiving an HMO's standard mental health care. Significant reductions in distress attributable to MCC were noted in some patient groups. No increases in overall medical costs and some decreased mental health utilization and costs were noted with MCC use. Practitioners can easily apply MCC to improving patients' quality of life and mental health, without adding to health care costs. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Can sensory stimulation improve the functional outcome in stroke patients?

After obtaining informed consent, we randomized 78 patients with severe hemiparesis of the left or right side within 10 days of stroke onset: 40 to a control group receiving daily physiotherapy and occupational therapy, and 38 to a group that, in addition, we treated with sensory stimulation (acupuncture) twice a week for 10 weeks. The median age was 76 years for both groups. Motor function, balance, and ADL (Barthel's Index) were assessed before the start of treatment and at 1 and 3 months after stroke onset; ADL was also assessed after 12 months. We assessed the quality of life (QL) using the Nottingham Health Profile 3, 6, and 12 months after stroke onset. Patients given sensory stimulation recovered faster and to a larger extent than the controls, with a significant difference for balance, mobility, ADL, QL, and days spent at hospitals/nursing homes. Whether acupuncture per se is responsible for the differences requires further study.     

Comparison of stroke features and disability in daily life in patients with ischemic stroke aged 55 to 70 and 71 to 85 years

BACKGROUND AND PURPOSE: This study compared stroke features and poststroke disability in two age groups of patients with ischemic stroke: younger (55 to 70 years) and older (71 to 85 years). Stroke has an impact on daily living in many areas, but whether risk factors, stroke features, and poststroke disability differ between young and old patients with stroke is not so well established. METHODS: A cohort of 486 ischemic stroke patients aged 55 to 85 years admitted consecutively to the Helsinki University Central Hospital (Finland) between December 1, 1993, and March 31, 1995, were examined 3 months after the index stroke. Structured medical, neurological, and radiological (MRI or CT) examinations, mental status, and emotional examination and interview of a close informant were done. Prestroke and poststroke activities of daily living were assessed with five scales: the Index of ADL, Instrumental Activities of Daily Living Scale, Functional Activities Questionnaire, Blessed Functional Activities Scale, and Barthel Index. RESULTS: History of cardiac failure (P < .001), atrial fibrillation (P < .001), and cardioembolic stroke (P = .011) was more frequent in the older age group, whereas stroke due to large-artery atherosclerosis (P = .048) was more common in the younger age group. The older patients more often had major dominant stroke syndrome (P = .018). Comparison of activities of daily living before and after stroke showed that the older age group deteriorated significantly more than the younger age group after adjustment for sex, education, and living conditions (Barthel Index, P = .005; other scales, P < .0001). CONCLUSIONS: The stroke patients in young and old age groups had different risk profiles and stroke features. The older stroke patients were more dependent and disabled beforehand, and after stroke they were relatively even more dependent than the patients in the younger age group. Because older patients already constitute the majority of stroke victims, the importance of early active diagnosis, treatment, rehabilitation, and guidance is stressed.     

Is day care equivalent to inpatient care for active rheumatoid arthritis? Randomised controlled clinical and economic evaluation

OBJECTIVE: To test the clinical equivalence and resource consequences of day care with inpatient care for active rheumatoid arthritis. DESIGN: Randomised controlled clinical trial with integrated cost minimisation economic evaluation. SETTING: Rheumatic diseases unit at a teaching hospital between 1994 and 1996. SUBJECTS: 118 consecutive patients with active rheumatoid arthritis randomised to receive either day care or inpatient care. MAIN OUTCOME MEASURES: Clinical assessments recorded on admission, discharge, and follow up at 12 months comprised: the health assessment questionnaire, Ritchie articular index, erythrocyte sedimentation rate, hospital anxiety and depression scale, and Steinbrocker functional class. Resource estimates were of the direct and indirect costs relating to treatment for rheumatoid arthritis. Secondary outcome measures (health utility) were ascertained by time trade off and with the quality of well being scale. RESULTS: Both groups had improvement in scores on the health assessment questionnaire and Ritchie index and erythrocyte sedimentation rate after hospital treatment (P < 0.0001) but clinical outcome did not differ significantly between the groups either at discharge or follow up. The mean hospital cost per patient for day care, 798 Pounds (95% confidence interval 705 Pounds to 888 Pounds), was lower than for inpatient care, 1253 Pounds (1155 Pounds to 1370 Pounds), but this difference was offset by higher community, travel, and readmission costs. The difference in total cost per patient between day care and inpatient care was small (1789 Pounds (1539 Pounds to 2027 Pounds) v 2021 Pounds (1834 Pounds to 2230 Pounds)). Quantile regression analysis showed a cost difference in favour of day care up to the 50th centile (374 Pounds; 639 Pounds to 109 Pounds). CONCLUSIONS: Day care and inpatient care for patients with uncomplicated active rheumatoid arthritis have equivalent clinical outcome with a small difference in overall resource cost in favour of day care. The choice of management strategy may depend increasingly on convenience, satisfaction, or more comprehensive health measures reflecting the preferences of patients, providers, and service commissioners.     

Life satisfaction and its related factors among institutionalized patients at a Hansen's disease sanatorium

We conducted a questionnaire survey on life styles and health status for 293 patients with Hansen's disease. They were admitted to the wards for disabled and physically able patients of Ohshima Seishoen, in Kagawa prefecture, in 1991. This institution is one of Japan's national leprosy sanitarians. We measured patients' life satisfaction with the Delighted-Terrible Scale. In this report, the distribution of life satisfaction and its associated factors were examined for 210(71.7%) respondents. Factors examined were length of treatment, physical health, and social aspects of life at the sanatorium. The major findings were as follows; 1. The patients aged under 60 had lower proportions of being satisfied with life than those aged 60 or older. The proportions of life satisfaction of the 40-59 age group were 17% for men and 22% for women, while for the 60 or older age groups were 33-44% for men and 41-45% for women. The proportions of life satisfaction in the 60 or older age groups were lower than those of community dwelling elderly persons. 2. We examined factors associated with life satisfaction for the respondents aged 60 or older. Dependence on activities of daily living (ADL) was associated with life satisfaction in some ADL items. Care and aid provided by the staff of the sanatorium may modify the relationship between ADL impairment and life satisfaction. For social aspects of life at the sanatorium, both having networks with family members and having resources other than family were associated with life satisfaction. Going out and positively spending their daily lives were associated with life satisfaction, too. These associations were significant for men. Similar patterns of association were observed for women, but were insignificant. This finding suggests that it is important for the health and medical care staff to pay attention to the social aspects of the life of elderly patients with Hansen's disease.