Autism, an extreme challenge to integrative medicine. Part: 1: The knowledge base.
(73/963)
Autism, archetype of the autistic spectrum disorders (ASD), is a neurodevelopmental disorder characterized by socially aloof behavior and impairment of language and social interaction. Its prevalence has surged in recent years. Advanced functional brain imaging has confirmed pervasive neurologic involvement. Parent involvement in autism management has accelerated understanding and treatment. Often accompanied by epilepsy, cognitive deficits, or other neurologic impairment, autism manifests in the first three years of life and persists into adulthood. Its etiopathology is poorly defined but likely multifactorial with heritability playing a major role. Prenatal toxic exposures (teratogens) are consistent with autism spectrum symptomatology. Frequent vaccinations with live virus and toxic mercurial content (thimerosal) are a plausible etiologic factor. Autistic children frequently have abnormalities of sulfoxidation and sulfation that compromise liver detoxification, which may contribute to the high body burden of xenobiotics frequently found. Frequent copper-zinc imbalance implies metallothionein impairment that could compound the negative impact of sulfur metabolism impairments on detoxification and on intestinal lining integrity. Intestinal hyperpermeability manifests in autistic children as dysbiosis, food intolerances, and exorphin (opioid) intoxication, most frequently from casein and gluten. Immune system abnormalities encompass derangement of antibody production, skewing of T cell subsets, aberrant cytokine profiles, and other impairments consistent with chronic inflammation and autoimmunity. Coagulation abnormalities have been reported. Part 2 of this review will attempt to consolidate progress in integrative management of autism, aimed at improving independence and lifespan for people with the disorder. (+info)
Understanding coordination of care from the consumer's perspective in a regional health system.
(74/963)
OBJECTIVE: To understand and develop a model about the meaning of coordination to consumers who experienced a transition from acute care to home care. STUDY DESIGN: A qualitative, exploratory study using Grounded Theory. DATA SOURCES/ANALYSIS: Thirty-three consumers in the Calgary Regional Health Authority who had experienced the transition from an acute care hospital back into the community with home care support were interviewed. They were asked to describe their transition experience and what aspects of coordination were important to them. Interviews were recorded, transcribed, and analyzed using constant comparison. The coding and retrieval of information was facilitated by the computer software program Nud*ist. PRINCIPAL FINDINGS: The resulting model has four components: (1) the meaning of coordination to consumers; (2) aspects of health care system support that are important for coordination; (3) elements that prepared consumers to return home; and (4) the components of a successful transition experience. Consumers appeared to play a crucial role in spanning organizational boundaries by participating in the coordination of their own care. CONCLUSIONS: Consumers must be included in health care decisions as recipients of services and major players in the transition processes related to their care. Health care providers need to ensure that consumers are prepared to carry out their coordination role and managers need to foster a culture that values the consumer "voice" in organizational processes. (+info)
A platform for population-based weight management: description of a health plan-based integrated systems approach.
(75/963)
OBJECTIVES: To describe an integrated, operational platform from which mail- and telephone-based health promotion programs are implemented and to specifically relate this approach to weight management programming in a managed care setting. APPROACH: In-depth description of essential systems structures, including people, computer technology, and decision-support protocols. The roles of support staff, counselors, a librarian, and a manager in delivering a weight management program are described. Information availability using computer technology is a critical component in making this system effective and is presented according to its architectural layout and design. Protocols support counselors and administrative support staff in decision making, and a detailed flowchart presents the layout of this part of the system. This platform is described in the context of a weight management program, and we present baseline characteristics of 1801 participants, their behaviors, self-reported medical conditions, and initial pattern of enrollment in the various treatment options. CONCLUSION: Considering the prevalence and upward trend of overweight and obesity in the United States, a need exists for robust intervention platforms that can systematically support multiple types of programs. Weight management interventions implemented using this platform are scalable to the population level and are sustainable over time despite the limits of defined resources and budgets. The present article describes an innovative approach to reaching a large population with effective programs in an integrated, coordinated, and systematic manner. This comprehensive, robust platform represents an example of how obesity prevention and treatment research may be translated into the applied setting. (+info)
An implementation framework for household and community integrated management of childhood illness.
(76/963)
This paper describes the development and recent history of the third component of the Integrated Management of Childhood Illness (IMCI) strategy, improving household and community practices (HH/C IMCI). An implementation framework for this third component, developed through review of experiences of non-governmental organizations (NGOs) working in community-based child health and nutrition programmes, is then presented. This Framework responds to demand from NGOs and their partners for a description of the different categories of community-level activities necessary for the implementation of a comprehensive child health and nutrition programme. These categories of activities facilitate the systematic cataloguing, synthesis and coordination of organizational activities and experience. It also serves as a reference tool for improving communication of related community child health activities, and a guide for designing appropriate behaviour change strategies. The Framework was endorsed by participants in an international workshop held in Baltimore, Maryland in January 2001, and specified three linked elements that are integral to HH/C IMCI, supported by a multi-sectoral platform that addresses constraints communities face in adopting practices that promote health and nutrition. The three programmatic Elements critical to HH/C IMCI programmes are (1). improving partnerships between health facilities or services and the communities they serve; (2). increasing appropriate and accessible care and information from community-based providers; and (3). integrating promotion of key family practices critical for child health and nutrition. The Framework presented in this paper is an ideal tool for describing, sharing and coordinating efforts in the field, and is purposely descriptive rather than prescriptive. (+info)
Improving the process through which health plans and providers exchange performance-related mammography data.
(77/963)
The ability of health plans to bring about quality improvement is limited by the fact that physician networks are highly differentiated, with physician groups participating in many plans and plans contracting with many physician groups. The primary purpose of our study was to investigate the problems in the current system of quality monitoring by managed-care organizations (MCOs) at a large integrated health care delivery system (Montefiore Medical Center) and to develop ways of addressing these problems through collaboration among MCOs. The project began by mapping the current system for collecting, reporting, and using performance data to improve performance, using breast cancer screening as an example. We found that neither health plans nor providers were satisfied with the current system. From the perspective of the health plans, the current quality monitoring was costly and, more important, was not yielding appreciable increases in screening rates. From the providers' perspective, multiple health plan requests for chart pulls and other data collection activities cost them substantial amounts of time and money and generated multiple mailings of educational materials and reports, but rarely supplied meaningful information about their performance. From the perspective of the hospital, the current procedure of reporting from MCO to provider or center bypassed the institution's own quality monitoring and management structure and thus limited the institution's ability to assist in quality improvement. This study clearly showed the importance of collaboration among plans at a given provider site. Specifically, it pointed to the need for provider-oriented reporting of data, rather than plan-oriented reporting, to give physicians numbers that they believe. It also showed the need to engage the institution's own quality-management system to assist in bringing about improvements. (+info)
Whom should we profile? Examining diabetes care practice variation among primary care providers, provider groups, and health care facilities.
(78/963)
OBJECTIVE: To evaluate the amount of variation in diabetes practice patterns at the primary care provider (PCP), provider group, and facility level, and to examine the reliability of diabetes care profiles constructed using electronic databases. DATA SOURCES/STUDY SETTING: Clinical and administrative data obtained from the electronic information systems at all facilities in a Department of Veterans Affairs' (VA) integrated service network for a study period of October 1997 through September 1998. STUDY DESIGN: This is a cohort study. The key variables of interest are different types of diabetes quality indicators, including measures of technical process, intermediate outcomes, and resource use. DATA COLLECTION/EXTRACTION METHODS: A coordinated registry of patients with diabetes was constructed by integrating laboratory, pharmacy, utilization, and primary care provider data extracted from the local clinical information system used at all VA medical centers. The study sample consisted of 12,110 patients with diabetes, 258 PCPs, 42 provider groups, and 13 facilities. PRINCIPAL FINDINGS: There were large differences in the amount of practice variation across levels of care and for different types of diabetes care indicators. The greatest amount of variance tended to be attributable to the facility level. For process measures, such as whether a hemoglobin A1c was measured, the facility and PCP effects were generally comparable. However, for three resource use measures the facility effect was at least six times the size of the PCP effect, and for inter-mediate outcome indicators, such as hyperlipidemia, facility effects ranged from two to sixty times the size of the PCP level effect. A somewhat larger PCP effect was found (5 percent of the variation) when we examined a "linked" process-outcome measure linking hyperlipidemia and treatment with statins). When the PCP effect is small (i.e., 2 percent), a panel of two hundred diabetes patients is needed to construct profiles with 80 percent reliability. CONCLUSIONS: little of the variation in many currently measured diabetes care practices is attributable to PCPs and, unless panel sizes are large, PCP profiling will be inaccurate. If profiling is to improve quality, it may be best to focus on examining facility-level performance variations and on developing indicators that promote specific, high-priority clinical actions. (+info)
Profiling resource use: do different outcomes affect assessments of provider efficiency?
(79/963)
OBJECTIVES: To examine whether 2 outcome measures result in different assessments of efficiency across 22 service networks within the Department of Veterans Affairs (VA). STUDY DESIGN: A retrospective analysis using VA inpatient and outpatient administrative databases. METHODS: A 60% random sample of veterans who used healthcare services during fiscal year 1997 was split into a 40% sample (n = 1,046,803) for development and a 20% sample (n = 524,461) for validation. Weighted concurrent case-mix models using adjusted clinical groups were developed to explain variation in 2 outcomes: "days of care"--the sum of a patient's inpatient and outpatient annual visit days, and "average accounting costs"--the sum of the average service costs multiplied by the units of service for each patient. Two profiling indicators were calculated for each outcome: an unadjusted efficiency index and an adjusted efficiency index. These indices were compared to examine network efficiency. RESULTS: Although about half the networks were identified as "efficient" before and after case-mix adjustment, assessments of individual network efficiency were affected by the adjustment. The 2 outcomes differed on which networks were efficient. For example, 4 networks that appeared as efficient based on days of care appeared as inefficient based on average costs. CONCLUSIONS: Assessments of provider efficiency across the 22 networks depended on the outcome measure used. Knowledge about the extent to which assessments of provider efficiency depend on the outcome measure used is an important step toward improved and more equitable comparisons across providers. (+info)
Mental health care and nutrition. Integrating specialist services into primary care.
(80/963)
PROBLEM BEING ADDRESSED: Primary care reform is an important component of health services restructuring. One of the goals of primary care reform is to integrate specialized services into primary care settings. To date, few programs have successfully achieved this. OBJECTIVE OF PROGRAM: To integrate specialized mental health services into the offices of family physicians through the Hamilton Health Services Organization (HSO) Mental Health and Nutrition Program. MAIN COMPONENTS OF PROGRAM: Since 1994, the Hamilton HSO Mental Health and Nutrition Program has integrated mental health counselors, psychiatrists, and dietitians into the offices of 87 family physicians. Activities of specialists are coordinated by a central administrative body. CONCLUSION: Lessons learned from this program can indicate how to succeed in integrating specialist services into primary care offices. (+info)