Managed public mental healthcare: issues, trends, and prospects.
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OBJECTIVE: To describe the structure and status of public mental healthcare and the impact of managed behavioral healthcare on this system. STUDY DESIGN AND METHODS: The structure and financing of public mental health systems were reviewed. Because there are no controlled multisite studies of managed public sector behavioral healthcare, case examples were used to illustrate trends and issues. DISCUSSION: The methods, results, and impact of public managed behavioral healthcare are incomplete and uncertain. The complexity of the public sector system, the patients served in it, and the services provided are daunting. The variability of patient needs, the role of Medicaid versus state funding, and the variable governance structures of local systems in different states make managed care methods more complex than in private markets. CONCLUSIONS: The organization, structure, and financing of public mental health systems have developed rapidly in the past generation as care has been moved from hospital to community. Early efforts to apply managed behavioral healthcare methods used in the private, commercially paid sector have not been very successful, and most public sector managed care efforts have been limited to Medicaid-paid care. The trend in public mental health systems is to "unpack" managed care and use its tools selectively. (+info)
Twenty year trends (1975-1995) in the incidence, in-hospital and long-term death rates associated with heart failure complicating acute myocardial infarction: a community-wide perspective.
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OBJECTIVES: To describe from a population-based perspective, recent and temporal (1975-1995) trends in the incidence, in-hospital and postdischarge case-fatality rates of heart failure (HF) complicating acute myocardial infarction (AMI). BACKGROUND: Extremely limited data are available describing the incidence and case-fatality rates associated with HF complicating AMI from a community-wide perspective. METHODS: The medical records of 6,798 residents of the Worcester, Massachusetts metropolitan area with validated MI and without previous HF hospitalized in 10 annual periods between 1975 and 1995 were reviewed. RESULTS: The proportion of AMI patients developing HF during hospitalization declined between 1975-1978 (38%) and 1993-1995 (33%) (p < 0.001). After controlling for potentially confounding factors, the risk of developing HF declined progressively, albeit modestly, over time. In-hospital case-fatality rates of patients with AMI complicated by HF declined by approximately 46% between 1975-1978 (33%) and 1993-1995 (18%) (p < 0.001). Improving trends in hospital survival were observed after adjusting for potentially confounding prognostic factors. The one-year post-discharge mortality rate for hospital survivors of HF did not change over the 20-year period under study, even after controlling for additional prognostic characteristics. CONCLUSIONS: The results of this community-wide study suggest encouraging declines in the incidence and hospital death rates associated with HF complicating AMI. Continued efforts need to be directed towards the prevention of HF given the magnitude of this clinical syndrome. Efforts of secondary prevention are needed to identify and improve the treatment of patients with symptomatic left ventricular dysfunction following AMI given the lack of improvement in the long-term prognosis of these patients. (+info)
Evidence for decline in disability and improved health among persons aged 55 to 70 years: the Framingham Heart Study.
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OBJECTIVES: This study detected secular change in disability and health among persons aged 55 to 70 years, the life period when increases in disability and morbidity begin and retirement occurs. METHODS: Cross-sectional comparisons were completed with data from similarly aged members of the original (n = 1760) and offspring (n = 1688) cohorts of the Framingham Heart Study, which represent 2 generations. Analyses were conducted by gender and on chronic disease subgroups by logistic regression. RESULTS: There was substantially less disability in the offspring cohort than in the original cohort. Thirty-six percent of offspring men were disabled vs 52% of original cohort men (P = .001); among women, these proportions were 54% vs 72% (P = .001). Fewer offspring perceived their health as fair or poor and fewer had chronic diseases. Offspring were more physically active and less likely to smoke or consume high amounts of alcohol, but their average weight was greater. The secular decline in disability was strongly evident among individuals with chronic diseases. CONCLUSIONS: Our findings depict a secular change toward a less disabled and globally healthier population in the period of life when retirement occurs. (+info)
The association between state housing policy and lead poisoning in children.
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OBJECTIVES: This study examined the effect of an active program of household lead paint hazard abatement, applied over 22 years, on childhood lead poisoning in Massachusetts. METHODS: A small areas analysis was used to compare screening blood lead levels of children in Worcester County, Mass (n = 27,590), with those in Providence County, RI (n = 19,071). Data were collapsed according to census tract. RESULTS: The percentage of children with lead poisoning (blood lead level > or = 20 micrograms/dL [Pe20]) was, on average, 3 times higher in Providence County census tracts (3.2% vs 0.9% in Worcester County census tracts, P < .0001), despite similar percentages of pre-1950s housing in both counties. The ratio of Pe20 in Providence vs Worcester County census tracts was 2.2 (95% confidence interval = 1.8, 2.7), after adjustment for differences in housing, sociodemographic, and screening characteristics. This estimate was robust to alternative regression methods and sensitivity analyses. CONCLUSIONS: Massachusetts policy, which requires lead paint abatement of children's homes and places liability for lead paint poisoning on property owners, may have substantially reduced childhood lead poisoning in that state. (+info)
Survey of acupuncturists: practice characteristics and pediatric care.
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OBJECTIVE: To describe the practice characteristics and pediatric care provided by licensed acupuncturists. DESIGN: Cross-sectional survey. SETTING: Boston metropolitan area. SUBJECTS: 227 licensed acupuncturists were surveyed; 140 (62%) responded. MAIN OUTCOME MEASURES: (1) DEMOGRAPHICS, (2) practice characteristics, (3) pediatric care, (4) recommendations of peers recognized as experts in pediatric acupuncture. RESULTS: (1) DEMOGRAPHICS: 70% Caucasian, 61% female; (2) practice characteristics: average of 39 visits weekly with an average charge of $54 for a 57-minute visit; patients were typically scheduled for follow-up once or twice weekly; only 5% of fees were covered by insurance; 80% recommended herbal remedies and 66% dispensed herbs in the office; (3) few acupuncturists treated more than one child per week; most used non-needle techniques or Japanese-style acupuncture to stimulate points in children; 85% would refer a febrile two-week-old infant immediately to a physician; (4) only 17 acupuncturists were recommended by three or more peers and saw three or more patients weekly; their practices were all in wealthy suburban areas. CONCLUSIONS: Most acupuncturists in the Boston area are Caucasian and female. Compared with physicians, they schedule patients for more frequent follow-up, allocate more time, are less likely to be reimbursed by insurance, and treat fewer children. Additional studies are needed to assess effectiveness, quality, and access to acupuncture services for adults and children. (+info)
Amino acid variants of the vitamin D-binding protein and risk of diabetes in white Americans of European origin.
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BACKGROUND: Genetic variants of vitamin D-binding protein (DBP) have been reported to be associated, not only with diabetes, but also with prediabetic traits, in several populations. There are two known polymorphisms in exon 11 of the DBP gene that result in amino acid variants: at codons 416 GAT-->GAG (Asp-->Glu) and 420 ACG-->AAG (Thr-->Lys). OBJECTIVE: To examine the association of these polymorphisms with diabetes in white Americans of European origin. METHODS: We studied unrelated individuals: 181 with type 1 diabetes, 215 with type 2 diabetes, and 163 healthy controls. Exon 11 was amplified using polymerase chain reaction and the two alleles were determined by digestion with specific endonucleases: HaeIII and StyI, respectively. RESULTS: At codon 416, Asp/Glu allele frequencies were 45%/55% in patients with type 1 diabetes, 43%/57% in patients with type 2 diabetes, and 46%/54% in controls (chi(2)=0.69, 2 d.f., P<0.71). At codon 420, corresponding Lys/Thr frequencies were 27%/73%, 30%/70%, and 30%/70% (chi(2)=1.25, 2 d.f., P=0.53). Distributions of genotypes at both loci, and the haplotypes defined by the two loci, were also very similar in all groups. CONCLUSION: DNA polymorphisms in the DBP gene are not associated with diabetes in white Americans of European origin. (+info)
During 1996-1998, CDC received reports from approximately 16 state health departments of Salmonella infections in persons who had direct or indirect contact with reptiles (i.e., lizards, snakes, or turtles). Salmonella infection can result in invasive illness including sepsis and meningitis, particularly in infants. Despite educational efforts, some reptile owners remain unaware that reptiles place them and their children at risk for salmonellosis. This report summarizes clinical and epidemiologic information in four cases and provides information about state regulations to prevent transmission of Salmonella spp. from reptiles to humans. (+info)
Cardiovascular disease and mortality in a community-based cohort with mild renal insufficiency.
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Cardiovascular disease and mortality in a community-based cohort with mild renal insufficiency. BACKGROUND: Little is known about the prevalence of cardiovascular disease (CVD) and associated risk factors in individuals with mild renal insufficiency (RI). Furthermore, the long-term outcomes associated with mild RI in the community have not been described. METHODS: Serum creatinine (SCr) was measured in 6233 adult participants of the Framingham Heart Study (mean age 54 years, 54% women). Mild RI was defined as SCr 136 to 265 micromol/liter (1.5 to 3.0 mg/dl) in men and 120 to 265 micromol/liter (1.4 to 3.0 mg/dl) in women. The lower limits for mild RI were defined by the sex-specific 95th percentile SCr values in a healthy subgroup of our sample. The upper limit for mild RI was chosen to exclude those subjects with more advanced renal failure. Cox proportional hazards analyses were used to determine the relationship of baseline RI to CVD and all-cause mortality. RESULTS: At baseline, 8.7% of men (N = 246) and 8.0% of women (N = 270) had mild RI. Nineteen percent of the subjects with mild RI had prevalent CVD. During 15 years of follow-up, there were 1000 CVD events and 1406 deaths. In women, mild RI was not associated with increased risk for CVD events [hazards ratio (HR) 1.04, 95% CI, 0.79 to 1.37] or all-cause mortality (HR 1.08, 95% CI, 0.87 to 1.34). In men, mild RI showed no significant associations with CVD events (HR 1.17, 95% CI, 0.88 to 1.57), but it was associated with all-cause mortality in age-adjusted (HR 1.42, 95% CI, 1.12 to 1.79) and multivariable adjusted (HR 1.31, 95% CI, 1.02 to 1.67) analyses. CONCLUSION: Mild RI in the community is common and is associated with a high prevalence of CVD. The association of RI with risk for adverse outcomes is strongly related to coexisting CVD and CVD risk factors. (+info)