Health-based payment and computerized patient record systems. (9/5627)

Health care information technology is changing rapidly and dramatically. A small but growing number of clinicians, especially those in staff and group model HMOs and hospital-affiliated practices, are automating their patient medical records in response to pressure to improve quality and reduce costs. Computerized patient record systems in HMOs track risks, diagnoses, patterns of care, and outcomes across large populations. These systems provide access to large amounts of clinical information; as a result, they are very useful for risk-adjusted or health-based payment. The next stage of evolution in health-based payment is to switch from fee-for-service (claims) to HMO technology in calculating risk coefficients. This will occur when HMOs accumulate data sets containing records on provider-defined disease episodes, with every service linked to its appropriate disease episode for millions of patients. Computerized patient record systems support clinically meaningful risk-assessment models and protect patients and medical groups from the effects of adverse selection. They also offer significant potential for improving quality of care.  (+info)

Review of psychosocial stress and asthma: an integrated biopsychosocial approach. (10/5627)

Environmental stressors may impact asthma morbidity through neuroimmunological mechanisms which are adversely impacted and/or buffered y social networks, social support, and psychological functioning. In addition, life stress may impact on health beliefs and behaviours that may affect asthma management. Whereas earlier psychosomatic models have supported a role for psychological stress in contributing to variable asthma morbidity among those with existing disease, a growing appreciation of the interactions between behavioural, neural, endocrine, and immune processes suggest a role for these psychosocial factors in the genesis of asthma as well. While a causal link between stress and asthma has not bee established, this review provides a framework in which we can begin to see links between these systems that might provide new insights to guide future explorations. The complexity of these interactions underscore the need for a multidisciplinary approach which combines the idea that the origin of asthma is purely psychogenic in nature with the antithetical consideration that the biological aspects are all important. These distinctions are artificial, and future research that synthesizes biological, psychological, sociocultural, and family parameters is urgently needed to further our understanding of the rising burden of asthma.  (+info)

Physical abuse during pregnancy: prevalence and risk factors. (11/5627)

BACKGROUND: Violence during pregnancy is a health and social problem that poses particular risks to the woman and her fetus. To address the lack of Canadian information on this issue, the authors studied the prevalence and predictors of physical abuse in a sample of pregnant women in Saskatoon. METHODS: Of 728 women receiving prenatal services through the Saskatoon District public health system between Apr. 1, 1993, and Mar. 31, 1994, 605 gave informed consent to participate in the study and were interviewed in the second trimester. Of these, 543 were interviewed again late in the third trimester. During the initial interview, information was collected on the women's sociodemographic characteristics, the current pregnancy, health practices and psychosocial variables. The second interview focused on the women's experience of physical abuse during the pregnancy and during the preceding year, the demographic characteristics and the use of alcohol or illicit drugs by their male partner. RESULTS: In all, 31 (5.7%) of the women reported experiencing physical abuse during pregnancy; 46 (8.5%) reported experiencing it within the 12 months preceding the second interview. Of the 31 women 20 (63.3%) reported that the perpetrator was her husband, boyfriend or ex-husband. Although all ethnic groups of women suffered abuse, aboriginal women were at greater risk than nonaboriginal women (adjusted odds ratio 2.8, 95% confidence interval [CI] 1.0-7.8). Women whose partner had a drinking problem were 3.4 times (95% CI 1.2-9.9) more likely to have been abused than women whose partner did not have a drinking problem. Perceived stress and number of negative life events in the preceding year were also predictors of abuse. Abused women tended to report having fewer people with whom they could talk about personal issues or get together; however, they reported socializing with a larger number of people in the month before the second interview than did the women who were not abused. INTERPRETATION: Physical abuse affects a significant minority of pregnant women and is associated with stress, lack of perceived support and a partner with a drinking problem.  (+info)

Effects of education and support on self-care and resource utilization in patients with heart failure. (12/5627)

AIMS: To test the effect of education and support by a nurse on self-care and resource utilization in patients with heart failure. METHODS: A total of 179 patients (mean age 73, 58% male, NYHA III-IV) hospitalized with heart failure were evaluated prospectively. Patients were randomized to the study intervention or to 'care as usual'. The supportive educative intervention consisted of intensive, systematic and planned education by a study nurse about the consequences of heart failure in daily life, using a standard nursing care plan developed by the researchers for older patients with heart failure. Education and support took place during the hospital stay and at a home visit within a week of discharge. Data were collected on self-care abilities, self-care behaviour, readmissions, visits to the emergency heart centre and use of other health care resources. RESULTS: Education and support from a nurse in a hospital setting and at home significantly increases self-care behaviour in patients with heart failure. Patients from both the intervention and the control group increased their self-care behaviour within 1 month of discharge, but the increase in the intervention group was significantly more after 1 month. Although self-care behaviour in both groups decreased during the following 8 months, the increase from baseline remained statistically significant in the intervention group, but not in the control group. No significant effects on resource utilization were found. CONCLUSIONS: Intensive, systematic, tailored and planned education and support by a nurse results in an increase in patients' self-care behaviour. No significant effects were found on use of health care resources. Additional organisational changes, such as longer follow-up and the availability of a heart failure specialist would probably enhance the effects of education and support.  (+info)

HIV stress in primary school teachers in Zambia. (13/5627)

A study was made of stress factors experienced by primary school teachers in Zambia after they had attended a course on stress management and counselling skills. Their pupils were significantly affected by poverty, death and illness of parents, fellow-pupils and teachers, teenage sex and pregnancy, violence in the home and, among girls, low self-esteem. The HIV epidemic had a major bearing on these factors, and there were wide-ranging effects on the teachers' own lives. Despite the training they had been given, many teachers felt that they could not adequately counsel their pupils on these matters. The teachers were in need of continuing support and training to enable them to cope with this aspect of their work.  (+info)

Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. (14/5627)

Recent studies provide clear and convincing evidence that psychosocial factors contribute significantly to the pathogenesis and expression of coronary artery disease (CAD). This evidence is composed largely of data relating CAD risk to 5 specific psychosocial domains: (1) depression, (2) anxiety, (3) personality factors and character traits, (4) social isolation, and (5) chronic life stress. Pathophysiological mechanisms underlying the relationship between these entities and CAD can be divided into behavioral mechanisms, whereby psychosocial conditions contribute to a higher frequency of adverse health behaviors, such as poor diet and smoking, and direct pathophysiological mechanisms, such as neuroendocrine and platelet activation. An extensive body of evidence from animal models (especially the cynomolgus monkey, Macaca fascicularis) reveals that chronic psychosocial stress can lead, probably via a mechanism involving excessive sympathetic nervous system activation, to exacerbation of coronary artery atherosclerosis as well as to transient endothelial dysfunction and even necrosis. Evidence from monkeys also indicates that psychosocial stress reliably induces ovarian dysfunction, hypercortisolemia, and excessive adrenergic activation in premenopausal females, leading to accelerated atherosclerosis. Also reviewed are data relating CAD to acute stress and individual differences in sympathetic nervous system responsivity. New technologies and research from animal models demonstrate that acute stress triggers myocardial ischemia, promotes arrhythmogenesis, stimulates platelet function, and increases blood viscosity through hemoconcentration. In the presence of underlying atherosclerosis (eg, in CAD patients), acute stress also causes coronary vasoconstriction. Recent data indicate that the foregoing effects result, at least in part, from the endothelial dysfunction and injury induced by acute stress. Hyperresponsivity of the sympathetic nervous system, manifested by exaggerated heart rate and blood pressure responses to psychological stimuli, is an intrinsic characteristic among some individuals. Current data link sympathetic nervous system hyperresponsivity to accelerated development of carotid atherosclerosis in human subjects and to exacerbated coronary and carotid atherosclerosis in monkeys. Thus far, intervention trials designed to reduce psychosocial stress have been limited in size and number. Specific suggestions to improve the assessment of behavioral interventions include more complete delineation of the physiological mechanisms by which such interventions might work; increased use of new, more convenient "alternative" end points for behavioral intervention trials; development of specifically targeted behavioral interventions (based on profiling of patient factors); and evaluation of previously developed models of predicting behavioral change. The importance of maximizing the efficacy of behavioral interventions is underscored by the recognition that psychosocial stresses tend to cluster together. When they do so, the resultant risk for cardiac events is often substantially elevated, equaling that associated with previously established risk factors for CAD, such as hypertension and hypercholesterolemia.  (+info)

Understanding HIV-related risk among persons with a severe and persistent mental illness: insights from qualitative inquiry. (15/5627)

We conducted focus groups with 36 men and women who were receiving treatment for a severe and persistent mental illness (SPMI) to learn more about the social context of their intimate relationships and the psychological antecedents of their sexual decision-making. Qualitative analysis of focus group transcripts indicated that a) sexual activity tended to be unplanned and occurred in social networks where HIV risk may be elevated, b) HIV-related knowledge was superficial and insufficient to guide safer sexual behavior, c) participants' HIV risk perception was often based upon factors unrelated to their sexual behaviors, and d) communication skills for HIV risk reduction were poor. We discuss how qualitative methods yielded insights not readily available through quantitative approaches and offer recommendations for HIV risk assessment and prevention among persons with an SPMI.  (+info)

The Resource Mothers Program for Maternal Phenylketonuria. (16/5627)

OBJECTIVES: The purpose of this study was to measure the effectiveness of resource mothers in reducing adverse consequences of maternal phenylketonuria. METHODS: Nineteen pregnancies in the resource mothers group were compared with 64 pregnancies in phenylketonuric women without resource mothers. Weeks to metabolic control and offspring outcome were measured. RESULTS: Mean number of weeks to metabolic control was 8.5 (SE = 2.2) in the resource mothers group, as compared with 16.1 (SE = 1.7) in the comparison group. Infants of women in the resource mothers group had larger birth head circumferences and higher developmental quotients. CONCLUSIONS: The resource mothers program described here improves metabolic control in pregnant women with phenylketonuria.  (+info)