Using an explicit guideline-based criterion and implicit review to assess antipsychotic dosing performance for schizophrenia.
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OBJECTIVE: Using structured implicit review as the gold standard, this study assessed the sensitivity and specificity of an explicit antipsychotic dose criterion derived from schizophrenia guidelines. DESIGN: Two psychiatrists reviewed medical records and made consensus-structured implicit review ratings of the appropriateness of discharge antipsychotic dosages for hospitalized patients who participated in a schizophrenia outcomes study. Structured implicit review ratings were compared with the explicit criterion: whether antipsychotic dose was within the guideline-recommended range of 300-1000 chlorpromazine milligram equivalents (CPZE). In addition, reasons for deviation from guideline dose recommendations were examined. SETTING AND STUDY PARTICIPANTS: A total of 66 patients hospitalized for acute schizophrenia at a Veterans Affairs medical center or state hospital in the southeastern US. MAIN OUTCOME MEASURES: The sensitivity and specificity of the explicit dose criterion at hospital discharge were determined in comparison with the gold standard of structured implicit review. RESULTS: At hospital discharge, 61% of patients (n = 40) were receiving doses within the guideline-recommended range. According to structured implicit review ratings, antipsychotic dose management was appropriate for 80% (n = 53) of patients. When the 300-1000 CPZE dose criterion (dosage within or outside the recommended range) was compared with structured implicit review, it demonstrated 84.6% sensitivity and 71.7% specificity for detecting inappropriate antipsychotic dose. CONCLUSIONS: The explicit antipsychotic dose criterion may provide a useful and efficient screen to identify patients at significant risk for quality of care problems; however, the relatively low specificity suggests that the measure may not be appropriate for quality measurement programs that compare performance among health plans. (+info)
Occupational exposure to crystalline silica and risk of systemic lupus erythematosus: a population-based, case-control study in the southeastern United States.
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OBJECTIVE: Crystalline silica may act as an immune adjuvant to increase inflammation and antibody production, and findings of occupational cohort studies suggest that silica exposure may be a risk factor for systemic lupus erythematosus (SLE). We undertook this population-based study to examine the association between occupational silica exposure and SLE in the southeastern US. METHODS: SLE patients (n = 265; diagnosed between January 1, 1995 and July 31, 1999) were recruited from 4 university rheumatology practices and 30 community-based rheumatologists in 60 contiguous counties. Controls (n = 355), frequency-matched to patients by age, sex, and state of residence, were randomly selected from driver's license registries. The mean age of the patients at diagnosis was 39 years; 91% were women and 60% were African American. Detailed occupational and farming histories were collected by in-person interviews. Silica exposure was determined through blinded assessment of job histories by 3 industrial hygienists, and potential medium- or high-level exposures were confirmed through followup telephone interviews. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were estimated by logistic regression. RESULTS: More patients (19%) than controls (8%) had a history of medium- or high-level silica exposure from farming or trades. We observed an association between silica and SLE (medium exposure OR 2.1 [95% CI 1.1-4.0], high exposure OR 4.6 [95% CI 1.4-15.4]) that was seen in separate analyses by sex, race, and at different levels of education. CONCLUSION: These results suggest that crystalline silica exposure may promote the development of SLE in some individuals. Additional research is recommended in other populations, using study designs that minimize potential selection bias and maximize the quality of exposure assessment. (+info)
Use of the SF-12 instrument for measuring the health of homeless persons.
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OBJECTIVE: To evaluate the construct validity of the Short Form 12-item Survey (SF-12) among users of a homeless day shelter. Adding brief health assessments has potential to provide information regarding the effect that programs have upon the health status and functioning of homeless persons. STUDY SETTING: A convenience sample of 145 homeless persons at a day shelter in an urban setting. STUDY DESIGN: Participants were verbally administered the SF-12 that provides information on mental and physical health status and the Dartmouth Improve Your Medical Care Survey (IYMC) that provides information on functional health, clinical symptoms, medical conditions, and health risk. The IYMC survey system has been widely used in clinical settings to assess health status and the outcomes of care. DATA COLLECTION/EXTRACTION METHODS: Construct validity was assessed by the following approaches: (a) the method of extreme groups was used where multivariate analysis of variance determined if SF-12 summary scores varied for individuals who differed in self-reported clinical symptoms and medical conditions, and (b) convergent validity was assessed by correlating SF-12 summary scores with the subscales. PRINCIPAL FINDINGS: Four to 10 point differences in physical health (PCS12) and 5-11 point differences in mental health (MCS12) were found between those who reported acute symptoms and medical conditions and those who did not. A 13-point difference in PCS12 scores and a 7-16-point difference in MCS12 scores were found for those who reported none or few to several symptoms or conditions. The summary scores and subscales yielded satisfactory convergent validity coefficients that ranged from 0.62 to 0.88 with one exception. CONCLUSIONS: The SF-12 shows promise as a valid outcome indicator for assessing and monitoring health status among the homeless. Its strengths include brevity and availability of norms for specific medical conditions. (+info)
Alternative mental health services: the role of the black church in the South.
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OBJECTIVES: This study determined the extent to which churches in the South were providing mental health and social services to congregations and had established linkages with formal systems of care. METHODS: A computer-assisted telephone interview (CATI) survey was conducted with pastors from 269 Southern churches. RESULTS: Black churches reported providing many more services than did White churches, regardless of urban or rural location. Few links between churches and formal provider systems were found, irrespective of the location--urban or rural--or racial composition of the churches. CONCLUSIONS: Results are discussed in terms of the potential for linking faith communities and formal systems of care, given the centrality of the Black church in historical context. (+info)
Breast, cervical, and colorectal carcinoma screening in a demographically defined region of the southern U.S.
(29/399)
BACKGROUND: The "Southern Black Belt," a term used for > 100 years to describe a subregion of the southern U.S., includes counties with high concentrations of African Americans and high levels of poverty and unemployment, and relatively high rates of preventable cancers. METHODS: The authors analyzed data from a state-based telephone survey of adults age >or= 18 years to compare the cancer screening patterns of African-American and white men and women in nonmetropolitan counties of this region, and to compare those rates with those of persons in other southern counties and elsewhere in the U.S. The primary study groups were comprised of 2165-5888 women and 1198 men in this region interviewed through the Behavioral Risk Factor Surveillance System. The respondents lived in predominantly rural counties in 11 southern states with sizeable African-American populations (>or= 24.5% of county residents). The main outcome measures were recent use of the Papanicolau (Pap) test, mammography, test for fecal occult blood in the stool (FOBT), and flexible sigmoidoscopy or colonoscopy. RESULTS: Between 1998-2000, 66.3% (95% confidence interval [95% CI] +/- 2.7%) of 1817 African-American women in the region age >or= 40 years had received a mammogram within the past 2 years, compared with 69.3% (95% CI +/- 1.8%) of 3922 white women (P = 0.066). The proportion of African-American and white women who had received a Pap test within the past 3 years was similar (85.7% [95% CI +/- 1.9%] vs. 83.4% [95% CI +/- 1.5%]; P = 0.068]. In 1997 and 1999, 29.3% of African-American women in these counties reported ever receiving an FOBT, compared with 36.9% in non-Black Belt counties and 42.5% in the remainder of the U.S. Among white women, 37.7% in Black Belt counties, 44.0% in non-Black Belt counties, and 45.3% in the remainder of the U.S. ever received an FOBT. Overall, similar patterns were noted among both men and women with regard to ever-use of FOBT, flexible sigmoidoscopy, or colonoscopy. Screening rates appeared to vary less by race than by region. CONCLUSIONS: The results of the current study underscore the need for continued efforts to ensure that adults in the nonmetropolitan South receive educational messages, outreach, and provider recommendations concerning the importance of routine cancer screening. (+info)
Self-reported reasons men decide not to participate in free prostate cancer screening.
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PURPOSE: To determine the reasons why men fail to participate in a free prostate cancer screening. DESIGN: Survey and secondary analyses using correlational design. SETTING: Community sites in the Southeastern United States. SAMPLE: The sample (N = 241) ranged in age from 40-68 years. Mean age was 50 years (SD = 7.4). Most of the men were African American (79%) and married (70%). Almost half of the subjects (44%) earned between $9,601 and $25,020 per year. METHOD: Telephone survey of men who did not participate in initial prostate cancer screening after educational program. MAIN RESEARCH VARIABLES: Demographics, self-reported reasons men decided not to participate in a free screening following a prostate cancer educational program, and predictors for subsequent participation in screening. FINDINGS: The main self-reported reason for not participating in a free prostate cancer screening opportunity was time problems. A significant relationship between income and physician problems existed among the men who did not participate. Twenty-one percent of the 241 men participated in a second opportunity for free prostate cancer screening. Men who cited "lost packet" as their reason for not participating in the first free screening were more than twice as likely to go for the second opportunity for free screening when offered another packet or voucher for a free screening with their physician of choice. CONCLUSIONS: "Time problems" was the most frequent self-reported reason men gave for failure to participate. Providing a follow-up phone call and vouchers a second time for reimbursement of the cost associated with a screening increased participation. Men often need assistance with locating physicians and nurse practitioners who will file for financial reimbursement. Appointment reminders are critical. IMPLICATIONS FOR NURSING: The findings of this study of the significant relationship between income and "physician problems" for not participating has implications for healthcare providers. Future programs could provide telephone follow-up with men and remail vouchers, as needed. In addition, men could be encouraged to designate one place in their households for health-related papers (for safekeeping). (+info)
Heritability of blood pressure and hemodynamics in African- and European-American youth.
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Hypertension prevalence is much higher in African-Americans (AAs) than in European-Americans (EAs). It is unknown whether this difference is related to potential ethnic differences in the relative contribution of genes and environment to population variation in blood pressure and underlying hemodynamics. We studied 308 EA and 226 AA twin pairs, including monozygotic and dizygotic twins, of the same as well as the opposite sex (mean+/-SD age, 14.7+/-3.1 years). Supine resting systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse pressure, and heart rate (HR) were measured by a Dinamap instrument and hemodynamics (stroke volume, cardiac index, and total peripheral resistance [TPR] index) by impedance cardiography. Ethnic and sex effects on genetic and environmental contributions to resting blood pressure and hemodynamics were estimated by genetic model fitting. For most measures, the best-fitting model showed no differences in heritability between AAs and EAs or between males and females, with heritabilities of 0.50 for cardiac index, of 0.64 for HR, and of SBP, pulse pressure, and stroke volume in between. Heritability of DBP was 0.45 in EAs and 0.58 in AAs with no effect of sex. For TPR index in EAs, 46% of the variance could be attributed to familial effects, but no significant distinction could be made between shared environmental and genetic factors. Heritability of TPR index in AAs was 0.51. Adjustment for obesity yielded virtually identical heritabilities. In summary, relative influences of genetic and environmental factors on blood pressure and hemodynamics in AA and EA youth are similar and independent of (genes for) obesity. (+info)
Developing seasonal ammonia emission estimates with an inverse modeling technique.
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Significant uncertainty exists in magnitude and variability of ammonia (NH3) emissions, which are needed for air quality modeling of aerosols and deposition of nitrogen compounds. Approximately 85% of NH3 emissions are estimated to come from agricultural nonpoint sources. We suspect a strong seasonal pattern in NH 3 emissions; however, current NH3 emission inventories lack intra-annual variability. Annually averaged NH 3 emissions could significantly affect model-predicted concentrations and wet and dry deposition of nitrogen-containing compounds. We apply a Kalman filter inverse modeling technique to deduce monthly NH3 emissions for the eastern U.S. Final products of this research will include monthly emissions estimates from each season. Results for January and June 1990 are currently available and are presented here. The U.S. Environmental Protection Agency (USEPA) Community Multiscale Air Quality (CMAQ) model and ammonium (NH4+) wet concentration data from the National Atmospheric Deposition Program (NADP) network are used. The inverse modeling technique estimates the emission adjustments that provide optimal modeled results with respect to wet NH4+ concentrations, observational data error, and emission uncertainty. Our results suggest that annual average NH 3 emissions estimates should be decreased by 64% for January 1990 and increased by 25% for June 1990. These results illustrate the strong differences that are anticipated for NH3 emissions. (+info)