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Little is known about the ways in which community-dwelling elderly individuals manage fecal incontinence (FI) in their daily lives. In this study, community-dwelling elderly individuals were surveyed at clinics of a health maintenance organization (HMO) to describe the self-care practices used to manage FI and to examine factors that influenced the number of self-care practices used and the reporting of FI to a health care practitioner. Responses of 242 elderly individuals who reported that they had FI several times per year were analyzed. The self-care practices used most commonly were changing diet, wearing a sanitary pad/brief, and reducing activity or exercise. Elderly women and those with a greater severity of FI and more chronic health problems engaged in more self-care practices. Factors associated with reporting FI to a clinician were considering FI to be a problem, uncertainty about the cause of FI, and changing diet to avoid FI. There is a need to promote effective management strategies for FI to older individuals living in the community. [ABSTRACT FROM AUTHOR]

An anonymous survey containing questions about the severity of fecal incontinence (FI)--frequency, amount, and type--and its correlates was distributed to community-living elderly at four managed-care clinics. Completed surveys were received from 1,352 respondents whose mean (+/-standard deviation) age was 75 +/- 6 years and 60% of whom were female. Approximately 19% reported having FI one or more times within the past year. Incontinence that soiled underwear or was of loose or liquid consistency was most common. More frequent FI and a greater amount of FI were significantly associated with loose or liquid stool consistency, defecation urgency, bowel surgery, and chronic health conditions. Therapies aimed at normalizing stool consistency or reducing urgency may be beneficial in lessening FI severity. Copyright 2004 Wiley Periodicals, Inc. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To test the substitution hypothesis, that community-based care reduces the probability of institutional placement for at-risk elderly. RESEARCH DESIGN: The closure of the Social Health Maintenance Organization (Social HMO) at HealthPartners (HP) in Minnesota in 1994 and the continuation of the Social HMO at Kaiser Permanente Northwest (KPNW) in Oregon/Washington comprised a 'natural experiment.' Using multinomial logistic regression analyses, we followed cohorts of Social HMO enrollees for up to 5 years, 1995 to 1999. To adjust for site effects and secular trends, we also followed age- and gender-matched Medicare-Tax Equity and Fiscal Responsibility Act (TEFRA) cohorts, enrolled in the same HMOs but not in the Social HMOs. SUBJECTS: All enrollees in the Social HMO for at least 4 months in 1993 and an age-gender matched sample of Medicare-TEFRA enrollees. To be included, individuals had to be alive and have a period out of an institution after January 1, 1995 (total n = 18,143). MEASURES: The primary data sources were the electronic databases at HP and KPNW. The main outcomes were long-term nursing home placement (90+ days) or mortality. Covariates were age, gender, a comorbidity index, and geographic site effect. RESULTS: Adjusting for variations in the 2 sites, we found no difference in probability of mortality between the 2 cohorts, but approximately a 40% increase in long-term institutional placement associated with the termination of the Social HMO at HealthPartners (odds ratio, 1.43; 95% confidence interval, 1.15-1.79). CONCLUSIONS: The Social HMO appears to help at-risk elderly postpone long-term nursing home placement. [ABSTRACT FROM AUTHOR]

A social health maintenance organization (SHMO) integrates acute and long-term care and provides an extended-care benefit for elderly who are at risk of institutionalization. This article reports findings from a case study of the termination of the Group Health SHMO in Minnesota. Interviews were conducted with social workers and at-risk elderly who had been receiving long-term care through the SHMO. The case study examines the post-SHMO transition and the process of replacing SHMO care coordination and long-term care services. Most of the elderly and their caregivers indicated they were 'losing ground' -- that is, they were paying more or getting less care. Some were paying more for less care. Because they tended to switch to private-pay arrangements and to rely more on informal care, it appears that their care system became much less stable after the closing of the SHMO. [ABSTRACT FROM AUTHOR]

Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and declare that all authors work in reproductive law. LRF is a lawyer and works in the areas of international law and family law, with experience of working on surrogacy cases. NG is founder and director of Brilliant Beginnings, a non-profit surrogacy agency. KH is a member of Surrogacy UK ethics committee and was a member of its working group on surrogacy law reform. She is also an advisory board member of My Surrogacy Journey. EJ was a member of the Human Fertilisation and Embryology Authority’s legislative reform advisory group. DES was one of the principal drafters of the New York Child Parent Security Act. She is on the board of New York Attorneys for Adoption and Family Formation and on the emeritus board of Family Equality Council. She was previously on the board of the Academy of Adoption and Assisted Reproduction.

The worldwide decline in pollinating insects is alarming. One of the main anthropogenic drivers is the massive use of pesticides in agriculture. Risk assessment procedures test pesticides for mortality rates of well-fed, parasite free individuals of a few non-target species. Sublethal and synergistic effects of co-occurring stressors are usually not addressed. Here, we present a simple, wildly applicable bio-essay to assess such effects. Using brood thermoregulation in bumblebee microcolonies as readout, we investigate how this collective ability is affected by long-term feeding exposure to the herbicide glyphosate (5 mg/l), the insecticide flupyradifurone (0.4 mg/l) and the combination of both, when co-occurring with the natural stressor of resource limitation. Documenting brood temperature and development in 53 microcolonies we find no significant effect of glyphosate, while flupyradifurone significantly impaired the collective ability to maintain the necessary brood temperatures, resulting in prolonged developmental times and a decrease in colony growth by over 50 %. This reduction in colony growth has the potential to significantly curtail the reproductive chances of colonies in the field. Our findings highlight the potentially devastating consequences of flupyradifurone use in agriculture even at sub-lethal doses and underline the urgent need for improved risk assessment procedures., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Oxidative stress is commonly implicated in the pathogenesis of motor neuron disease. However, the cause and effect relationship between oxidative stress and motor neuron degeneration is poorly defined. We recently identified denervation at the neuromuscular junction in mice lacking the antioxidant enzyme, Cu,Zn-superoxide dismutase (SOD1) (Fischer et al., 2011). These mice show a phenotype of progressive muscle atrophy and weakness in the setting of chronic oxidative stress. Here, we investigated further the extent of motor neuron pathology in this model, and the relationship between motor pathology and oxidative stress. We report preferential denervation of fast-twitch muscles beginning between 1 and 4 months of age, with relative sparing of slow-twitch muscle. Motor axon terminals in affected muscles show widespread sprouting and formation of large axonal swellings. We confirmed, as was previously reported, that spinal motor neurons and motor and sensory nerve roots in these mice are preserved, even out to 18 months of age. We also found preservation of distal sensory fibers in the epidermis, illustrating the specificity of pathology in this model for distal motor axons. Using HPLC measurement of the glutathione redox potential, we quantified oxidative stress in peripheral nerve and muscle at the onset of denervation. SOD1 knockout tibial nerve, but not gastrocnemius muscle, showed significant oxidation of the glutathione pool, suggesting that axonal degeneration is a consequence of impaired redox homeostasis in peripheral nerve. We conclude that the SOD1 knockout mouse is a model of oxidative stress-mediated motor axonopathy. Pathology in this model primarily affects motor axon terminals at the neuromuscular junction, demonstrating the vulnerability of this synapse to oxidative injury., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Mutations in Cu,Zn superoxide dismutase (SOD1) are associated with familial amyotrophic lateral sclerosis (ALS). Mutant SOD1 causes a complex array of pathological events, through toxic gain of function mechanisms, leading to selective motor neuron degeneration. Mitochondrial dysfunction is among the well established toxic effects of mutant SOD1, but its mechanisms are just starting to be elucidated. A portion of mutant SOD1 is localized in mitochondria, where it accumulates mostly on the outer membrane and inside the intermembrane space (IMS). Evidence in cultured cells suggests that mutant SOD1 in the IMS causes mitochondrial dysfunction and compromises cell viability. Therefore, to test its pathogenic role in vivo we generated transgenic mice expressing G93A mutant or wild-type (WT) human SOD1 targeted selectively to the mitochondrial IMS (mito-SOD1). We show that mito-SOD1 is correctly localized in the IMS, where it oligomerizes and acquires enzymatic activity. Mito-G93ASOD1 mice, but not mito-WTSOD1 mice, develop a progressive disease characterized by body weight loss, muscle weakness, brain atrophy, and motor impairment, which is more severe in females. These symptoms are associated with reduced spinal motor neuron counts and impaired mitochondrial bioenergetics, characterized by decreased cytochrome oxidase activity and defective calcium handling. However, there is no evidence of muscle denervation, a cardinal pathological feature of ALS. Together, our findings indicate that mutant SOD1 in the mitochondrial IMS causes mitochondrial dysfunction and neurodegeneration, but per se it is not sufficient to cause a full-fledged ALS phenotype, which requires the participation of mutant SOD1 localized in other cellular compartments.

Motor axon degeneration is a critical but poorly understood event leading to weakness and muscle atrophy in motor neuron diseases. Here, we investigated oxidative stress-mediated axonal degeneration in mice lacking the antioxidant enzyme, Cu,Zn superoxide dismutase (SOD1). We demonstrate a progressive motor axonopathy in these mice and show that Sod1(-/-) primary motor neurons extend short axons in vitro with reduced mitochondrial density. Sod1(-/-) neurons also show oxidation of mitochondrial--but not cytosolic--thioredoxin, suggesting that loss of SOD1 causes preferential oxidative stress in mitochondria, a primary source of superoxide in cells. SOD1 is widely regarded as the cytosolic isoform of superoxide dismutase, but is also found in the mitochondrial intermembrane space. The functional significance of SOD1 in the intermembrane space is unknown. We used a transgenic approach to express SOD1 exclusively in the intermembrane space and found that mitochondrial SOD1 is sufficient to prevent biochemical and morphological defects in the Sod1(-/-) model, and to rescue the motor phenotype of these mice when followed to 12 months of age. These results suggest that SOD1 in the mitochondrial intermembrane space is fundamental for motor axon maintenance, and implicate oxidative damage initiated at mitochondrial sites in the pathogenesis of motor axon degeneration.

Axonal degeneration is a common pathologic feature in peripheral neuropathy, neurodegenerative disease, and normal aging. Oxidative stress may be an important mechanism of axonal degeneration, but is underrepresented among current experimental models. To test the effects of loss of the antioxidant enzyme Cu,Zn-superoxide dismutase (SOD1) on axon survival, we cultured dorsal root ganglion (DRG) neurons from SOD1 knockout mice. Beginning as early as 48-72 h, we observed striking degeneration of Sod1-/- axons that was prevented by introduction of human SOD1 and was attenuated by antioxidant treatment. To test susceptibility to increased superoxide production, we exposed wild-type DRGs to the redox-cycling herbicides paraquat and diquat (DQ). Dose-dependent axon degeneration was observed, and toxicity of DQ was exacerbated by SOD1 deficiency. MTT staining suggested that DRG axons are more susceptible to injury than their parent cell bodies in both paradigms. Taken together, these data demonstrate susceptibility of DRG axons to oxidative stress-mediated injury due to loss of SOD1 or excess superoxide production. These in vitro models provide a novel means of investigating oxidative stress-mediated injury to axons, to improve our understanding of axonal redox control and dysfunction in peripheral neuropathy.

Environmental cues are used by many organisms to time life history transitions and can be important for trematode host location. However, while much is understood about how larval trematodes locate hosts, much less is known about the potential role of host cues in the timing of trematode egg development and hatching. We addressed the potential role of host chemical cues in mediating hatching of Echinostoma trivolvis miracidia by comparing hatching in response to cues from the first intermediate host (the snail Planorbella trivolvis), a non-host snail (the snail Goniobasis proxima), and a non-host invertebrate (earthworm, Lumbricus terrestris). We hypothesized that in the presence of cues from their first intermediate host, E. trivolvis would hatch sooner and would be more synchronized than when host cues were absent. However, we found that hatching was unaffected by our cue treatments. In all treatments, hatching uniformly began at 13 days and was nearly evenly spread over the next 3 weeks.

Purpose: In this study, we compared the rate of depression diagnoses in adults with and without diabetes mellitus, while carefully controlling for number of primary care visits., Methods: We matched adults with incident diabetes (n = 2,932) or prevalent diabetes (n = 14,144) to nondiabetic control patients based on (1) age and sex, or (2) age, sex, and number of outpatient primary care visits. Logistic regression analysis was used to assess the association between various predictors and a diagnosis of depression in each diabetes cohort relative to matched nondiabetic control patients., Results: With matching for age and sex alone, patients with prevalent diabetes having few primary care visits were significantly more likely to have a new depression diagnosis than matched control patients (odds ratio [OR] = 1.46, 95% confidence interval [CI], 1.19-1.80), but this relationship diminished when patients made more than 10 primary care visits (OR = 0.95, 95% CI, 0.77-1.17). With additional matching for number of primary care visits, patients with prevalent diabetes mellitus with few primary care visits were more likely to have a new diagnosis of depression than those in control group (OR = 1.32, 95% CI, 1.07-1.63), but this relationship diminished and reversed when patients made more than 4 primary care visits (OR = 0.99, 95% CI, 0.80-1.23). Similar results were observed in the subset of patients with incident diabetes and their matched control patients., Conclusions: Patients with diabetes have little or no increase in the risk of a new diagnosis of depression relative to nondiabetic patients when analyses carefully control for the number of outpatient visits. Studies showing such an association may have inadequately adjusted for comorbidity or for exposure to the medical care system.

Growing evidence from animal models and patients with amyotrophic lateral sclerosis (ALS) suggests that distal axonal degeneration begins very early in this disease, long before symptom onset and motor neuron death. The cause of axonal degeneration is unknown, and may involve local axonal damage, withdrawal of trophic support from a diseased cell body, or both. It is increasingly clear that axons are not passive extensions of their parent cell bodies, and may die by mechanisms independent of cell death. This is supported by studies in which protection of motor neurons in models of ALS did not significantly improve symptoms or prolong lifespan, likely due to a failure to protect axons. Here, we will review the evidence for early axonal degeneration in ALS, and discuss possible mechanisms by which it might occur, with a focus on oxidative stress. We contend that axonal degeneration may be a primary feature in the pathogenesis of motor neuron disease, and that preventing axonal degeneration represents an important therapeutic target that deserves increased attention., (Copyright (c) 2007 S. Karger AG, Basel.)

The "slow Wallerian degeneration" (Wld(S)) gene is neuroprotective in numerous models of axonal degeneration. Axonal degeneration is an early feature of disease progression in the SOD1G93A mouse, a widely used model of familial amyotrophic lateral sclerosis (fALS). We crossed the Wld(S) mouse with the SOD1G93A mouse to investigate whether the Wld(S) gene could prolong survival and modify neuropathology in these mice. SOD/Wld(S) mice showed levels of motor axon loss similar to that seen in SOD1G93A mice. The presence of the Wld(S) gene, however, modestly prolonged survival and delayed denervation at the neuromuscular junction. Prolonged survival was more prominent in female mice and did not depend on whether animals were heterozygous or homozygous for the Wld(S) gene. We also report that SOD1G93A mice show significant degeneration of sensory axons during the course of disease, supporting previous data from humans demonstrating that ALS is not purely a motor disorder.

The SOD1 mutant mouse is the most widely used model of human amyotrophic lateral sclerosis (ALS). To determine where and when the pathological changes of motor neuron disease begins, we performed a comprehensive spatiotemporal analysis of disease progression in SOD1(G93A) mice. Quantitative pathological analysis was performed in the same mice at multiple ages at neuromuscular junctions (NMJ), ventral roots, and spinal cord. In addition, a patient with sporadic ALS who died unexpectedly was examined at autopsy. Mice became clinically weak at 80 days and died at 131 +/- 5 days. At 47 days, 40% of end-plates were denervated whereas there was no evidence of ventral root or cell body loss. At 80 days, 60% of ventral root axons were lost but there was no loss of motor neurons. Motor neuron loss was well underway by 100 days. Microglial and astrocytic activation around motor neurons was not identified until after the onset of distal axon degeneration. Autopsy of the ALS patient demonstrated denervation and reinnervation changes in muscle but normal appearing motor neurons. We conclude that in this widely studied animal model of human ALS, and in this single human case, motor neuron pathology begins at the distal axon and proceeds in a "dying back" pattern.

Objectives: To determine whether depression is treated differently in older and younger patients in primary care clinics., Design: Administrative data were used to identify patients with a depression diagnosis code. The sources of data were baseline and 3-month follow-up surveys, the health plan electronic database, and chart audits., Setting: Nine primary care clinics owned by a health maintenance organization in the Midwest., Participants: The study sample (N=1023) consisted of adult patients, aged 19 to 93, and was divided into six age groups, from young adult, under age 35, to old old, 75 or older., Measurements: Independent variables were a series of dummy variables: age groups, baseline depression severity, sex, and incident depression. Outcomes were defined as care processes (assessment, resources) and improvement in depression symptoms (Center for Epidemiologic Studies-Depression scale short form). Univariate and multivariate logistic regression analyses were used to analyze patient characteristics, depression symptoms, and care process variables. Significance level was reported based on the chi-square test of probability, P

Objectives: To understand the process, outcomes, and patient satisfaction of usual primary care for patients given a diagnostic code for depression., Study Design: Health plan data were used to identify patients with a diagnostic code for depression (and no such diagnosis in the preceding 6 months). Patients were surveyed by mail soon after the coded visit and again 3 months later about the care they had received; their charts were also audited., Methods: The 274 patients in 9 primary care clinics who responded to both surveys reported on their personal characteristics, depression symptoms and history, the care received in that initial visit, and the follow-up care during the next 3 months. They also reported on their satisfaction with various aspects of that care., Results: These patients were likely to be given antidepressant medications as their main or only treatment. Referral for mental health therapies was not used often, even though referral is readily available in this setting; other types of self-management recommendations and support were even less frequent. Patient outcomes and levels of satisfaction during a 3-month follow-up period were unimpressive., Conclusions: To successfully maintain a key role in the care of this important problem for their patients, primary care physicians may need to incorporate a more comprehensive and systematic approach to management that involves other team members and is more satisfying to patients.

Context: The belief that expanding the role of pharmacists in patient care could improve the safety and efficacy of drug therapy is growing. Specifically, pharmaceutical care programs through which pharmacists provide direct and ongoing counseling to patients have been introduced. Whether such programs reduce medication-related problems or health care utilization is unknown., Objective: To assess whether a pharmaceutical care program decreases health care utilization, medication use, or charges., Design: Nonrandomized, controlled trial., Setting: Staff clinic and freestanding contract pharmacies affiliated with a large HMO in greater Minneapolis-St. Paul (6 intervention pharmacies, 143 control pharmacies)., Study Population: Adult HMO enrollees (n = 921) with heart or lung disease who used one of the selected pharmacies., Intervention: Patients at intervention pharmacies were invited to participate in the pharmaceutical care program. The protocol-based program consisted of scheduled meetings between trained pharmacists and patients to assess drug therapy, plan goals, and intervene through counseling and/or consultation with other health professionals., Outcome Measures: Change in number of outpatient clinic visits, unique medications dispensed, and total charges over 1 year of follow-up., Results: In an intention-to-treat analysis (after adjustment for gender, age, Charlson Comorbidity Index, disease category, and the baseline value of the utilization measure), the number of unique medications for patients in the pharmaceutical care group increased more than in the usual care group (1.0 vs. 0.4 unique medications; P = 0.03). There was no difference between the two groups in the change in total number of clinic visits or total costs. In secondary adherence analyses, participants were more likely than the usual care group to increase the number of clinic visits (1.2 vs. -0.9; P = < 0.01) and number of unique medications (1.0 vs. 0.2; P = 0.02)., Conclusion: Pharmaceutical care for patients with chronic health conditions appears to be associated with a modest increase rather than a decrease in health care utilization.

Objectives: To assess the separate effects of depressive symptoms and antidepressant treatment on healthcare utilization and cost., Setting: Social Health Maintenance Organization (HMO) at HealthPartners in Minnesota., Participants: Geriatric Social HMO enrollees were screened for depressive symptoms using the 30-item Geriatric Depression Scale. A stratified sample was created, composed of geriatric enrollees with depressive symptoms, with antidepressant prescriptions, or with neither (n = 516)., Design: Regression analyses were conducted with separate equations for utilization and charge outcome variables, both outpatient and inpatient (log-transformed). The Charlson Comorbidity Index, age, and gender served as covariates., Measurement: Depressive symptoms were identified through the Diagnostic Interview Schedule. Antidepressant treatment was determined from the HMO pharmacy database., Results: Having depressive symptoms was associated with a 19 increase in the number of outpatient encounters and a 30 increase in total outpatient charges. Antidepressant treatment was associated with a 32 increase in total outpatient charges but was not significantly associated with number of outpatient encounters. Depressive symptoms and antidepressant therapy were not significantly associated with inpatient utilization or charges., Conclusion: This study found that patients with depressive symptoms generated more outpatient health care and higher charges but not necessarily more inpatient care. Our findings suggest that programs targeted to geriatric patients whose depression is comorbid with other chronic medical conditions might be cost-effective and particularly appropriate for geriatric care.

Background: The DIAMOND Project (Depression Is A MANageable Disorder), a nonrandomized controlled effectiveness trial, was intended to improve the long-term management of depression in primary care medical clinics. The project tested whether a quality improvement (QI) intervention could implement a systems approach-so that there would be more reliable and effective monitoring of patients with depression, leading to better outcomes. THE QUALITATIVE STUDY: A study was conducted in 1998-2000 to determine why a quality improvement intervention to improve depression care did not have a significant impact. Data consisted of detailed notes from observations of 12 project-related events (for example, team meetings and presentations) and open-ended interviews with a purposive sampling of 17 key informants. Thematic analytic methods were used to identify themes in the contextual data., Principal Findings: Overall, the project implementation was very limited. Five themes emerged: (1) The project received only lukewarm support from clinic and medical group leadership. (2) Clinicians did not perceive an urgent need for the new care system, and therefore there was a lack of impetus to change. (3) The improvement initiative was perceived as too complex by the physicians. (4) There was an inherent disconnect between the commitment of the improvement team and the unresponsiveness of most other clinic staff. (5) The doctor focus in clinic culture created a catch-22 dilemma-the involvement and noninvolvement of physicians were both problematic., Conclusion: Problems in both predisposing and enabling factors accounted for the ultimate failure of the DIAMOND quality improvement effort.

Context: Although new strategies for managing depression in primary care (e.g., nurse telephone calls, collaborative care) have been shown to be effective, no models are available for their systematic implementation in the "real world.", Objective: To test whether a continuous quality improvement (CQI) intervention could be used to implement systems in primary care clinics to improve the care and outcomes for patients diagnosed with depression., Design: Before-after study with concurrent controls., Intervention: A multidisciplinary team from the three intervention clinics developed and implemented a graded set of five care management options, ranging from watchful waiting (nurse telephone call in 4 to 6 weeks) to mental health management, which clinicians could order for their patients with depression., Setting: 9 primary care clinics in greater Minneapolis-St. Paul, Minnesota., Patients: Outpatients 18 years of age and older whose primary care clinic visit included an International Classification of Diseases, 9th revision, code for depression and who completed baseline and 3-month follow-up surveys before and after the intervention., Main Outcome Measures: Measures of process of care (follow-up depression visits to physician, mental health visits, follow-up telephone calls) and outcomes of care (improved depression symptoms over 3 months, satisfaction with care)., Results: Although the CQI team appeared to function well, only 30 of the 257 patients identified from depression-coded visits for this study were referred to the new system during the 3-month evaluation period. In both the intervention and control clinics, follow-up visits, mental health referrals, and follow-up telephone calls did not improve significantly from the preintervention levels of about 0.5 for a primary care visit, 0.4 for a mental health visit, or 0.1 for a follow-up phone call per person. The same was true of patient outcomes: The proportion of patients in the intervention and control clinics who had improved depression symptoms and those who were very satisfied with their depression care did not change significantly from the preintervention levels of 43% and 26%, respectively., Conclusions: Our attempt to improve the primary care management of depression failed because physicians used the new order system so infrequently. Whether a greater leadership commitment to change or a different improvement process would alter our findings is an open question.

Objective: To assess whether osteoporosis education, with and without bone mineral density (BMD) testing, increases the initiation of lifestyle changes and pharmaceutical treatment to prevent osteoporosis., Design: A total of 508 women, aged 54-65, from a large managed care organization who were not on osteoporosis prevention therapy participated in an intervention study. Participants were randomly assigned to either an education class on osteoporosis (n = 301) or education plus BMD (n = 207). A control group of 187 women receiving no intervention were also surveyed to serve as comparison. Group differences and differences based on BMD test result were compared 6 months after education regarding self-reported changes in health behaviors using chi2 tests and logistic regression analyses., Results: Of the 508 intervention participants, 455 (90%) responded to the follow-up survey. Initiation of hormone replacement therapy was reported by 9%, with 5% reporting starting alendronate. More than half reported changes in diet, exercise, or calcium intake. Forty-three percent increased their vitamin D intake. There were no significant group differences in behavior except with regard to pharmaceutical therapy; subjects with education plus BMD were three times more likely than those receiving education only to report starting hormone replacement therapy (p = 0.004). Low BMD scores were associated with increasing vitamin D intake (p = 0.03) and starting medication (p = 0.001). Women in the intervention groups were significantly more likely to report modifying their diet (p < 0.001), calcium (p < 0.01), and vitamin D intake (p < 0.0001) than women in the control group, not exposed to education., Conclusion: Education regarding osteoporosis prevention seems to encourage women to make lifestyle changes. The inclusion of BMD testing enhances the likelihood that women will consider pharmaceutical therapy.

Objective: To describe the components of and staff reaction to an educational outreach program about hepatitis C (HCV) at a managed care organization in Minnesota. PROJECT PROTOCOL: Educational programs for primary care clinicians consisted of lunch-and-learn sessions conducted in 2 phases. In phase 1 (1997-1998), educational programs were offered in 4 clinics; in phase 2 (1999), these programs were offered to a larger number of clinics. There was a structured, 2-stage recruitment process, and the protocol included multiple contacts that involved sending educational materials to participants several weeks before the program. A development team, comprised of key health maintenance organization (HMO) stakeholders, provided consultation., Evaluation: The initiative reached more than 1000 healthcare professionals, including 150 physicians. The educational programs received very high ratings, and pre- and posttests documented significant improvement in knowledge about HCV., Conclusions: This successful educational initiative had 5 key elements: (1) value to healthcare staff (i.e., importance of the topic and quality of the programs); (2) incentives (i.e., convenience, free lunch, and continuing medical education/continuing education unit credits); (3) repeated exposures (i.e., multiple opportunities for learning, both oral and written); (4) commitment by key stakeholders at the HMO and the clinics; and (5) an exceptionally well-organized implementation plan.

Background: Chronic infection with hepatitis C virus (HCV) is a major public health problem and is associated with over 10,000 deaths a year in the United States. In its early stages, HCV tends to be asymptomatic and can be detected only through screening., Objectives: To develop and validate a database risk algorithm for HCV infection using electronic data at HealthPartners, a health maintenance organization (HMO) in Minnesota. A secondary objective was to evaluate the benefit of screening health care workers for HCV., Methods: A database risk algorithm was developed using diagnostic and procedure codes in the administrative database to identify at-risk enrollees. One thousand three hundred eighty enrollees (an at-risk sample and a control sample) and 502 health care workers participated in anonymous screening. Both descriptive statistics and logistic regression were used to examine the frequency of HCV infection, associations with risk factors, self-selection factors in participation, and concordance between the database risk algorithm and the risk profile questionnaire., Results: Eleven enrollees tested positive for HCV, 9 from the at-risk sample and 2 from the control sample. All health care workers tested negative for HCV. Both lifestyle and medical risk factors were associated with positive test results for HCV. Enrollees with alcohol-drug diagnoses were less likely to participate in screening. A substantial proportion of enrollees with risk factors was identified either by the database risk algorithm or the risk profile questionnaire, but not by both., Conclusion: While the frequency of HCV infection was lower than previous estimates for the US population, the strong correlation with risk factors suggests that using the database risk algorithm for screening is a useful approach. Managed care plans with suitable data on their enrollee populations are in a key position to serve an important public health role in detecting asymptomatic patients who are infected with HCV.

Objective: To assess factors associated with participation in pharmaceutical care and the benefits of participation--in terms of amount of information about medications, administration of medications, and awareness of side effects., Design: Quasi-experimental design, with a control group. Medication Survey, administered 6 months after pharmaceutical care intervention to participants, refusers, and controls. Logistic regression analyses., Setting: Three staff clinic pharmacies and three contract clinic pharmacies affiliated with a health maintenance organization (HMO)., Patients and Other Participants: Patients with chronic health conditions (asthma, chronic obstructive pulmonary disease, or heart disease) enrolled at six intervention sites, identified through the HMO's electronic pharmacy database. Control sample with the same chronic health conditions, without access to pharmaceutical care (n = 210 participants, 162 refusers, and 368 controls; overall adjusted response rate = 72%)., Intervention: Pharmaceutical care, in the form of a comprehensive drug therapy management program., Main Outcome Measures: Predictors of participation, amount of information about medications, use of reminder methods, and awareness of side effects., Results: The following variables were significantly associated with the probability of participating in pharmaceutical care (P < .05): number of medications, employment, income, health status, education, and living situation. Participants were more likely than controls to say they received "a lot of information" from their pharmacist about all aspects of medications (odds ratio [OR], 1.75 to 2.68). Participants were more likely to report leaving their medication container in a visible place and using two or more reminder methods (OR, 1.87 to 1.48). There were no significant differences in the probability of missing doses. Participants were more likely to report experiencing "symptoms or problems" associated with prescription medications (OR, 1.81)., Conclusion: Pharmaceutical care appears to increase the information given to patients about medications, promote more effective self-administration of medications by encouraging patients to use systematic reminders, and increase awareness of medication side effects.

Background: Many problems have been identified in the usual care of patients with depression, including lack of identification, overreliance on medications, and inadequate treatment and follow-up. Most of these problems can be attributed to an absence of depression care systems in primary care practice. We collected information from a group of practices to assess the need for and acceptability of such systems., Methods: We conducted 4 focus groups with primary care physicians and their staffs to identify attitudes and perceived behaviors for depression problems and to determine the participants' level of acceptance of alternative systematic approaches. We also surveyed clinicians and a sample of patients who recently visited their practices., Results: Systematic screening was viewed unfavorably, and many barriers were identified with collaborative care with mental health clinicians. Participants did support involvement of other office staff and more systematic follow-up for patients with depression. The patient survey suggested that some patients with depressive symptoms were unrecognized and undertreated, but the key finding was considerable variation in care among practices., Conclusions: These findings suggest that a more systematic approach could improve the problems associated with treatment of patients with depression in primary care and would be acceptable to physicians if introduced appropriately. There are at least 2 promising approaches to introducing such changes. One involves external feedback of data about their care to the practices, followed by offering a variety of systems concepts and tools. The other involves an internal change process in which a multiclinic improvement team collects its own data and develops its own systematic solutions using rapid-cycle testing.

This study compares expenditures on health care services for enrollees in a social health maintenance organization (S/HMO) and a Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA)-risk Medicare health maintenance organization (HMO). In addition to the traditional Medicare services covered by the TEFRA HMO, the S/HMO provided a long-term care (LTC) benefit and case management services for chronic illness. There do not appear to be any overall savings associated with S/HMO membership, including any savings from substitution of S/HMO-specific services for other, traditional services covered by both the S/HMO and the TEFRA HMO.

Background: Case studies from Project IMPROVE, the first randomized controlled trial to evaluate the effectiveness of continuous quality improvement (CQI) in primary care, were subjected to a qualitative analysis. Three questions were addressed: How does change in the health care environment affect a quality improvement (QI) process? How does clinic organization influence a QI process? and What is the impact of a QI process on clinic organization?, Method: Case studies were conducted in 6 clinics that had been randomly selected from the 22 clinics participating in the IMPROVE intervention. The case study data consisted of observations of CQI team meetings, open-ended interviews with 30 informants (team members plus others in the clinics), interviews with IMPROVE consultants, and documentation from the project. The data were analyzed to identify themes and generate concepts, assess and compare the informants' experiences, and develop a conceptual framework stimulated by research and theory literature., Results: Change and uncertainty in the health care environment both complicated the QI process and motivated participation in improvement. The smaller clinics appeared to have more difficulty with the QI process because of limited resources and lack of compatibility between the QI approach and their clinic organization. Project IMPROVE had two qualitative effects on clinics: increased awareness of preventive services and application of the CQI method to other problems and issues., Conclusion: QI initiatives can help clinics adapt to a changing health care environment and create functioning teams or groups that can address a variety of organization problems and tasks. The process should be flexible to accommodate varying organization structures and cultures.

Background: Depression is under-diagnosed and under-treated in the primary care sector. The purpose of this study was to determine the association between self-reported indications of depression by community-dwelling elderly enrollees in a managed care organization and clinical detection of depression by primary care clinicians., Methods: This was a 2-year cohort study of elderly people (n = 3410) who responded to the Geriatric Depression Scale (GDS) at the midpoint of the study period. A broad measure of clinical detection was used consisting of one or more of three indicators: diagnosis of depression, visit to a mental health specialist, or antidepressant medication treatment., Results: Approximately half of the community-based elderly people with self-reported indications of depression (GDS > or = 11) did not have documentation of clinical detection of depression by health providers. Physician recognition of depression tended to increase with the severity of enrollees' self-reported feelings of depression. Men 65-74 years old and those > or = 85 years old were at highest risk for under-detection of depression by primary care providers., Conclusions: Clinical detection of depression of elderly people living in the community continues to be a problem. The implications of failure to recognize the possibility of depression among elderly White men suggest a serious public health problem.

The IMPROVE Project is a 4-year randomized controlled trial to test the hypothesis that HMOs can improve preventive services in their contracted primary clinics by assisting clinics to implement continuous quality improvement (CQI) and an organized system for preventive services. This paper describes findings from case studies of CQI teams in two demonstration sites where the CQI approach was tested. The case study analysis is based on interviews and observations conducted about 10 to 12 months after the CQI teams began. Initial responses of clinic staff to the IMPROVE Project included a mixture of interest in CQI, enthusiasm for prevention-oriented care, concern about the burden the project might impose, and skepticism. There were two formidable barriers to change: time and inertia. Environmental changes in the parent organizations also complicated and impeded the CQI process within the clinics. The thematic analysis identified four factors that appear to be important in implementing a CQI process in a clinic setting: awareness, momentum, ownership, and communication.

How an "emergency" is defined by an internist and an emergency physician is the focus of this paper, which originated in a study of nonemergency use of two urban hospital emergency departments by Medicaid, uninsured, and commercially insured patients. Retrospective medical record reviews of 219 patients conducted independently by these two physicians revealed agreement on clinical impressions but dramatic divergence regarding the designation of visits as "emergencies" and the appropriate treatment location. Subsequent interviews with each physician suggested that the divergence of opinion regarding the definition of a true emergency is ideologically motivated and specialty related. Considered in the context of ED studies, which show enormous variations in the percentage of cases judged to be "emergencies," defining an "emergency" may be more a matter of physician training, specialty, and beliefs than of science. Further analysis revealed no correlation between patients' perceptions and either physician's judgments concerning what constitutes an "emergency," suggesting that neither specialty's assumptions are sensitive to patients' experience of the physical pain and anxiety that frequently lead them to present to the ED.

Using data from diverse sources, we conclude that the jobs of paraprofessional home care workers who provide ongoing care for older clients would be more intrinsically rewarding and offer better conditions for high-quality care if workers had more contact with supervisors and peers, more information about clients and care plans, clearer accountability, and more authority. The home care worker's relationship with clients, which also affects quality of care, can be improved by addressing such issues as adequate compatibility, communication, boundary maintenance, balance of power, commitment, and flexibility.

In-depth interviews were conducted with 54 home care clients and their home health aides and personal care attendants. The interview data reveal that home care relationships tend to be both formal and informal, in that job responsibilities tend to be diffusely defined and home care workers often become involved in the "backstage" world of their clients. The study also suggests, however, that personal bonds may be problematic for both workers and clients. For workers there is the risk of exploitation; for clients, there is the potential for loss of control over their own care. The quality of relationships also affects quality of care.

We used findings from the Minnesota Senior Study to examine the theoretical and methodological difficulties of defining, coding, and analyzing data on older volunteers. This study, the first statewide survey of the needs and resources of the elderly in Minnesota in almost 20 years, found that over half (52%) of older Minnesotans do volunteer work for organizations--considerably higher than has been found in national surveys. Problems in definition and methodology, however, have confounded analyses. This paper proposes a new conceptual model for classifying volunteer roles, based on three dimensions: whether the voluntary service is "formal" or "informal"; whether the activity entails a regular or an occasional time commitment; and the nature of the service activity (person-to-community, person-to-object, or person-to-person).

The authors report the results of a comprehensive national study of the provision of home health care (HHC) through health maintenance organizations (HMOs), funded by a 1987 grant from the National Center for Health Services Research. The initial study included a literature review, interviews of 125 HHC providers and researchers, case studies of 6 HMOs, and a survey of 103 HMOs with Medicare contracts (as of March 1988). Upon discovery of controversy over the role of the HMO physician, the authors conducted an additional substudy of 30 primary care physicians. The article focuses on findings concerning the HMO physician in HHC and the implications for physicians generally, in light of what the larger study and additional data (January 1989-January 1990) show about HMO development and home health care.

The vast majority of the HMOs responding to the survey in this study use home health care as a substitute for acute inpatient hospitalization, contract out for services with community-based home health agencies, reimburse on a discounted fee-for-service basis, and use prior authorization and concurrent review as the primary methods to control the use of home health care. These findings suggest that HMO home health care services mirror the inadequacies of Medicare home health care in that they are acute care-focused and not intended to fill the supportive and maintenance care needs of the chronically ill elderly. HMOs, however, are typically more flexible in their service provision than is Medicare. Need for home health care is determined primarily on prospective, case-by-case evaluations of cost effectiveness, not on retrospective determinations based on strict, and sometimes arbitrary, guidelines and limitations. This, however, does raise some important issues for access and quality and for the relationship between HMOs and home health agencies. Is cost containment the only legitimate reason for providing home health care? Should home health care be used solely as a substitute for acute inpatient hospitalization? Where does the locus of authority lie for deciding coverage of home health care services? This study uncovered several issues related to the provision of home health care in HMOs that created conflict and uncertainty for all parties. These issues included: conflicting roles for HMOs, whether to provide services internally or externally, contracting between HMOs and home health agencies, the locus of authority for utilization review, the role of physicians, quality assurance, and perceived problems with the Health Care Financing Administration. HMOs are often perceived as failing to do an adequate job of providing home health care services because of the difficulty in satisfying conflicting considerations in three key areas: whether home health care should be focused on cost containment or meeting unmet needs, whether home health care should be focused on acute or long term care, and the unrealistic expectations patients and providers have of HMOs. HMOs primarily provide home health care in an effort to contain costs, particularly by using home health care to substitute for inpatient hospitalization. While HMO representatives acknowledge the importance of home health care in improving the patient's and family's quality of life by providing supportive or chronic maintenance care, the use of home health care for this purpose is generally not allowed by HMOs.(ABSTRACT TRUNCATED AT 400 WORDS)

There are several recurrent themes that reflect the concerns of nurses who seek entry into graduate programs in psychiatric nursing. Four of the themes that will be presented are an emphasis on mental health, a desire to seek varied points to entry into health care, increased interaction with other health workers and participation in social change. The themes are interrelated and reflect a view of nursing responsibilities and an awareness of the needs for a comprehensive approach to health care. These views are typical of a range of concerns within the nursing profession. Although nursing comprises the largest number of prepared health care workers, nursing is a marginal group within the system. There is considerable discussion of a need for revision of health care systems and of need to utilize manpower resources most effectively. System change is a difficult process and one can only speculate about the outcomes. It is difficult to predict whether the beliefs and values of nurses and nursing a marginal group, can be shared within the health care system.

This exploratory study examines grandparenthood as a role relationship. Grandmothers, in describing the transition to grandparenthood, tended to emphasize emotional/symbolic investment in grandchildren rather than instrumental/interactional dimensions of relationships. The data suggest that grandparental role conceptions are modified by family network variable: Ambiguity in the grandmother role is magnified by geographical distance and by paternal (rather than maternal) grandmotherhood.