Wishard Volunteer Advocates Program: an intervention for at-risk, incapacitated, unbefriended adults.

Unbefriended, incapacitated individuals who lack surrogates to make medical decisions present a complex problem to the healthcare providers who treat them. Adults without surrogates are among the most vulnerable in the community and are often alone and estranged from family, neglected and abused, and at risk of receiving inappropriate medical treatment. This article describes the program model and outcomes for the first 2 years of the Wishard Volunteer Advocates Program (WVAP), a guardianship program using trained, supervised volunteers as surrogates for unbefriended, incapacitated individuals. Of the 50 individuals enrolled during the study period, 20 were female, and 39 were Caucasian and 11 African American. Their average age was 67. Nineteen were insured with Medicare as primary and Medicaid as supplementary insurance. Ninety-eight percent had four or more comorbid conditions at the time of the index hospitalization. Before program referral, many lived alone in unsafe conditions. Adult Protective Services was involved in almost half of the cases at the time of the index hospitalization. Approximately half of the participants required some type of property management. Healthcare usage data demonstrated that most were not receiving medical care before WVAP enrollment; the data indicated a decrease in emergency department visits and hospitalization after WVAP enrollment. The WVAP completed Medicaid applications for 12 participants, resulting in $297,481.62 in reimbursement for the index hospitalization and a payer source for subsequent hospitalization and long-term care. The volunteer advocate model provides an efficient and quality mechanism for providing unbefriended individuals with surrogates.

Family structure and income during the stages of childhood and subsequent prosocial behavior in young adulthood.

This study investigated whether family structure transition and low income are risk factors in the development of prosocial behavior. Models of young adults' prosocial behavior - charitable giving and volunteering - were estimated as functions of their family structure and income during the stages of childhood. Participants were a representative sample of 1011 American young adults. In the full sample, family structure transition during adolescence was negatively associated with subsequent charitable giving in young adulthood. Low income during adolescence was negatively associated with both giving and volunteering in young adulthood. European-American young men also exhibited a negative association between family structure transition during adolescence and subsequent volunteering. The results did not seem to describe African-American young adults. Keeping this qualification in mind, the results suggest that adolescence is a sensitive stage in the development of charitable giving and volunteering.

The relationship between the ABO discrepancy index and treatment duration in a graduate orthodontic clinic.

OBJECTIVE: To test the hypothesis that there is no relationship between the components of the American Board of Orthodontics (ABO) discrepancy index (DI) and duration of orthodontic treatment. MATERIALS AND METHODS: A retrospective review of 732 patient records with permanent dentition was performed. Pretreatment radiographs and casts were used to determine the DI score. Other data collected were total treatment duration, age, sex, ethnicity, and the date fixed appliances were removed. Reliability tests showed substantial agreement between examiners (Cohen's kappa 0.68-0.94). Pearson and Spearman correlation coefficients were used to assess the association between the DI scores and length of treatment. A multiple variable regression analysis was used to determine which variables predict treatment duration (P < .05 significant). RESULTS: There was a significant association between the DI and treatment duration. There was a significant multivariate association for DI components (occlusions, crowding, overjet, cephalometrics, overbite, lateral open bite, and tooth transposition) and treatment duration. CONCLUSIONS: The hypothesis was rejected. This retrospective study of university clinical records showed that the average increase in treatment duration was about 11 days for each point increase in total DI score. Treatment duration was differentially increased by various components of the DI: approximately 6.5 months for tooth transposition; approximately 1 month for crowding, overjet, or overbite; approximately 3 weeks for occlusion discrepancies; approximately 2 weeks for lateral open bite; and approximately 5 days for cephalometric discrepancies.

Research to Encourage Exercise for Fibromyalgia (REEF): use of motivational interviewing design and method.

Fibromyalgia (FM), defined as the presence of both chronic widespread pain and the finding of 11/18 tender points on examination, is an illness associated with major personal and societal burden. Supervised aerobic exercise is an important treatment modality to improve patient symptoms. Unfortunately, adherence to an exercise regimen after a structured supervised program is disappointingly low. Since FM is a chronic illness, studies are needed to test strategies that would enhance exercise adherence in these individuals. Individuals who are able to adhere to exercise almost always maintain the symptomatic benefits of exercise. The objective of this paper was to describe the protocol of the Research to Encourage Exercise for Fibromyalgia (REEF). REEF is a randomized attention-controlled trial that seeks to test the efficacy of 6 sessions of telephone delivered motivational interviewing (MI) that targets exercise adherence to improve FM-relevant clinical outcomes (i.e., physical function and pain severity). The trial has recently completed enrolling 216 subjects, and randomization has resulted in well-balanced groups. Details on the study design, MI program, and treatment fidelity are provided in the paper. Outcome assessments at week 12, week 24 and week 36 will test the immediate, intermediate and long-term effects of exercise-based MI on adherence (as measured by the Community Health Activities Model Program for Seniors/CHAMPS and accelerometer) and clinical outcomes. When completed, REEF will determine whether exercise-based MI could be utilized as a management strategy to sustain the clinical benefits of exercise for FM.

A survey of United States periodontists' knowledge, attitudes, and behaviors related to tobacco-cessation interventions.

BACKGROUND: Because of the clear causal relationship between smoking and periodontal disease, and the negative effect of smoking on wound healing, it is of great importance to evaluate the tobacco-cessation interventions provided by periodontal practices. The use of tobacco-cessation interventions in clinical practice can be measured by whether the practitioner uses any of the "5 A's" defined by the 2008 United States Public Health Services Clinical Practice Guideline. METHODS: Surveys were mailed to 1,000 active members of the American Academy of Periodontology. The surveys assessed the periodontists' demographic information, educational and professional background, knowledge and attitudes about tobacco cessation, and use of interventions in the daily practice of periodontics. RESULTS: Data were collected from 231 periodontists via a self-administered survey. Most (92%) believed that tobacco cessation is a responsibility of the dental profession. A pattern of declining levels of involvement was seen as the providers moved through the suggested "5 A's" for promoting tobacco cessation. Providers with formal tobacco-cessation training were more likely to perform interventions. The primary perceived barriers to providing tobacco-cessation interventions were low patient acceptance of treatment, lack of time, and lack of training. CONCLUSION: The findings of this study indicate that periodontists believe that tobacco-cessation interventions are a responsibility of the dental profession; however, because of several perceived barriers, reported rates of comprehensive tobacco interventions in periodontal practices are low.

Medical decision-making during the guardianship process for incapacitated, hospitalized adults: a descriptive cohort study.

BACKGROUND: It is sometimes necessary for courts to appoint guardians for adult, incapacitated patients. There are few data describing how medical decisions are made for such patients before and during the guardianship process. OBJECTIVE: To describe the process of medical decision-making for incapacitated, hospitalized adults for whom court-appointed guardians are requested. DESIGN: Retrospective, descriptive cohort study. MEASUREMENTS: Patients were identified from the legal files of a public, urban hospital. Medical and legal records were reviewed for demographic data, code status, diagnoses, code status orders and invasive procedures and person authorizing the order or procedure, dates of incapacitation and appointment of temporary guardian, reason for guardianship, and documentation of communication with a guardian. RESULTS: A total of 79 patients met inclusion criteria; 68.4% were male and 56.2% African-American. The median age was 65 years. Of the 71 patients with medical records available 89% of patients had a temporary guardianship petitioned because of the need for placement only. Seventeen patients had a new DNR order written during hospitalization, eight of which were ordered by physicians without consultation with a surrogate decision maker. Overall, 32 patients underwent a total of 81 documented invasive procedures, 16 of which were authorized by the patient, 15 by family or friend, and 11 by a guardian; consent was not required for 39 of the procedures because of emergency conditions or because a procedure was medically necessary and no surrogate decision maker was available. CONCLUSIONS: Although most of the guardianships were requested for placement purposes, important medical decisions were made while patients were awaiting appointment of a guardian. Hospitalized, incapacitated adults awaiting guardianship may lack a surrogate decision maker when serious decisions must be made about their medical care.