An iron triangle ROI model for health care.

OBJECTIVE: Few, if any, return on investment (ROI) analyses of health programs make systematic considerations of patient access, instead focusing principally on gains related to cost and quality. The objective of this study was to develop an open-source model that adds an estimation of gains in patient access to a traditional ROI analysis. A classification system for quantifying gains in patient access is proposed. MATERIALS AND METHODS: An Excel-based ROI model was built that not only incorporated traditional ROI considerations - cost savings and patient cases avoided - but also addressed changes in patient access. The model was then applied in a case study using New Mexico Medicaid data and two proposed initiatives - a statewide health information exchange (HIE) and a community health worker (CHW) program that focused on chronic disease patients. Savings, Health, Outreach, and Access estimates were derived from the literature. ROI estimates were produced that also incorporated relative gains in patient access. RESULTS: Combined, the HIE and CHW programs are predicted to generate a positive ROI by the fourth year, growing to 45% by the program's tenth year. Total estimated cumulative cost for both programs after 10 years is $9,555,226. Total estimated cumulative saving for both programs after 10 years is $11,332,899. Access-related costs begin moderately in year 1 at $122,766 and grow to $1,858,274 by year 10. The model estimates an Access score of 19 in year 1. This figure grew to 380 by year 10. CONCLUSION: Our model shows that a rough estimation of gains in to patient access can be incorporated to traditional ROI analyses. The results of our case study suggest that a CHW program and statewide HIE can generate a positive ROI for the state's Medicaid program.

Addressing the "other" health literacy competencies--knowledge, dispositions, and oral/aural communication: development of TALKDOC, an intervention assessment tool.

Most health literacy assessments evaluate literacy skills including reading, writing; numeracy and interpretation of tables, graphs, diagrams and charts. Some assess understanding of health systems, and the ability to adequately apply one's skills to specific health-related tasks or demands in health situations. However, to achieve functional health literacy, the ability to "obtain, process, and understand basic health information and services needed to make appropriate health decisions," other health literacy dimensions should be assessed: a person's knowledge and attitudes about a health issue affects his or her ability to and interest in participating in his or her own care. In patient care settings, the abilities to listen, ask questions and check one's understanding are crucial to making appropriate decisions and carrying out instructions. Although literacy is a skill associated with educational attainment and therefore difficult to change in a short time, health education interventions can address health literacy domains such as knowledge, attitudes and oral communication skills. For this reason, an instrument that can assess these constructs is a valuable part of a health educator's toolbox. The authors describe the development and process and outcomes of testing a novel instrument targeted to assess HPV and cervical cancer health literacy competencies, TALKDOC, including its validation with the Health Activities Literacy Scale.

Evaluation for community-based programs: the integration of logic models and factor analysis.

PURPOSE: To discuss the utility of and value of the use of logic models for program evaluation of community-based programs and more specifically, the integration of logic models and factor analysis to develop and revise a survey as part of an effective evaluation plan. PRINCIPAL RESULTS: Diverse stakeholders with varying outlooks used a logic model as a framework to reach agreement on a plan for a state-wide evaluation. This evaluation plan utilized a survey of sixth grade students, administered before and after exposure to a year-long abstinence education program. Components of the logic model were linked to specific survey questions. Exploratory factor analysis was then used to assess whether and how the questions in the survey fit with the constructs of the model; confirmatory factor analysis was used to test the hypothesis that the factors identified in the exploratory analysis were consistently represented in the survey. MAJOR CONCLUSIONS: A logic model is a tool that engages stakeholders to link evaluation instruments more closely to specific program objectives. Thus, stakeholders can more closely assess the extent to which project outcomes have been achieved. In addition, use of factor analysis in the evaluation process can help the stakeholders better understand whether evaluation instruments such as a survey adequately assess program effectiveness. Lastly, a logic model process can help to achieve consensus among diverse stakeholders, by allowing them to focus on objectives that are concrete, measurable, and mutually acceptable.

Health literacy demands of written health information materials: an assessment of cervical cancer prevention materials.

BACKGROUND: Health literacy requires reading and writing skills as well as knowledge of health topics and health systems. Materials written at high reading levels with ambiguous, technical, or dense text, often place great comprehension demands on consumers with lower literacy skills. This study developed and used an instrument to analyze cervical cancer prevention materials for readability, comprehensibility, suitability, and message design. METHODS: The Suitability Assessment of Materials (SAM) was amended for ease of use, inclusivity, and objectivity with the encouragement of the original developers. Other novel contributions were specifically related to "comprehensibility" (CAM). The resulting SAM + CAM was used to score 69 materials for content, literacy demand, numeric literacy, graphics, layout/typography, and learning stimulation variables. Expert reviewers provided content validation. Inter-rater reliability was "substantial" (kappa = .77). RESULTS: The mean reading level of materials was 11th grade. Most materials (68%) scored as "adequate" for comprehensibility, suitability, and message design; health education brochures scored better than other materials. Only one-fifth were ranked "superior" for ease of use and comprehensibility. CONCLUSIONS: Most written materials have a readability level that is too high and require improvement in ease of use and comprehensibility for the majority of readers.

Coordinated school health programs and academic achievement: a systematic review of the literature.

BACKGROUND: Few evaluations of school health programs measure academic outcomes. K-12 education needs evidence for academic achievement to implement school programs. This article presents a systematic review of the literature to examine evidence that school health programs aligned with the Coordinated School Health Program (CSHP) model improve academic success. METHODS: A multidisciplinary panel of health researchers searched the literature related to academic achievement and elements of the CSHP model (health services, counseling/social services, nutrition services, health promotion for staff, parent/family/community involvement, healthy school environment, physical education, and health education) to identify scientifically rigorous studies of interventions. Study designs were classified according to the analytic framework provided in the Guide developed by the Community Preventive Services Task Force. RESULTS: The strongest evidence from scientifically rigorous evaluations exists for a positive effect on some academic outcomes from school health programs for asthmatic children that incorporate health education and parental involvement. Strong evidence also exists for a lack of negative effects of physical education programs on academic outcomes. Limited evidence from scientifically rigorous evaluations support the effect of nutrition services, health services, and mental health programs, but no such evidence is found in the literature to support the effect of staff health promotion programs or school environment interventions on academic outcomes. CONCLUSIONS: Scientifically rigorous evaluation of school health programs is challenging to conduct due to issues related to sample size, recruitment, random assignment to condition, implementation fidelity, costs, and adequate follow-up time. However, school health programs hold promise for improving academic outcomes for children.

New Mexico community voices: policy reform to reduce oral health disparities.

Using a socio-ecological framework to guide the initiative, New Mexico Community Voices developed, with state and local stakeholders, responsive oral health policies to address oral health disparities. Several policy objectives were achieved: increasing awareness of the public health importance of oral health; improving access to dental services for uninsured or underserved populations; enhancing dental services specialty care; and increasing sustainable oral health infrastructure through pipeline development of oral health providers to relieve service shortages and diversify the oral health workforce. Improving access to oral health and augmenting numbers of dental providers in rural areas were also successful. The governor has appointed the New Mexico Oral Health Advisory Council to address state oral health issues. The New Mexico partnerships have demonstrated how effective policy change can generate important incremental shifts in oral health care delivery and provide best practice models that diminish the oral health crisis faced by underserved populations.

An invisible disability: Qualitative research on upper extremity disorders in a university community.

OBJECTIVES: To understand how upper extremity disorders related to computer use affect graduate and undergraduate university students; and, to develop hypotheses for prevention and management of these disorders. METHODS: Focus group discussions concerning upper extremity disorders were conducted among sixteen symptomatic undergraduate and graduate students at a private university in the US. Discussions were tape recorded, transcribed, coded for themes, and analyzed qualitatively. RESULTS: The findings point to four main themes: 1). the essential role of computers in academic, social, and personal activities; 2). the negative impact of upper extremity disorders on students' physical and emotional well-being, including their career aspirations; 3). students' expectations and perceptions of medical care providers; and 4). recommendations for interventions. CONCLUSION: Students with upper extremity disorders experience numerous adverse consequences on a college campus. Effective strategies for prevention, and treatment of upper extremity disorders in young adults in universities are needed. Based on this research, an educational and skills development intervention would appear to be appropriate for preventing disability due to upper extremity disorders.