Rationale and design of the Clinic and Community Approaches to Healthy Weight Randomized Trial.

BACKGROUND: Recent studies have demonstrated the effectiveness of family-centered, pediatric weight management programs in reducing childhood obesity. Yet, programs to optimize the care of low-income children with obesity are needed. We sought to examine the comparative effectiveness of two, potentially scalable pediatric weight management programs delivered to low-income children in a clinical or community setting. MATERIALS AND METHODS: The Clinic and Community Approaches to Healthy Weight Trial is a randomized trial in two communities in Massachusetts that serve a large population of low-income children and families. The two-arm trial compares the effects of a pediatric weight management program delivered in the Healthy Weight Clinics of two federally qualified health centers (FQHC) to the Healthy Weight and Your Child programs delivered in two YMCAs. Eligible children are 6 to 12 years old with a body mass index (BMI) ≥ 85th percentile seen in primary care at the two FQHCs. Both programs are one-year in duration and have at least 30 contact hours throughout the year. Measures are collected at baseline, 6 months, and 1 year. The main outcome is 1-year change in BMI (kg/m2) and percent change of the 95th percentile (%BMIp95). CONCLUSION: The Clinic and Community Approaches to Healthy Weight Trial seeks to 1) examine the comparative effects of a clinical and community based intervention in improving childhood obesity, and 2) inform the care of >7 million children with obesity covered by the Children's Health Insurance Program or Medicaid.

Changes in Coping Behavior and the Relationship to Personality, Health Threat Communication and Illness Perceptions from the Diagnosis of Diabetes: A 2-year Prospective Longitudinal Study.

Coping behavior is of critical importance in diabetes because of its impact upon self-care and hence eventual medical outcome. We examined how coping behavior and its relationship to personality, diabetes health threat communication (DHTC) and illness representations changes after diagnosis of diabetes. Newly diagnosed diabetic patients were assessed after diagnosis and at 6, 12 and 24 months using the DHTC, Illness Perceptions and Coping inventory questionnaires. Personality traits were assessed at baseline. Active coping, planning, positive reinterpretation and growth (PRG), seeking emotional and instrumental (social) support decreased over the 2 years from diagnosis while passive acceptance increased. Openness/intellect and conscientiousness traits were associated with active coping and seeking instrumental support. Openness/intellect also associated with planning and PRG. These relationships did not vary over time. Perceived threat and serious consequences were associated with active coping but the effect diminished over time. Illness coherence (understanding of diabetes), personal and treatment control were associated with active coping, planning and seeking instrumental support and did not change over time. The coping strategies most commonly employed by diabetic patients are adaptive. Coping behavior changes over the 2 years from diagnosis. Promoting better understanding of diabetes, perceptions of personal control and treatment effectiveness are more likely than perception of health threat to sustain adaptive problem focused coping behavior.

Heart hospitals, medicare, and cross-subsidization.

BACKGROUND: Compared with heart hospitals (HHs), does Medicare provide better reimbursement to traditional hospitals (THs)? METHODS: Diagnosis Related Group (DRG)-specific data from Hospital Compare (www.hospitalcompare.hhs.gov) were used to compare Medicare reimbursement to hospitals in nine HH markets, representing 10% of the national HH market. RESULTS: On average, markets contained 1.2 HHs and 8.1 THs. Average market size for invasive cardiac services was $13+/-8.4 million, with HHs having 36.1% of the market share. Compared with HHs, THs received significantly better reimbursement for coronary artery bypass graft (CABG: $20,281+/-3,047 HH versus $23,958+/-4,562 TH; p=0.004), percutaneous coronary intervention (PCI: $11,230+/-742 HH versus $13,347+/-2,662 TH; p<0.001), heart valve replacement ($33,710+/-4,056 HH versus $39,819+/-6,356 TH; p=0.001), pacemaker implantation ($11,245+/-706 HH versus $13,212+/-2,043 TH; p<0.001), heart failure ($5,622+/-489 HH versus $6,482+/-1,010 TH; p<0.001), chronic obstructive pulmonary disease (COPD: $4,893+/-802 HH versus $5,641+/-841 TH; p=0.013), pneumonia ($5,708+/-763 HH versus $6,456+/-1,136 TH; p=0.012), and diabetes ($4,115+/-355 HH versus $4,963+/-812 TH; p<0.001). CONCLUSIONS: The excessive reimbursement granted to THs for non-cardiac services is likely to reflect a policy decision to assist these hospitals with their cross-subsidization of other services. If Medicare is to cut reimbursement to TH for CABG, PCI, or other services, Medicare should be asked to pay more for the services (e.g. emergency room care) that it currently reimburses only indirectly through the process of cross-subsidization.

Development of the Diabetes Health Threat Communication Questionnaire (DHTCQ).

OBJECTIVES: (1) To develop a brief instrument, the Diabetes Health Threat Communication Questionnaire (DHTCQ) to measure diabetes patients' (type1 and type 2) perceptions of the health threat communication process (i) at time of diagnosis and (ii) since diagnosis; (2) to assess the measure' psychometric properties. METHODS: Data from a pilot study (n=110) and a prospective longitudinal study (n=158, within 3 months of diagnosis and n=147, 6 months after baseline) were examined in order to demonstrate reliability and validity of the DHTCQ. RESULTS: Principal components factor analysis revealed 2 meaningful factors (Reassurance and Threat) with satisfactory internal consistency (Cronbach' alpha) and adequate test-retest reliability. Correlational analyses supported the measure' construct validity. CONCLUSION: Initial support for the psychometric properties of the DHTCQ was shown. Perceptions of health threat communication were associated with patients' illness representations of diabetes (beliefs and feelings about diabetes and its treatment). PRACTICE IMPLICATIONS: The DHTCQ may be used to assess patient perceptions of health communication and shape subsequent communication. The findings may help to improve practitioner/patient interaction leading to more adaptive representations of diabetes.

Understanding why people with type 1 diabetes do not attend for specialist advice: a qualitative analysis of the views of people with insulin-dependent diabetes who do not attend diabetes clinic.

Attendance at diabetes clinic is associated with improved medical outcome, however, significant numbers of people with type 1 diabetes choose not to attend. In order to understand the reasons underlying this decision, qualitative interviews were carried out with 12 long-term non-attenders. Three distinct groups emerged differing in terms of their cognitive and emotional responses to diabetes and their coping strategies: (1) the 'High fear' group; (2) the 'Patient as expert' group; and (3) the 'Low motivation' group. These differences should be recognized and suitable approaches developed to ensure that all people with diabetes are able to accept appropriate specialist support.

Using the IPQ and PMDI to predict regular diabetes care-seeking among patients with Type 1 diabetes.

OBJECTIVES: The objectives were, first, to identify factors associated with regular diabetes care-seeking and, second, to compare the performance of the Illness Perception Questionnaire (IPQ) and a modified version of the Personal Models of Diabetes Interview (PMDI) in predicting care-seeking. METHOD: This was a cross-sectional study involving 42 patients who had not attended hospital diabetes clinic for a period of 18 months or more and 42 matched controls receiving specialist care. Differences in illness representations between clinic attenders and non-attenders were examined. Due to the variability in care-seeking between non-attenders (ranging from no contact with health professionals to regular general practitioners care), participants were then reclassified for further analyses into those receiving regular care from either hospital diabetes clinic or general practice (n = 52) and those receiving no regular care (n = 32). RESULTS: Patients not seeking regular care held more negative views of the control, course and consequences of diabetes than those who received regular care. Regression analyses showed that the most important construct was treatment effectiveness. Treatment effectiveness (PMDI) and control (IPQ) dimensions were associated with clinic attendance. PMDI constructs of treatment effectiveness, threat and worries were associated with regular care-seeking. CONCLUSIONS: IPQ and PMDI results were generally consistent. In order to understand diabetes care-seeking behaviour it is important to measure beliefs about the benefits of treatment recommendations in addition to those of the disease itself. Emotional and cognitive responses to diabetes should be assessed.

A survey of the health needs of hospital staff: implications for health care managers.

Developing strategies to address the health needs of the National Health Services (NHS) workforce are of concern to many health care managers. Focal to the development of such strategies are of being in receipt of baseline information about employees expressed health needs and concerns. This article addresses obtaining such baseline information and presents the findings of a health needs survey of acute hospital staff in a trust in North Wales. The total population of trust employees were surveyed (n = 2300) and a 44% (n = 1021) response rate was achieved. A number of positive findings are given. Included are that the majority of those surveyed stated that their current health status is good, are motivated to improve their health further, do not smoke and their alcohol consumption is within recommended levels. There appears, however, to be a number of areas where trust managers can help its staff improve their health. Included are trust initiatives that focus on weight control and taking more exercise. In addition, there appears to be a reported lack of knowledge and positive health behaviour amongst the male respondents surveyed that would imply the trust needs to be more effective in promoting well man type issues. Finally there appears to be a general lack of pride in working for the trust and a pervasive feeling that the trust does not care about its employees that needs to be addressed. It is concluded that the findings of this survey have implications for management practices in the trust where the survey was conducted and also wider applicability to the management of health care professionals. For example, addressing work-related psychological and physical problems of employees are of importance to all health care managers. This is especially so when considering recruitment and retention issues.