Asthma in Head Start children: prevalence, risk factors, and health care utilization.

PURPOSES: 1. To identify the prevalence and severity of asthma in a Massachusetts Head Start program; 2. To identify associated risk factors for children with asthma; 3. To assess factors associated with health care utilization for asthma management. METHOD: Parents of 316 Head Start children were interviewed using a close-ended survey questionnaire. Survey A was used for demographics and general health screening. Survey B documented more specific asthma information. FINDINGS: There was a 35% prevalence rate of asthma in this preschool Head Start population. Most children had mild to moderate degrees of severity. Atopy, environmental triggers, and tobacco smoke exposure were common risk factors. Seventy-four percent of these children with asthma had used the emergency department at least once in their lifetime for asthma management. Forty-one percent had been hospitalized at least one time for asthma. CONCLUSIONS: These findings are consistent with previous studies that support the need for asthma outreach and interventions in at-risk Head Start preschool populations.

Effects of dronabinol on anorexia and disturbed behavior in patients with Alzheimer's disease.

A placebo-controlled crossover design, with each treatment period lasting 6 weeks, was used to investigate effects of dronabinol in 15 patients with a diagnosis of probable Alzhemer's disease who were refusing food. Eleven patients completed both study periods; one patient who died of a heart attack 2 weeks before the end of the study was also included in the analysis. The study was terminated in 3 patients: one developed a grand mal seizure and 2 developed serious intercurrent infections. Body weight of study subjects increased more during the dronabinol treatment than during the placebo periods. Dronabinol treatment decreased severity of disturbed behavior and this effect persisted during the placebo period in patients who received dronabinol first. Adverse reactions observed more commonly during the dronabinol treatment than during placebo periods included euphoria, somnolence and tiredness, but did not require discontinuation of therapy. These results indicate that dronabinol is a promising novel therapeutic agent which may be useful not only for treatment of anorexia but also to improve disturbed behavior in patients with Alzheimer's disease.

Factors associated with achievement of goals for home health care.

With the introduction of Medicare's Prospective Payment System (PPS) and DRGs, the economic value of home health care services lies in its ability to reduce total patient care costs by the substitution of outpatient home care for inpatient hospital care. Analysis of service delivery patterns utilized by home health agencies in meeting goals for patient care will be an important ingredient in meeting these objectives. The purpose of this study was to determine if important patient characteristics known at the onset of home health care are predictive of utilization of home health services and/or the likelihood of meeting goals for home care established at the time of certification of care. Multivariate models were developed which predicted the odds of terminating with goals met based upon age, intensity of utilization, functional limitations, prognosis, presence of a caregiver, and type of patient condition. Results indicated that variability in likelihood of meeting goals for care is much better predicted by patient characteristics than by utilization of home care services.

Preventable hospitalizations: a tool for planning and marketing ambulatory health care services.

As the health care system evolves towards increased levels of managed care, planners and managers will need to understand how the utilization of ambulatory care services influences the use of more expensive hospital care. Preventable hospitalization, an index based on Ambulatory Care Sensitive (ACS) conditions, is proposed as an indicator for identifying communities with significant ambulatory care needs. The design and marketing of ambulatory health care services functionally adapted to meet the challenges of managed care will require new forms of health care information to plan, market, monitor, and evaluate the outcomes of health care policies and programs. An example is presented of the use of preventable hospitalizations as indicators of ambulatory care needs in 48 communities in Massachusetts.

Effect of fever-management strategy on the progression of dementia of the Alzheimer type.

This study was undertaken to determine if the progression of dementia of the Alzheimer type (DAT) is accelerated by an intercurrent infection and if management strategy (aggressive or palliative care) would modify this effect. A prospective cohort study compared the progression of DAT in patients in three 25-bed dementia special care units that provide a hospice option for care. There were three groups of patients, as follows: (a) developed a fever and received aggressive care (FAC, n = 30), (b) developed a fever and received palliative care (FPC, n = 19), and (c) did not develop a fever (NF, n = 46). The presence of a fever episode did not have an effect of its own on DAT progression. Over a 3-month period, DAT severity increased in most patients, but more so in FAC patients. Thus aggressive medical treatment of infections did not affect the underlying disease process and was associated with an acceleration of the progression of severity of DAT. Providing palliative care is recommended because it prevents patients from undergoing invasive diagnostic workups and treatments, does not accelerate the progression of DAT, and conserves scarce health care resources.

Effect of seizures on progression of dementia of the Alzheimer type.

A survey of institutionalized patients with clinical diagnosis of probable dementia of the Alzheimer type (DAT) indicated that 21% of patients developed seizures after the onset of DAT. Of the total of 27 patients, 11 developed seizures at home and 16 after institutionalization. In 9 of 11 patients (82%), who suffered the initial seizure at home, the patients' condition suddenly worsened and required long-term care admission within 6 months of the seizure onset. Language function declined significantly more rapidly in 5 patients with seizures than in controls matched by age and duration of DAT.

Is hospice care appropriate for Alzheimer patients?

Hospice care can benefit late-stage Alzheimer's patients, but caregivers and families must first be aware of the complications and treatment difficulties that often accompany Alzheimer's disease. From this awareness they can determine whether and when hospice care is appropriate for their patients or loved ones.

Palliative fever management in Alzheimer patients. quality plus fiscal responsibility.

Aggressive medical treatment of infections does not affect the progressive course of dementia of the Alzheimer type (DAT) and has limited effect on the mortality rate. Utilization of health care resources and discomfort during a fever episode were compared in three differing treatment conditions: in 18 patients in a dementia special care unit (DSCU) who received palliative management, 26 patients in a DSCU who were treated aggressively, and 17 DAT patients in traditional long-term care units who were treated aggressively. Both groups of patients in the DSCU had lower discomfort scores, lower utilization of high-cost health care resources, and higher utilization of analgesics and narcotics. A nursing model of care incorporating hospice concepts into the DSCU is suggested.

Predicting short-term survival for patients with advanced Alzheimer's disease.

OBJECTIVE: The purpose of this study was to develop a statistical model for predicting short term survival in patients with dementia of the Alzheimer type (DAT). DESIGN: A prospective cohort study. SETTING: Three 25-bed intermediate medical care units using a structured approach to patient care management including palliative care options and patients from a second, traditional long-term care setting. PARTICIPANTS: Of 104 patients with advanced DAT monitored for 34 months, 68 patients (97% white male) who had at least one fever episode were included in the model development phase. Data from 71 additional DAT patients with at least one fever episode were used to test the statistical model. MAIN OUTCOME MEASURES: Six-month survival following a fever episode. RESULTS: Older age and higher severity of DAT at the time of the fever episode, palliative care, and hospital admission for long-term care within 6 months prior to the fever were found to be positively associated with likelihood of mortality within 6 months of the fever onset. Adjusted odds ratios for each of these variables were statistically significant. The model performed well in subsequent testing on an independent sample of patients. CONCLUSION: Results provide a formula which can be used to predict likelihood of dying within 6 months following onset of a fever in DAT patients. This statistical prediction is recommended for use in combination with clinical judgment to certify DAT patients for Medicare hospice coverage.

Assessment of discomfort in advanced Alzheimer patients.

An objective scale for measuring discomfort in noncommunicative patients with advanced Alzheimer's disease was empirically generated from the perspectives of nursing staff practicing on special care Alzheimer units and was judged to have content validity. On the basis of a pilot test, the discomfort scale was reduced to nine items. Quantifiable scoring procedures and a rater training program were developed. The scale (DS-DAT) was tested longitudinally for 6 months with 82 subjects at two sites. Psychometric properties, measurement issues, and recommendations for use in practice and research are discussed.

Effect of antibiotic treatment on outcome of fevers in institutionalized Alzheimer patients.

Fever episodes in 104 institutionalized patients with Alzheimer's disease were prospectively evaluated to determine the impact of antibiotic treatment on fever outcomes. During the 34-month observation period, 75 patients developed 172 episodes of fever and 29 patients had no fevers. Patients who developed fevers had more advanced disease than patients who did not. Patients who received diagnostic workup of all fevers and treatment with antibiotics (Antibiotic Group) were compared with patients who received comfort measures only (Palliative Group). The incidence of fever was similar in the Antibiotic and Palliative groups. Survival analysis revealed that, for the more severely affected patients, there was no difference in survival between the groups. Among less severely affected patients, survival was higher for the Antibiotic than the Palliative Group. These results suggest that treatment of fever with antibiotics does not alter the outcome of fever in patients with advanced Alzheimer's disease.

KIE: The object of this study was to compare the effectiveness of antibiotic treatment for fever with a palliative approach in a group of hospitalized patients with Alzheimer's disease. One hundred and four patients were divided into three groups, based on the occurrence of fever and on the treatment strategy used, and observed for 34 months. Those who developed fevers had more advanced disease than those who did not. The incidence of fever was similar for the antibiotic and palliative groups, and for the more severely demented patients in each group there was no difference in survival. Among less demented patients those who received antibiotics had a higher rate of survival than those who received palliative treatment. The authors suggest that these observations should be taken into account by health personnel and family members weighing the benefits and burdens of diagnostic workups and treatments in Alzheimer's patients with fevers.

Predicting cost for new HMO subscribers.

The purpose of the project was to develop a model for predicting costs for potential new HMO subscribers, using available cost data from fiscal year 1985 for current enrollees of a large HMO. Regression analysis of aggregated clinic, referral, and hospital cost data using a log transformation of cost indicated that 20 percent of the variation in cost could be explained by sex and coverage type of the subscriber, compared with 7 percent explainable by a simple comparison of costs for single versus family subscribers. Subscriber age, while by itself a significant and nonlinear predictor of cost, was not significant when controlled for coverage type. Application of the model to 28 large companies yielded predicted costs well correlated with observed costs (r = .75, p less than .01). Prediction was significantly better for companies with low observed mean costs than for companies with high observed mean costs.

Assessment of genetic predisposition to alcoholism in male alcoholics.

Association between the history of alcoholism in different relatives with the development of alcoholism in male probands was analysed using the rate of development of alcoholism as a marker of genetic predisposition. It was found that a history of alcoholism in parents, grandparents and siblings of parents was associated with an accelerated rate in the development of alcoholism while a history of alcoholism in siblings and children of probands was not. The rate of development of alcoholism was positively associated with the number of generations of the proband's family in which alcoholism occurred.

Relationship of family history of alcoholism to patterns of drinking and physical dependence in male alcoholics.

The occurrence of physical dependence, morning drinking and binge drinking was assessed in alcoholic men in relation to family history of problem drinking. The incidence of physical dependence, binge drinking and morning drinking was higher in men with a family history of problem drinking than in men without such a history. Physical dependence also developed earlier in family history positive subjects than in family history negative ones. The incidence of physical dependence was higher in subjects who reported binge drinking or morning drinking than in others. These results indicate that family history of problem drinking is associated with severe alcohol abuse resulting in early development of physical dependence.

Variation in length of time to development of alcoholism by family history of problem drinking.

Patients hospitalized for treatment of alcoholism were asked to provide information on family history of drinking problems, age at onset of drinking, and timing of the occurrence of problems due to use of alcohol in their lives, using a time scale. Analysis of data from 256 male patients indicated a strong association between a family history of problem drinking and development of alcoholism at a young age. Mean age at the time the patients could be defined as alcoholic, based on the chronological history of the time of occurrence of symptoms, ranged from 27.2 years for bilineal family history positive patients to 38.5 years for those with negative family history, and the difference could not be explained by differences in age at onset of drinking. The results indicate that the increased risk of alcoholism among individuals with family history of problem drinking, which has been postulated on the basis of many cross-sectional studies, is likely to be overestimated.

Randomized response estimates of problem use of alcohol among employed females.

As part of the evaluation of an alcoholism orientation program conducted in 12 federal agencies, 378 female employees were asked to provide personal information about problems associated with their use of alcohol. The optimized form of the unrelated question randomized response technique (RRT) was used to provide for a comparison of estimates of frequency of problem drinking obtained with guaranteed confidentiality of response versus estimates obtained using a conventional anonymous questionnaire. The estimated proportion of alcoholics or possible alcoholics among participants in the orientation program was 34.3% (+/- 4.9) by the RRT and 21.9% (+/- 3.6) by direct response. Significant underreporting of alcoholism was found among older respondents (greater than or equal to 36 years), lower GS level respondents (less than grade 6), those with low seniority (less than 8 years), and those never married. Further, significant underreporting was found among those who claimed they were told they had to attend the program versus others, and among those who claimed they were not curious about the topic of alcoholism versus others. The RRT is recommended for use in experimental situations where answers to sensitive questions are needed to evaluate program success. The necessity for caution in interpretation of apparent differences in respondent characteristics with respect to problems with alcohol use is discussed. Finally, the findings indicate the importance of providing avenues by which confidential treatment for alcoholism can be obtained.

Randomized response technique for estimating alcohol use and noncompliance in hypertensives.

Hypertensives reported a greater incidence of daily use of alcohol and higher noncompliance in taking prescribed medicines by a randomized response technique with a dichotomous response as compared with direct response, and more mean drinks per week, but similar compliance in taking prescribed medicines, by a randomized response technique with a quantitative response as compared with direct response.

Self reports on alcohol use and compliance with antihypertensive medication.

Adverse effects of alcohol drinking were investigated in 240 hypertensive patients. Perceived interaction between alcohol and antihypertensive medication was reported by 9.9% of patients but the symptoms were rather mild. Except for the fact that the patients who perceived drug-alcohol interaction had higher diastolic blood pressure than the rest of the patients there was no evidence that alcohol use decreased compliance with antihypertensive treatment. Most heavy alcohol users believed that they should take their antihypertensive medication while drinking and reported doing so. Indiscriminate emphasis on avoidance of drug-alcohol combination might decrease blood pressure control of these patients.