A narrative review of healthcare financing and reimbursement of nutritional support for patients in Singapore.

AIMS: Nutritional support is used frequently in Singapore's healthcare settings, but limited research has been published on how it is financed. This paper aims to provide a narrative review on the financing of nutritional support in Singapore for acute care, step-down care, intermediate and long-term care (ILTC), community and home settings. METHODS: A structured search strategy was applied to available electronic databases using selected search terms, with additional reports and grey literature identified using iterative searches. RESULTS: A limited number of publications were found via electronic databases. The majority of publications were from governmental reports/ press releases, and healthcare organizations' websites. While funds are available via MediSave, MediShield Life, MediFund, and various other schemes, they may not be sufficient for individuals on long-term nutritional support. CONCLUSIONS: More funding sources for nutritional support are urgently required for patients in ILTC. Means-testing mechanism and targeting may need to improve to ensure access to financial assistance for nutritional support and prevent poorer outcomes and higher medical costs. Medical providers, dietitians, pharmacists and social workers play a role in determining need, prescribing and accessing nutritional support for optimal care of individuals in hospitals and ILTC. Future policies will need to address the issues of access to nutritional support in the elderly and low-income populations.

A systematic review of the cost and economic outcomes of home enteral nutrition.

OBJECTIVES: Studies are lacking in the health economic implications of home enteral nutrition (HEN) in home-residing and long-term care/institutionalized patients. The aims of this review were to determine the total costs, the cost-effectiveness and other economic outcomes for HEN. DESIGN: A systematic search of randomized trials and observational studies available from January 2000 to April 2016 was performed using standard literature and electronic databases. Inclusion criteria were adults receiving HEN with economic outcomes in the long-term care or home settings. There was no restriction to the control groups used in the studies. RESULTS: A total of 10 studies met the inclusion criteria. The majority of the studies were not specifically designed for economic evaluation. Cost per QALY was lower in residents residing in home compared to long-term care facilities, and HEN appeared to be cost-effective for those with pressure ulcers. Higher costs were incurred for patients with dementia on HEN. Lower hospitalization costs and infection rates were reported for patients who switched to commercial feeds from blenderized food. The availability of nutritional support teams may decrease overall costs but these studies were of poor study quality. CONCLUSIONS: The lack of good quality economic evaluation studies affected the ability to conclude the overall cost-effectiveness of HEN. There is a trend for cost-saving and improved clinical outcomes in some populations. HEN is unlikely beneficial for patients with dementia. The availability of a nutrition support team may lead to cost savings and improved clinical outcomes for HEN.

Validation of an updated evidence-based protocol for proactive gastrostomy tube insertion in patients with head and neck cancer.

BACKGROUND/OBJECTIVES: Evidence-based practice guidelines are available to assist in the decision making for nutrition interventions in patients with head and neck cancer. Re-assessment of guideline recommendations is important with changing demographics, new treatment regimens, advancing radiotherapy techniques, such as helical intensity-modulated radiotherapy, and the emergence of new literature. The aim of this study was to validate the updated high-risk category definition in our local hospital protocol for the swallowing and nutrition management of patients with head and neck cancer to determine the ongoing predictive ability for identifying proactive gastrostomy requirement in a new cohort. SUBJECTS/METHODS: Patients attending a major tertiary hospital for head and neck cancer treatment from 2010 to 2011 were included (n=270). Data were collected on patient demographics (age and gender), clinical factors (tumour site, staging and treatment), nutrition outcome measures (weight, enteral feeding) and protocol adherence. Sensitivity and specificity were calculated and compared with the original validation study. RESULTS: Proactive gastrostomy tubes were inserted in 86 patients. Overall protocol adherence was 93%. Sensitivity improved to 72% (increase of 18%) and specificity improved to 96% (increase of 3%) compared with the original validation study where patients received three-dimensional (3-D) conformal radiotherapy. CONCLUSIONS: The results of this study confirm that the updated high-risk category in the protocol for the swallowing and nutrition management of patients with head and neck cancer remains valid to predict proactive gastrostomy in a mixed population receiving helical intensity-modulated radiotherapy and 3-D conformal radiotherapy. The protocol has an improved sensitivity and specificity and hence remains just as relevant for advanced techniques of radiation treatment delivery.

New radiotherapy techniques do not reduce the need for nutrition intervention in patients with head and neck cancer.

BACKGROUND/OBJECTIVES: Since 2007, our institution has used validated guidelines for the insertion of proactive gastrostomy feeding tubes in patients with head and neck cancer. Helical intensity-modulated radiotherapy (H-IMRT) delivered by Tomotherapy, is an advanced radiotherapy technique introduced at our centre in 2010. This form of therapy reduces long-term treatment-related toxicity to normal tissues. The aim of this study is to compare weight change and need for tube feeding following H-IMRT (n=53) with patients that would have previously been treated with three-dimensional conformal radiotherapy (n=134). SUBJECTS/METHODS: Patients with head and neck cancer assessed as high nutritional risk with recommendation for proactive gastrostomy were identified from cohorts from 2007 to 2008 and 2010 to 2011. Retrospective data were collected on clinical factors, weight change from baseline to completion of treatment, incidence of severe weight loss (⩾ 10%) and tube feeding. Statistical analyses to compare outcomes between the two treatments included χ(2)-test, Fisher's exact and two-sample Wilcoxon tests (P<0.05). RESULTS: The H-IMRT cohort had higher proportions of patients with definitive chemoradiotherapy (P=0.032) and more advanced N stage (P<0.001). Nutrition outcomes were not significantly different between H-IMRT and conformal radiotherapy, respectively: need for proactive gastrostomy (n=49, 92% versus n=115, 86%, P=0.213), median percentage weight change (-7.2% versus -7.3%, P=0.573) and severe weight loss incidence (28% versus 27%, P=0.843). CONCLUSIONS: Both groups had median weight loss >5% and high incidences of tube feeding and severe weight loss. Nutrition intervention remains critical in this patient population, despite advances in radiotherapy techniques, and no changes to current management are recommended.

Kinetic theory molecular dynamics and hot dense matter: theoretical foundations.

Electrons are weakly coupled in hot, dense matter that is created in high-energy-density experiments. They are also mildly quantum mechanical and the ions associated with them are classical and may be strongly coupled. In addition, the dynamical evolution of plasmas under these hot, dense matter conditions involve a variety of transport and energy exchange processes. Quantum kinetic theory is an ideal tool for treating the electrons but it is not adequate for treating the ions. Molecular dynamics is perfectly suited to describe the classical, strongly coupled ions but not the electrons. We develop a method that combines a Wigner kinetic treatment of the electrons with classical molecular dynamics for the ions. We refer to this hybrid method as "kinetic theory molecular dynamics," or KTMD. The purpose of this paper is to derive KTMD from first principles and place it on a firm theoretical foundation. The framework that KTMD provides for simulating plasmas in the hot, dense regime is particularly useful since current computational methods are generally limited by their inability to treat the dynamical quantum evolution of the electronic component. Using the N-body von Neumann equation for the electron-proton plasma, three variations of KTMD are obtained. Each variant is determined by the physical state of the plasma (e.g., collisional versus collisionless). The first variant of KTMD yields a closed set of equations consisting of a mean-field quantum kinetic equation for the electron one-particle distribution function coupled to a classical Liouville equation for the protons. The latter equation includes both proton-proton Coulombic interactions and an effective electron-proton interaction that involves the convolution of the electron density with the electron-proton Coulomb potential. The mean-field approach is then extended to incorporate equilibrium electron-proton correlations through the Singwi-Tosi-Land-Sjolander (STLS) ansatz. This is the second variant of KTMD. The STLS contribution produces an effective electron-proton interaction that involves the electron-proton structure factor, thereby extending the usual mean-field theory to correlated but near equilibrium systems. Finally, a third variant of KTMD is derived. It includes dynamical electrons and their correlations coupled to a MD description for the ions. A set of coupled equations for the one-particle electron Wigner function and the electron-electron and electron-proton correlation functions are coupled to a classical Liouville equation for the protons. This latter variation has both time and momentum dependent correlations.

Telephone-delivered nutrition and exercise counselling after auto-SCT: a pilot, randomised controlled trial.

Adverse changes in nutrition-related outcomes including quality of life (QoL) occur after PBSC transplantation. This randomised controlled trial aims to evaluate the impact of nutrition and exercise counselling provided at hospital discharge on nutritional status, body composition and QoL post transplantation. Usual care (UC) (n=19) received no intervention after discharge; extended care (EC) (n=18) received fortnightly telephone counselling from a dietitian and exercise physiologist up to 100 days post transplantation. Nutritional status (patient-generated subjective global assessment, and diet history), QoL (EORTC QLQ-C30 version 3) and body composition (air displacement plethysmography) were assessed at pre-admission, discharge and 100 days post transplantation. Intervention groups were compared using two-sample t-tests of changes in the outcomes; results were adjusted using analysis of covariance. EC exhibited clinically important but not statistically significant increases in protein intake (14.7 g; confidence interval (CI) 95% -6.5, 35.9, P=0.165), cognitive functioning (7.2; CI 95% -7.9, 22.2, P=0.337) and social functioning (16.5; CI 95% -7.3, 40.3, P=0.165) compared with UC. Relative to pre-admission, EC experienced less weight loss than UC (-3.3 kg; CI 95% -6.7, 0.2, P=0.062). Physical activity was not significantly different between the groups. Ongoing nutrition and exercise counselling may prevent further weight loss and improve dietary intake and certain QoL components in autologous PBSC transplantation patients following hospitalisation.

Concurrent and predictive evaluation of malnutrition diagnostic measures in hip fracture inpatients: a diagnostic accuracy study.

BACKGROUND/OBJECTIVES: Differences in malnutrition diagnostic measures impact malnutrition prevalence and outcomes data in hip fracture. This study investigated the concurrent and predictive validity of commonly reported malnutrition diagnostic measures in patients admitted to a metropolitan hospital acute hip fracture unit. SUBJECTS/METHODS: A prospective, consecutive level II diagnostic accuracy study (n=142; 8 exclusions) including the International Classification of Disease, 10th Revision, Australian Modification (ICD10-AM) protein-energy malnutrition criteria, a body mass index (BMI) <18.5 kg/m(2), the Mini-Nutrition Assessment Short-Form (MNA-SF), pre-operative albumin and geriatrician individualised assessment. RESULTS: Patients were predominantly elderly (median age 83.5, range 50-100 years), female (68%), multimorbid (median five comorbidities), with 15% 4-month mortality. Malnutrition prevalence was lowest when assessed by BMI (13%), followed by MNA-SF (27%), ICD10-AM (48%), albumin (53%) and geriatrician assessment (55%). Agreement between measures was highest between ICD10-AM and geriatrician assessment (κ=0.61) followed by ICD10-AM and MNA-SF measures (κ=0.34). ICD10-AM diagnosed malnutrition was the only measure associated with 48-h mobilisation (35.0 vs 55.3%; P=0.018). Reduced likelihood of home discharge was predicted by ICD-10-AM (20.6 vs 57.1%; P=0.001) and MNA-SF (18.8 vs 47.8%; P=0.035). Bivariate analysis demonstrated ICD10-AM (relative risk (RR)1.2; 1.05-1.42) and MNA-SF (RR1.2; 1.0-1.5) predicted 4-month mortality. When adjusted for age, usual place of residency, comorbidities and time to surgery only ICD-10AM criteria predicted mortality (odds ratio 3.59; 1.10-11.77). Albumin, BMI and geriatrician assessment demonstrated limited concurrent and predictive validity. CONCLUSIONS: Malnutrition prevalence in hip fracture varies substantially depending on the diagnostic measure applied. ICD-10AM criteria or the MNA-SF should be considered for the diagnosis of protein-energy malnutrition in frail, multi-morbid hip fracture inpatients.

The malnutrition screening tool versus objective measures to detect malnutrition in hip fracture.

BACKGROUND: The Malnutrition Screening Tool (MST) is the most commonly used screening tool in Australia. Poor screening tool sensitivity may lead to an under-diagnosis of malnutrition, with potential patient and economic ramifications. The present study aimed to determine whether the MST or anthropometric parameters adequately detect malnutrition in patients who were admitted to a hip fracture unit. METHODS: Data were analysed for a prospective convenience sample (n = 100). MST screening was independently undertaken by nursing staff and a nutrition assistant. Mid upper arm circumference (MUAC) was measured by a trained nutrition assistant. Nutritional risk [MST score ≥ 2, body mass index (BMI) < 22 kg m(-2) , or MUAC < 25 cm] was compared with malnutrition diagnosed by accredited practicing dietitians using International Classification of Diseases version 10-Australian Modification (ICD10-AM) coding criteria. RESULTS: Malnutrition prevalence was 37.5% using ICD10-AM criteria. Delirium, dementia or preadmission cognitive impairment was present in 65% of patients. The BMI as a nutrition risk screen was the most valid predictor of malnutrition (sensitivity 75%; specificity 93%; positive predictive value 73%; negative predictive value 84%). Nursing MST screening was the least valid (sensitivity 73%; specificity 55%; positive predictive value 50%; negative predictive value 77%). There was only fair agreement between nursing and nutrition assistant screening using the MST (κ = 0.28). CONCLUSIONS: In this population with a high prevalence of delirium and dementia, further investigation is warranted into the performance of nutrition screening tools and anthropometric parameters such as BMI. All tools failed to predict a considerable number of patients with malnutrition. This may result in the under-diagnosis and treatment of malnutrition, leading to case-mix funding losses.

The effectiveness of a specialised oral nutrition supplement on outcomes in patients with chronic wounds: a pragmatic randomised study.

BACKGROUND: Nutrition supplements enriched with immune function enhancing nutrients have been developed to aid wound-healing, although evidence regarding their effectiveness is limited and systematic reviews have lead to inconsistent recommendations. The present pragmatic, randomised, prospective open trial evaluated a wound-specific oral nutrition supplement enriched with arginine, vitamin C and zinc compared to a standard supplement with respect to outcomes in patients with chronic wounds in an acute care setting. METHODS: Twenty-four patients [11 males and 13 females; mean (SD) age: 67.8 (22.3) years] with chronic wounds (14 diabetic or venous ulcers; 10 pressure ulcers or chronic surgical wounds) were randomised to receive either a wound-specific supplement (n = 12) or standard supplement (n = 12) for 4 weeks, with ongoing best wound and nutrition care for an additional 4 weeks. At baseline, and at 4 and 8 weeks, the rate of wound-healing, nutritional status, protein and energy intake, quality of life and product satisfaction were measured. Linear mixed effects modelling with random intercepts and slopes were fitted to determine whether the wound-specific nutritional supplement had any effect. RESULTS: There was a significant improvement in wound-healing in patients receiving the standard nutrition supplement compared to a wound-specific supplement (P = 0.044), although there was no effect on nutritional status, dietary intake, quality of life and patient satisfaction. CONCLUSIONS: The results of the present study indicate that a standard oral nutrition supplement may be more effective at wound-healing than a specialised wound supplement in this clinical setting.

Cost effectiveness of nutrition support in the prevention of pressure ulcer in hospitals.

BACKGROUND/OBJECTIVES: This study estimates the economic outcomes of a nutrition intervention to at-risk patients compared with standard care in the prevention of pressure ulcer. SUBJECTS/METHODS: Statistical models were developed to predict 'cases of pressure ulcer avoided', 'number of bed days gained' and 'change to economic costs' in public hospitals in 2002-2003 in Queensland, Australia. Input parameters were specified and appropriate probability distributions fitted for: number of discharges per annum; incidence rate for pressure ulcer; independent effect of pressure ulcer on length of stay; cost of a bed day; change in risk in developing a pressure ulcer associated with nutrition support; annual cost of the provision of a nutrition support intervention for at-risk patients. A total of 1000 random re-samples were made and the results expressed as output probability distributions. RESULTS: The model predicts a mean 2896 (s.d. 632) cases of pressure ulcer avoided; 12, 397 (s.d. 4491) bed days released and corresponding mean economic cost saving of euros 2 869 526 (s.d. 2 078 715) with a nutrition support intervention, compared with standard care. CONCLUSION: Nutrition intervention is predicted to be a cost-effective approach in the prevention of pressure ulcer in at-risk patients.

Nutritional status of long-term patients in the acute care setting.

The nutritional status of 926 patients (51.4% female) at an acute tertiary private hospital with a length of stay ≥14 days was assessed using Subjective Global Assessment. The prevalence of malnutrition was 42.5% (37.2% length of stay of 14-27 days, 51.6% ≥28 days). From logistic regression analysis, length of stay and age were independent predictors of malnutrition. It is important that the nutritional status of longer stay patients is monitored and appropriate nutrition support is commenced.

Influence of deuteration on lithium acetate dihydrate studied by inelastic X-ray scattering, density functional theory, thermal expansion, elastic and thermodynamic measurements.

The influence of deuteration on the properties of lithium acetate dihydrate has been investigated by thermal expansion measurements, ultrasound spectroscopy and calorimetry. Inelastic X-ray scattering has been employed to investigate if the low temperature structural phase transition can be detected by a change in the vibrational spectrum. Density functional theory, DFT, calculations have been employed to complement the experimental investigations. The thermal expansion coefficients and the specific heat of the deuterated compound differ significantly from the protonated form. The differences in the elastic stiffness coefficients are just above the detection limit of the technique employed here. Temperature dependent inelastic X-ray spectroscopic measurements show no significant change of the vibrational spectrum when crossing the transition temperature. The DFT calculations show that the methyl group dynamics are best described in the framework of coupled rotators of opposing methyl groups. One of the coupled rotational modes corresponds to a hindered rotator with a barrier of 15 meV, while the other is a free rotator.

The Malnutrition Screening Tool is a useful tool for identifying malnutrition risk in residential aged care.

BACKGROUND: The Malnutrition Screening Tool (MST) is a valid nutrition screening tool in the acute hospital setting but has not been assessed in residential aged care facilities. The aim of this secondary analysis was to determine whether the MST could be a useful nutrition screening tool when compared with a full nutrition assessment by Subjective Global Assessment (SGA) in the residential aged care setting. METHODS: Two hundred and eighty-five residents (29% male; mean age 84 +/- 9 years) from eight residential aged care facilities in Australia participated in the study. A secondary analysis of data collected during a nutrition intervention study was conducted. The MST consists of two questions related to recent weight loss and appetite. Although the MST was not specifically applied, weight loss and appetite information was available and an estimated MST score (0-5) was calculated. Nutritional status was assessed by a research assistant trained in using the SGA. RESULTS: Malnutrition prevalence was 42.8% (122 malnourished out of 285 residents). Compared to the SGA, the MST was an effective predictor of nutritional risk (sensitivity = 83.6%, specificity = 65.6%, positive predictive value = 0.65, negative predictive value = 0.84). CONCLUSIONS: The components of the MST have acceptable sensitivity and specificity, suggesting that it can play a valuable role in quickly identifying the risk of malnutrition in the residential aged care setting. Further prospective research using the MST tool against a broader array of objective and subjective nutritional parameters is required to confirm its validity as a screening tool in aged care settings.

Maintaining nutrition in aged care residents with a train-the-trainer intervention and Nutrition Coordinator.

OBJECTIVE: To investigate the impact of a train-the-trainer program on the nutritional status of older people in residential care. DESIGN: Prospective, randomized controlled study. SETTING: Eight nursing homes in Southeast Queensland, Australia. PARTICIPANTS: A total of 352 residents participated - 245 were female (69.6%). The mean age was 84.2 years and the majority (79.4%) were classified as high dependency. INTERVENTION: Residents from four nursing homes were randomly selected for a nutrition education program coordinated by Nutrition Coordinators. Residents from the other four nursing homes (control) received usual care. MEASUREMENTS: The Subjective Global Assessment was used to determine prevalence of malnutrition at baseline and six months post intervention. The Resident Classification Scale measured functional dependency. Prescribed diet, fluids, oral hygiene status and allied health referrals were obtained by chart audit. RESULTS: Approximately half the residents were well nourished with 49.4% moderately or severely malnourished. Residents in the intervention group were more likely to maintain or improve their nutritional status compared with the control group who were more likely to experience a deterioration (P=0.027). The odds of the control group being malnourished post test was 1.6 times more likely compared with the intervention group but this did not reach statistical significance (P=0.1). CONCLUSION: The results of the study encourage the implementation of a Nutrition Coordinator program to maintain nutritional status of aged care residents. Nevertheless, malnutrition rates continue to be unacceptably high. In a rapidly aging society, the aged care sector needs to confront malnutrition and provide better resources for staff to take measures against this problem.

Nutritional status of patients who have fallen in an acute care setting.

BACKGROUND: Falls may result in injury, loss of independence and higher healthcare costs. The aim of this study was to examine the nutritional status of patients who had fallen in an acute care setting. METHODS: Forty-nine patients who had experienced a fall while admitted at an Australian private hospital participated in the study (age: 71.2 (SD 14.1) years; 21 male: 28 female). Nutritional status was assessed using subjective global assessment. Protein and energy intake was determined by dietary history and analysed using Australian computerised food composition data. RESULTS: According to subjective global assessment, 27 patients were well nourished and 22 malnourished (21 moderately, one severely malnourished). Well nourished fallers had significantly higher BMI (mean difference 3.7 kg/m(2), CI: 1.2-6.2), dietary protein (mean difference 19.8 g, CI: 2.0-37.5) and energy intake (mean difference 1751 kJ, CI: 332-3170) compared to malnourished fallers. There was no difference in severity of falls based on nutritional status, weight or BMI. CONCLUSIONS: There was a high prevalence of malnutrition and poor intake in this sample of patients who had fallen in hospital. Nutrition assessment and intervention for patients who have fallen in the acute care setting should be considered.

Principal component, Varimax rotation and cost analysis of volume effects in rectal bleeding in patients treated with 3D-CRT for prostate cancer.

We investigate the utility of principal component analysis as a tool for obtaining dose-volume combinations related to rectal bleeding after radiotherapy for prostate cancer. A direct implementation of principal component analysis reduces the number of degrees of freedom from the patient's dose-volume histograms that are associated with bleeding. However, when low-variance principal components are strongly correlated to outcome, their interpretation is problematic. A Varimax rotation is employed to aid in interpretability of the low-variance principal components. This procedure brings us closer to finding unique dose-volume combinations related to outcome but reintroduces correlation, requiring analysis of the overlap of information contained in such modes. Finally, we present examples of cost-benefit analyses for candidate dose-volume constraints for use in treatment planning.

Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area.

Malnutrition occurs frequently in patients with cancer of the gastrointestinal (GI) or head and neck area and can lead to negative outcomes. The aim of this study is to determine the impact of early and intensive nutrition intervention (NI) on body weight, body composition, nutritional status, global quality of life (QoL) and physical function compared to usual practice in oncology outpatients receiving radiotherapy to the GI or head and neck area. Outpatients commencing at least 20 fractions of radiotherapy to the GI or head and neck area were randomised to receive intensive, individualised nutrition counselling by a dietitian using a standard protocol and oral supplements if required, or the usual practice of the centre (general advice and nutrition booklet). Outcome parameters were measured at baseline and 4, 8 and 12 weeks after commencing radiotherapy using valid and reliable tools. A total of 60 patients (51 M : 9 F; mean age 61.9+/-14.0 years) were randomised to receive either NI (n=29) or usual care (UC) (n=31). The NI group had statistically smaller deteriorations in weight (P<0.001), nutritional status (P=0.020) and global QoL (P=0.009) compared with those receiving UC. Clinically, but not statistically significant differences in fat-free mass were observed between the groups (P=0.195). Early and intensive NI appears beneficial in terms of minimising weight loss, deterioration in nutritional status, global QoL and physical function in oncology outpatients receiving radiotherapy to the GI or head and neck area. Weight maintenance in this population leads to beneficial outcomes and suggests that this, rather than weight gain, may be a more appropriate aim of NI.

An assessment of a premedical program in terms of its ability to serve black Americans.

If special programs to increase the number of blacks gaining entry into health professional schools can identify whom they best serve, changes in either the selection process or the curriculum can increase their effectiveness. As one part of an evaluation of the effectiveness of the various components of the prehealth professions program at Xavier University of Louisiana (XU), black freshmen entering the university from 1981 to 1983 in the university's premedical program were tracked to determine who gained entry into medical and related mainline health professional schools upon graduation.The analyses indicate that high-ability black freshmen entering Xavier are more than twice as likely to gain admission into medical school than are their black counterparts nationally, and that this difference is statistically significant beyond the 99 percent level. Fifty-seven percent of high-ability black freshmen (those with American College Testing [ACT] composite scores of 24 or above, the top 2 percent of blacks nationally) who entered XU's biology or chemistry programs during the period under study gained entry into medical school upon graduation, whereas a study by the Educational Testing Service indicates that only 24 percent of similar blacks nationally gain entry into any graduate or professional school.The present study suggests that XU's premedical program serves those blacks who are not in the high-ability group (those whose ACT scores are below 24) at least as well (relative to the national average) as it does the top students. It therefore seems reasonable to assume that XU's premedical program is successful because it increases the probability that students gain admission into health professional schools rather than because of any preselection of students. These results are similar to those obtained from a comparable analysis of XU's prepharmacy program, the other component of prehealth at Xavier.