Registered Nurse Strain Detection Using Ambient Data: An Exploratory Study of Underutilized Operational Data Streams in the Hospital Workplace.

BACKGROUND: Registered nurses (RNs) regularly adapt their work to ever-changing situations but routine adaptation transforms into RN strain when service demand exceeds staff capacity and patients are at risk of missed or delayed care. Dynamic monitoring of RN strain could identify when intervention is needed, but comprehensive views of RN work demands are not readily available. Electronic care delivery tools such as nurse call systems produce ambient data that illuminate workplace activity, but little is known about the ability of these data to predict RN strain. OBJECTIVES: The purpose of this study was to assess the utility of ambient workplace data, defined as time-stamped transaction records and log file data produced by non-electronic health record care delivery tools (e.g., nurse call systems, communication devices), as an information channel for automated sensing of RN strain. METHODS: In this exploratory retrospective study, ambient data for a 1-year time period were exported from electronic nurse call, medication dispensing, time and attendance, and staff communication systems. Feature sets were derived from these data for supervised machine learning models that classified work shifts by unplanned overtime. Models for three timeframes -8, 10, and 12 hours-were created to assess each model's ability to predict unplanned overtime at various points across the work shift. RESULTS: Classification accuracy ranged from 57 to 64% across three analysis timeframes. Accuracy was lowest at 10 hours and highest at shift end. Features with the highest importance include minutes spent using a communication device and percent of medications delivered via a syringe. CONCLUSION: Ambient data streams can serve as information channels that contain signals related to unplanned overtime as a proxy indicator of RN strain as early as 8 hours into a work shift. This study represents an initial step toward enhanced detection of RN strain and proactive prevention of missed or delayed patient care.

Subtle cues: Qualitative elicitation of signs of capacity strain in the hospital workplace.

Through everyday care experiences, nurses develop expertise in recognition of capacity strain in hospital workplaces. Through qualitative interview, experienced nurses identify common activity changes and adaptive work strategies that may signal an imbalance between patient demand and service supply at the bedside. Activity change examples include nurse helping behaviors across patient assignments, increased volume of nurse calls from patient rooms, and decreased presence of staff at the nurses' station. Adaptive work strategies encompass actions taken to recruit resources, move work in time, reduce work demands, or reduce thoroughness of task performance. Nurses' knowledge of perceptible signs of strain provides a foundation for future exploration and development of real-time indicators of capacity strain in hospital-based work systems.

Better access, quality, and cost for clinically complex veterans with home-based primary care.

In successfully reducing healthcare expenditures, patient goals must be met and savings differentiated from cost shifting. Although the Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) program for chronically ill individuals has resulted in cost reduction for the VA, it is unknown whether cost reduction results from restricting services or shifting costs to Medicare and whether HBPC meets patient goals. Cost projection using a hierarchical condition category (HCC) model adapted to the VA was used to determine VA plus Medicare projected costs for 9,425 newly enrolled HBPC recipients. Projected annual costs were compared with observed annualized costs before and during HBPC. To assess patient perspectives of care, 31 veterans and caregivers were interviewed from three representative programs. During HBPC, Medicare costs were 10.8% lower than projected, VA plus Medicare costs were 11.7% lower than projected, and combined hospitalizations were 25.5% lower than during the period without HBPC. Patients reported high satisfaction with HBPC team access, education, and continuity of care, which they felt contributed to fewer exacerbations, emergency visits, and hospitalizations. HBPC improves access while reducing hospitalizations and total cost. Medicare is currently testing the HBPC approach through the Independence at Home demonstration.

A systematic review of clinician and staff views on the acceptability of incorporating remote monitoring technology into primary care.

OBJECTIVE: Remote monitoring technology (RMT) may enhance healthcare quality and reduce costs. RMT adoption depends on perceptions of the end-user (e.g., patients, caregivers, healthcare providers). We conducted a systematic review exploring the acceptability and feasibility of RMT use in routine adult patient care, from the perspectives of primary care clinicians, administrators, and clinic staff. MATERIALS AND METHODS: We searched the databases of Medline, IEEE Xplore, and Compendex for original articles published from January 1996 through February 2013. We manually screened bibliographies of pertinent studies and consulted experts to identify English-language studies meeting our inclusion criteria. RESULTS: Of 939 citations identified, 15 studies reported in 16 publications met inclusion criteria. Studies were heterogeneous by country, type of RMT used, patient and provider characteristics, and method of implementation and evaluation. Clinicians, staff, and administrators generally held positive views about RMTs. Concerns emerged regarding clinical relevance of RMT data, changing clinical roles and patterns of care (e.g., reduced quality of care from fewer patient visits, overtreatment), insufficient staffing or time to monitor and discuss RMT data, data incompatibility with a clinic's electronic health record (EHR), and unclear legal liability regarding response protocols. CONCLUSIONS: This small body of heterogeneous literature suggests that for RMTs to be adopted in primary care, researchers and developers must ensure clinical relevance, support adequate infrastructure, streamline data transmission into EHR systems, attend to changing care patterns and professional roles, and clarify response protocols. There is a critical need to engage end-users in the development and implementation of RMT.

A qualitative study of rural primary care clinician views on remote monitoring technologies.

PURPOSE: Remote monitoring technologies (RMTs) may improve the quality of care, reduce access barriers, and help control medical costs. Despite the role of primary care clinicians as potential key users of RMTs, few studies explore their views. This study explores rural primary care clinician interest and the resources necessary to incorporate RMTs into routine practice. METHODS: We conducted 15 in-depth interviews with rural primary care clinician members of the Oregon Rural Practice-based Research Network (ORPRN) from November 2011 to April 2012. Our multidisciplinary team used thematic analysis to identify emergent themes and a cross-case comparative analysis to explore variation by participant and practice characteristics. RESULTS: Clinicians expressed interest in RMTs most relevant to their clinical practice, such as supporting chronic disease management, noting benefits to patients of all ages. They expressed concern about the quantity of data, patient motivation to utilize equipment, and potential changes to the patient-clinician encounter. Direct data transfer into the clinic's electronic health record (EHR), availability in multiple formats, and review by ancillary staff could facilitate implementation. Although participants acknowledged the potential system-level benefits of using RMTs, adoption would be difficult without payment reform. CONCLUSIONS: Adoption of RMTs by rural primary care clinicians may be influenced by equipment purpose and functionality, implementation resources, and payment. Clinician and staff engagement will be critical to actualize RMT use in routine primary care.

Long-term outcomes of shamanic treatment for temporomandibular joint disorders.

BACKGROUND: Temporomandibular joint disorders (TMDs) are chronic, often refractory, pain conditions affecting the jaw and face. Patients least likely to respond to allopathic treatment have the most marked biologic responsiveness to external stressors and concomitant psychosocial and emotional difficulties. From a shamanic healing perspective, this describes individuals who are thought to be "dispirited" and may benefit from this ancient form of spiritual healing. OBJECTIVE: To report on the long-term quantitative and qualitative outcomes relative to end-of-treatment status of a phase I study that evaluated the feasibility and efficacy of shamanic healing for people with TMDs. METHODS/DESIGN: Participants were contacted by telephone at one, three, six, and nine months after treatment and asked to report pain and disability outcomes and qualitative feedback. SETTING: Portland, OR. PARTICIPANTS: Twenty-three women aged 25 to 55 years diagnosed with TMD. PRIMARY OUTCOME MEASURES: Participants rated their TMD-related pain and disability (on the TMD Research Diagnostic Criteria Axis II Pain Related Disability and Psychological Status Scale) at each follow-up call and were asked to describe their condition qualitatively. RESULTS: Improvements in usual pain, worst pain, and functional impairment reported at end of treatment did not change during the 9 months after treatment ended (p > 0.18). CONCLUSION: Shamanic healing had lasting effects on TMDs in this small cohort of women.

Hospital to home health care transition: patient, caregiver, and clinician perspectives.

Increasing national attention is focused on improving posthospital transitions. Home health patients are in an opportune position to provide insight into this transition as they resume care for themselves with informal caregivers and home health professionals. This qualitative study describes the experiences of patients, informal caregivers, and home health clinicians during the posthospital transition. A total of 40 patients, 35 informal caregivers, and 15 clinicians participated in this study. Patients recalled receiving discharge instructions but with few details and limited information about follow-up actions if they had problems. Discharge instructions were a versatile means of communication. Home health clinicians used these instructions to guide discussions with patients and their caregivers. Both informal caregivers and home health care clinicians emphasized the inadequate preparation of caregivers during the discharge process. More attention is needed to proactively engage informal caregivers and involve home health clinicians who can facilitate the implementation of discharge plans to improve patient outcomes.

Journey into healing: the transformative experience of shamanic healing on women with temporomandibular joint disorders.

OBJECTIVE: To evaluate participants' perceptions of illness, healing process, and experience of effects from shamanic treatment as reported from in-depth interviews. THEORETICAL FRAMEWORK: Consistent with a whole systems research model, qualitative methods were used to evaluate the outcomes and experiences of clinical trial participants. Quantitative results are reported elsewhere. METHOD: Twenty participants completed five visits with a randomly assigned shamanic practitioner and completed pretreatment and posttreatment in-depth interviews conducted by trained, qualitative researchers. CONTEXT: Some physical and psychological symptoms associated with temporomandibular joint disorders (TMD) may be indicative of the shamanic definition of soul loss. Because this was the first clinical trial of shamanic healing for TMD pain, a mixed-methods approach enabled researchers to capture a wide range of participants' experiences. PARTICIPANTS: Eligible volunteers were women aged between 25 to 55 years, naive to shamanic healing, with a confirmed diagnosis of TMD and a pain level of three or higher on the Research Diagnostic Criteria Axis II questionnaire. DATA COLLECTION: For consistency, interviewers followed a guide that allowed individual experiences to emerge. Interviews lasted about one hour, were recorded, and professionally transcribed. ANALYSIS AND INTERPRETATION: Following standard qualitative analysis procedures, researchers developed and applied thematic codes to transcribed text of interviews. Coded text was reviewed to generate summaries of thematic content. MAIN RESULTS: Although participants described physical changes, three times as much text was devoted to changes in self-awareness, capacity for coping, improvement in relationships, and taking better care of themselves. Their experience describes a process of transformation.

An HMO-based prospective pilot study of energy medicine for chronic headaches: whole-person outcomes point to the need for new instrumentation.

OBJECTIVES: The purpose of this study was to evaluate an energy healing treatment for possible inclusion as a Kaiser Permanente Northwest (KPNW) Pain Clinic provided therapy, and to identify the appropriate number of treatment sessions for a Pain Clinic protocol, should the intervention prove successful. In addition, our intent was to document the full range of outcomes experienced by patients undergoing energy healing, including whole-person and transformative outcomes should they occur. SETTING: The setting for this study was Kaiser Permanente Northwest Pain Clinic. PARTICIPANTS: Thirteen (13) patients with chronic headache who were members of the KPNW Health Plan were recruited through flyers or mailings. METHODS: Thirteen (13) participants received at least three energy healing sessions at approximately weekly intervals. Assessments were based on pre- and post-treatment qualitative interviews. INTERVENTION: The treatment consisted of three Healing Touch sessions provided by a Certified Healing Touch Practitioner. Treatments contained elements common to all sessions, and elements that were tailored to the individual subject. RESULTS: Twelve (12) of 13 participants experienced improvement in frequency, intensity, or duration of pain after three treatments. In addition, 11 of 13 participants experienced profound shifts in their view of themselves, their lives, and their potential for healing and transformation. These changes lasted from 24 hours to more than 6 months at follow-up. CONCLUSIONS: Energy healing can be an important addition to pain management services. More in-depth qualitative research is needed to explore the diversity of outcomes facilitated by energy healing treatments. Furthermore, the development of new instrumentation is warranted to capture outcomes that reflect transformative change and changes at the level of the whole person.

Community characteristics affecting emergency department use by Medicaid enrollees.

OBJECTIVES: In seeking to identify modifiable, system-level factors affecting emergency department (ED) use, we used a statewide Medicaid database to study community variation in ED use and ascertain community characteristics associated with higher use. METHODS: This historical cohort study used administrative data from July 1, 2003 to December 31, 2004. Residence ZIP codes were used to assign all 555,219 Medicaid enrollees to 130 primary care service areas (PCSAs). PCSA characteristics studied included rural/urban status, presence of hospital(s), driving time to hospital, and several measures of primary care capacity. Statistical analyses used a 2-stage model. In the first stage (enrollee level), ED utilization rates adjusted for enrollee demographics and medical conditions were calculated for each PCSA. In the second stage (community level), a mixed effects linear model was used to determine the association between PCSA characteristics and ED use. RESULTS: ED utilization rates varied more than 20-fold among the PCSAs. Compared with PCSAs with primary care capacity less than need, PCSAs with capacity 1 to 2 times the need had 0.12 (95% CI: -0.044, -0.20) fewer ED visits/person/yr. Compared with PCSAs with the nearest hospital accessible within 10 minutes, PCSAs with the nearest hospital >30 minutes' drive had 0.26 (95% CI: -0.38, -0.13) fewer ED visits/person/yr. CONCLUSIONS: Within this Medicaid population, ED utilization was determined not only by patient characteristics but by community characteristics. Better understanding of system-level factors affecting ED use can enable communities to improve their health care delivery systems-augmenting access to care and reducing reliance on EDs.

Understanding how clinician-patient relationships and relational continuity of care affect recovery from serious mental illness: STARS study results.

OBJECTIVE: Recommendations for improving care include increased patient-clinician collaboration, patient empowerment, and greater relational continuity of care. All rely upon good clinician-patient relationships, yet little is known about how relational continuity and clinician-patient relationships interact, or their effects on recovery from mental illness. METHODS: Individuals (92 women, 85 men) with schizophrenia, schizoaffective disorder, affective psychosis, or bipolar disorder participated in this observational study. Participants completed in-depth interviews detailing personal and mental health histories. Questionnaires included quality of life and recovery assessments and were linked to records of services used. Qualitative analyses yielded a hypothesized model of the effects of relational continuity and clinician-patient relationships on recovery and quality of life, tested using covariance structure modeling. RESULTS: Qualitative data showed that positive, trusting relationships with clinicians, developed over time, aid recovery. When "fit" with clinicians was good, long-term relational continuity of care allowed development of close, collaborative relationships, fostered good illness and medication management, and supported patient-directed decisions. Most valued were competent, caring, trustworthy, and trusting clinicians who treated clinical encounters "like friendships," increasing willingness to seek help and continue care when treatments were not effective and supporting "normal" rather than "mentally ill" identities. Statistical models showed positive relationships between recovery-oriented patient-driven care and satisfaction with clinicians, medication satisfaction, and recovery. Relational continuity indirectly affected quality of life via satisfaction with clinicians; medication satisfaction was associated with fewer symptoms; fewer symptoms were associated with recovery and better quality of life. CONCLUSIONS: Strong clinician-patient relationships, relational continuity, and a caring, collaborative approach facilitate recovery from mental illness and improved quality of life.

Feasibility and short-term outcomes of a shamanic treatment for temporomandibular joint disorders.

CONTEXT: Temporomandibular joint disorders (TMDs) are chronic, recurrent, non-progressive pain conditions affecting the jaw and face. Patients least likely to respond to allopathic treatment are those with the most marked biological responsiveness to external stressors and concomitant emotional and psychosocial difficulties. These characteristics describe individuals who are "dispirited" and may benefit from shamanic healing, an ancient form of spiritual healing. OBJECTIVE: This phase 1 study tested feasibility and safety of shamanic healing for TMDs. DESIGN: Participants were randomized to 1 of 4 shamanic practitioners and attended 5 shamanic healing sessions. Self-reported pain and disability were recorded at baseline and each treatment visit and at 1, 3, 6, and 9-month follow-ups. Participants also were clinically evaluated at baseline and end of treatment. In-depth interviews, part of our mixed methods design, were conducted at baseline and end of treatment to evaluate acceptability and nonclinical changes associated with treatment. SETTING: Portland, Oregon. PATIENTS OR OTHER PARTICIPANTS: Twenty-three women with diagnosed TMDs. INTERVENTION: Shamanic treatment carried out during 5 treatment visits. MAIN OUTCOME MEASURES: Change from baseline to posttreatment in diagnosis of TMDs by Research Diagnostic Criteria (RDC) exam and participant self-ratings on the "usual" pain, "worst" pain, and functional impact of TMDs subscales of the RDC Axis II Pain Related Disability and Psychological Status Scale. This paper reports on outcomes at end of treatment. RESULTS: This study demonstrated the feasibility and acceptability of clinical trials of shamanic healing. The mean of usual pain went from 4.96 to 2.70, P<.0001; worst pain from 7.48 to 3.60, P<.0001, and functional impact of TMDs from 3.74 to 1.15, P<.0052. Only 4 women were clinically diagnosed with TMDs at the end of treatment.

Youth: a health plan-based lifestyle intervention increases bone mineral density in adolescent girls.

OBJECTIVE: To test the efficacy of a health plan-based lifestyle intervention to increase bone mineral density in adolescent girls. DESIGN: Two-year randomized, controlled trial. SETTING: Large health maintenance organization. PARTICIPANTS: Girls 14 to 16 years old with body mass index below the national median. Intervention Behavioral intervention (bimonthly group meetings, quarterly coaching telephone calls, and weekly self-monitoring) designed to improve diet and increase physical activity. MAIN OUTCOME MEASURES: Total bone mineral density was measured by dual-energy x-ray absorptiometry. Behavioral outcomes included intake of calcium, vitamin D, soda, and fruits and vegetables; high-impact and strength-training physical activity; measures of strength and fitness; and biomarkers (osteocalcin and naltrexone). RESULTS: Compared with control subjects, girls in the intervention group had significantly higher bone mineral density in the spine and trochanter regions during the first study year, which was maintained during the second study year. The naltrexone biomarker demonstrated a greater relative decrease in the intervention group compared with the control group, with nonsignificant changes in osteocalcin consistent with more bone building in the intervention group. Participants in the intervention group reported significantly greater consumption of calcium in both study years, vitamin D in the first year, and fruits and vegetables in both years. We found no effect on soda consumption or target exercise rates. CONCLUSIONS: A comprehensive health care-based lifestyle intervention can effectively improve dietary intake and increase bone mineral gains in adolescent girls. To our knowledge, this study is the first to significantly improve bone mass in adolescent girls in a non-school-based intervention. Trial Registration ClinicalTrials.gov Identifier: NCT00067600.

Randomized trial of a whole-system ayurvedic protocol for type 2 diabetes.

CONTEXT: Though complementary and alternative medicine (CAM) treatments are popular, evidence to support their application to diabetes care is scarce. Previous CAM diabetes research has generally focused on single modalities, but CAM practitioners more commonly prescribe complex, multimodality interventions. OBJECTIVES: The aims of this study were to determine the feasibility and clinical impact of a whole-system, Ayurvedic intervention for newly diagnosed people with type 2 diabetes. DESIGN: Patients were randomly assigned to either an experimental or control arm. SETTING: Group model health maintenance organization. PARTICIPANTS: We recruited 60 adult patients with baseline glycosylated hemoglobin (HbA1c) values between 6.0 and 8.0. INTERVENTION: Treatment for the experimental group included exercise, an Ayurvedic diet, meditation instruction, and an Ayurvedic herb supplement (MA 471). Control patients attended standard diabetes education classes with primary care clinician follow-up. MEASUREMENTS: Clinical outcomes were assessed at 3 and 6 months and included HbA1c, fasting glucose, lipids, blood pressure, and weight. RESULTS: Ninety-two percent of randomized patients completed the study, and there were no significant adverse study-related events. Using analysis of co-variance (ANCOVA), we found no significant differences for clinical outcomes at 6 months between on-study patient groups, though trends favored the Ayurvedic group. When we included a factor measuring how much baseline HbA1c exceeded the mean (6.5%), however, we found statistically significant improvements in the Ayurvedic group for HbA1c (P = .006), fasting glucose (P = .001), total cholesterol (P = .05), low-density lipoprotein (LDL) cholesterol (P = .04), and weight (P = .035). CONCLUSIONS: These results suggest that the Ayurvedic intervention may benefit patients with higher baseline HbA1c values, warranting further research.

Physicians, patients, and the electronic health record: an ethnographic analysis.

PURPOSE: Little is known about the effects of the electronic health record (EHR) on physician-patient encounters. The objectives of this study were to identify the factors that influence the manner by which physicians use the EHR with patients. METHODS: This ethnographic study included 4 qualitative components: 80 hours of participant observation in 4 primary care offices in the Pacific Northwest; individual interviews with 52 patients, 12 office staff members, 23 physicians, and 1 nurse-practitioner; videotaped reviews of 29 clinical encounters; and 5 focus-group interviews with physicians and computer advocates. The main outcome measures were factors that influence how physicians use the EHR. Researchers qualitatively derived these factors through serial reviews of data. RESULTS: This study identified 14 factors that influence how EHRs are used and perceived in medical practice today. These factors were categorized into 4 thematic domains: (1) spatial--effect of the physical presence and location of EHRs on interactions between physicians and patients; (2) relational--perceptions of physicians and patients about the EHR and how those perceptions affected its use; (3) educational--issues of developing physicians' proficiency with and improving patients' understandings about EHR use; and (4) structural--institutional and technological forces that influence how physicians perceived their use of EHR. CONCLUSIONS: This study found that the introduction of EHRs into practice influences multiple cognitive and social dimensions of the clinical encounter. It brings into focus important questions that through further inquiry can determine how to make best use of the EHR to enhance therapeutic relationships.

Improving services for sex partners of chlamydia-infected patients in an HMO.

OBJECTIVE: To improve services for sex partners of chlamydia-infected patients (ie, chlamydia partner services [CPS]) at an HMO. STUDY DESIGN: Assessment of current CPS policy, practices, and opinions in Kaiser Permanente Northwest Region (KPNW) and in local health departments, and design, implementation, and evaluation of 4 CPS interventions. METHODS: We reviewed KPNW policy documents, conducted focus groups with KPNW clinicians, and did phone interviews with KPNW chlamydia-infected patients and health department disease intervention specialists. We then implemented 3 informational interventions: CPS information was added to the after-visit summary given to patients tested for chlamydia; information on how to test, treat, and counsel chlamydia-infected patients was added to KPNW's electronic clinical-decision tool; and CPS information and a direct link to KPNW's chlamydia screening and treatment guidelines were added to KPNW's Web site. We also organized training for KPNW clinicians to review the roles of CPS and disease intervention specialists. We evaluated intervention uptake and impact by reviewing electronic medical charts, Web site "hits," and posttraining evaluations. RESULTS: Clinicians and disease intervention specialists reported that KPNW's CPS policy and the roles of disease intervention specialists regarding KPNW patients were unclear. Clinicians and patients wanted more CPS information. Clinicians commonly used the after-visit summary and Web-based CPS information and reported that training improved CPS knowledge. However, none used the clinical-decision tool. CONCLUSIONS: Several simple, centralized informational interventions to improve CPS were feasible and used by KPNW clinicians. These interventions could potentially be used in other settings structured like KPNW.

Clinician style and examination room computers: a video ethnography.

BACKGROUND AND OBJECTIVES: The use of computers in medical examination rooms is growing. Advocates of this technology suggest that all family physicians should have and use examination room computers (ERCs) within the near future. This study explored how family physicians incorporate the use of ERCs in their interactions with patients. METHODS: This qualitative study involved five family physicians, one family nurse practitioner, and a convenience sample of 29 patients. Data included videotaped visits, clinician interviews, and videotape reviews. The setting was an urban family practice with a 7-year history of viewing electronic medical records. The main outcome measures were themes emergent from videotaped data. RESULTS: We identified three distinct practice styles that shaped the use of the ERC: informational, interpersonal, and managerial styles. Clinicians with an informational style are guided by their attention to gathering data as prompted by the computer screen. Clinicians with an interpersonal style focus their attention and body language on patients. Clinicians with a managerial style bridge informational and interpersonal styles by alternating their attention in defined intervals between patients and the computer. CONCLUSIONS: Family physicians have varying practice styles that affect the way they use examination room computers during visits with patients.

YOUTH: decisions and challenges in designing an osteoporosis prevention intervention for teen girls.

BACKGROUND: This paper describes decisions about the experimental design for the Youth, Osteoporosis, and Understanding Total Health Project (YOUTH), a trial designed to test the efficacy of a health plan-based lifestyle intervention for increasing bone mineral density among adolescent women 14 to 16 years of age. METHODS: This randomized controlled trial recruited adolescent women who were at higher risk for developing osteoporosis (body mass index 16-23) from a large HMO in the Pacific Northwest. The intervention focused on improving diet (high calcium foods, fruits, and vegetables) and increasing physical activity (high impact and spinal motion). The intervention included both group and individual activities. The primary endpoint in the study was total bone mineral density as measured by dual-energy X-ray absorptiometry (DEXA). RESULTS: Baseline data were collected on the trial cohort of 228 adolescent women and their families. This paper discusses how researchers met the following challenges in designing and implementing the trial: determining appropriate dietary and exercise targets to affect bone mineral density in adolescents; choosing suitable assessments; and developing an intervention well suited for implementation in a non-school (health plan) setting. We also discuss the rationale for the specific study population chosen (females, younger adolescents). CONCLUSIONS: The YOUTH project is one of very few preventive research interventions with adolescents conducted in a health plan setting. Many of the recruitment and intervention strategies used in this trial may be appropriate for adoption in other health plan-based prevention studies.

Smoking as a weight-control strategy among adolescent girls and young women: a reconsideration.

Many studies have reported that adolescent girls and young women smoke to control their weight. The majority of these studies are cross-sectional and report on correlational data from quantitative surveys. This article presents data from ethnographic interviews with 60 smokers, interviewed in high school and in follow-up interviews at age 21. Contrary to previous research, this study found little evidence for the sustained use of smoking as a weight-control strategy. In high school, smokers were no more likely than nonsmokers to be trying to lose weight. In the follow-up study, 85 percent of informants replied that they had never smoked as a way to control their weight. One-half of informants at age 21 believed that smoking as a weight-control strategy would be ineffective, while the other one-half had no idea whether it would work or not. Researchers need to exert caution in propagating the idea that smoking is commonly used as a conscious and sustained weight-control strategy among adolescent females and young women.

On the integration of complementary and conventional medicine within health maintenance organizations.

The integration of complementary and alternative medicine (CAM) with conventional medicine continues across practice settings and modalities. Managed care is of particular interest to practitioners, policy makers, and researchers concerned with the evolution of CAM integration. Within health maintenance organizations (HMOs), availability, coverage, and support of CAM are variable. We present an organizational model within which we identify factors that influence the degree of CAM integration within HMOs. We describe avenues through which CAM is currently available within the Northwest Region of Kaiser Permanente (KPNW). We also describe research methods applicable to the study of CAM integration within HMOs.