CHECK: A randomized trial evaluating the efficacy and cost-effectiveness of home visitation in pediatric weight loss treatment.

BACKGROUND: Socioeconomically-disadvantaged households have a high prevalence of pediatric overweight/obesity, and also face barriers to accessing weight loss treatment in healthcare settings. Delivering family-based pediatric weight loss treatment in the home setting may enhance its efficacy by facilitating treatment attendance, enabling more tailored treatment recommendations informed by observations of the home environment, and increasing accountability. This paper describes the design of the Creating Health Environments for Chicago Kids (CHECK) Trial, which evaluates the efficacy, cost-effectiveness, and mechanisms of home visitation in family-based pediatric weight loss treatment for children in low-income households. DESIGN: CHECK is a two-arm, parallel group, randomized controlled trial that is enrolling N = 266 children, ages 6-12 y, who have overweight/obesity (BMI percentile ≥85) and live in a low-income household. Participants are randomized in a 1:1 ratio to either standard of care family-based weight loss treatment delivered in the home, or the identical intervention delivered in an academic medical center. The primary outcome is change in child BMI z-score from baseline to 12 months. Program delivery costs are rigorously documented to enable cost-effectiveness analyses from the societal and payer perspectives. Objectively-documented changes to the home environment and aspects of intervention delivery (e.g., hours of in-person contact received, quantity of behavioral goals set per session) will be tested as hypothesized treatment mechanisms. IMPLICATIONS: Findings will inform the design of future interventions, and treatment dissemination decisions by public health agencies and third-party payers. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03195790.

Quality Measures and Quality Improvement Initiatives in Osteoporosis-an Update.

PURPOSE OF REVIEW: The aims of this review are to summarize current performance for osteoporosis quality measures used by Centers for Medicare and Medicaid (CMS) for pay-for-performance programs and to describe recent quality improvement strategies around these measures. RECENT FINDINGS: Healthcare Effectiveness Data and Information (HEDIS) quality measures for the managed care population indicate gradual improvement in osteoporosis screening, osteoporosis identification and treatment following fragility fracture, and documentation of fall risk assessment and plan of care between 2006 and 2016. However, population-based studies suggest achievement for these process measures is lower where reporting is not mandated. Performance gaps remain, particularly for post-fracture care. Elderly patients with increased comorbidity are especially vulnerable to fractures, yet underperformance is documented in this population. Gender and racial disparities also exist. As has been shown for other areas of health care, education alone has a limited role as a quality improvement intervention. Multifactorial and systems-based interventions seem to be most successful in leading to measurable change for osteoporosis care and fall prevention. Despite increasing recognition of evidence-based quality measures for osteoporosis and incentives to improve upon performance for these measures, persistent gaps in care exist that will require further investigation into sustainable and value-adding quality improvement interventions.

Understanding patient beliefs regarding the use of imaging in the management of low back pain.

BACKGROUND: Imaging for low back pain (LBP) remains common despite guidelines recommending against routine imaging. Patient beliefs about imaging may contribute to the problem. This study aimed to quantitatively investigate patient beliefs regarding the need for imaging in managing LBP and to investigate whether personal characteristics, pain characteristics or back pain beliefs are associated with imaging beliefs. METHODS: A survey was performed of consecutive patients presenting to general medical practitioners in Sydney, Australia. Nine medical clinics were selected across varied socioeconomic regions. Survey questions assessed beliefs about the importance of imaging for LBP, collected demographic information, LBP history and general beliefs about back pain. Descriptive statistics and multivariate logistic regression were used to analyse findings. RESULTS: Three hundred completed surveys were collected with a 79.6% response rate. The mean age was 44 years and 60.7% of respondents were women. Exactly, 54.3% (95% CI: 48.7-58.9%) believed that imaging was necessary for the best medical care for LBP. Exactly, 48.0% (95% CI: 42.4-53.6%) believed that everyone with LBP should obtain imaging. Increased age, lower education level, non-European or non-Anglo-saxon cultural background, history of previous imaging and Back Beliefs Questionnaire scores were associated with beliefs that imaging was necessary. CONCLUSION: Approximately, half of all patients presenting to a medical doctor consider low back imaging to be necessary. This may have important implications for overutilization of low back imaging investigations. Knowledge of the factors associated with the patient's belief that imaging is necessary may be helpful in designing appropriate interventions to reduce unnecessary imaging for LBP.

[In the heart of the district. 50 interviews with the health professionals of the Lazio Region districts, Italy]. / Nel cuore del distretto. 50 interviste con gli operatori dei distretti sanitari della Regione Lazio.

This article aims to explore some key issues relating to the health districts of the Lazio Region, in particular the major critical aspects as well as some strengths highlighted by the operators. In the Lazio Region there are 12 Local Health Units, divided into 55 health districts. In recent years, the majority of the authors analized theoretical models proposed by regional standards, while the strengths and weaknesses of the district, as well as the organizational difficulties and problems experienced daily by the operators have not been investigated. It was decided to use qualitative methods of research, through open interviews with 50 operators in 15 health districts of the Region. Interviews were analysed utilizing software Nvivo. Some codes were identified to guide interviews. We can summarize the emergency issues at least in three major areas: 1) the organization of the district, 2) the management of personnel and resources, 3) the care pathways. It is hoped that, during next years, the research directed at health district analysis will grow, with particular reference to quantitative and qualitative investigations, in order to build a body of knowledge from practical experience of health professionals.

Can a participatory approach contribute to food chain risk analysis?

We consider food chain risks and specifically address stakeholder participation in the risk analysis process. We combine social and natural science perspectives to explore the participation process in relation to food risks and, in particular, to consider how some specific participation processes might be scientifically evaluated and how stakeholder participation in general might be incorporated into food risk decision making. We have built considerations based on three large integrative case studies that examine aspects of participatory processes. Here we use the case studies collectively to illustrate observations and beliefs concerning the nature of the interaction of stakeholders with established quantitative risk methodologies. This account is not supported by any large volume of analysis. The views in the report are expressed in relation to an accepted risk analysis framework and also with respect to probabilistic modeling of risks and are illustrated where possible with anecdotal reports of actual case study events.

Association between exposure/non-exposure to the mandatory seat belt law with regards to compliance in vehicle accident victims--a hospital review.

OBJECTIVE: Injuries sustained in motor vehicle accidents (MVAs) are a major challenge to the Jamaican healthcare system. In November 1999, Jamaica enacted legislation to make seat belt usage in motor vehicles compulsory. The effect of this policy change on seat belt usage is unclear. This study therefore sought to determine the prevalence of seat belt usage and to determine the association between exposure/non-exposure to the mandatory seat belt law and seat belt use in subjects who presented to the Accident and Emergency Department (A&E) of the University Hospital of the West Indies (UHWI) as a result of motor vehicle accidents. METHODS: Subjects were recruited from June to November 2003, post-seat belt law (POBL) period, and May to October 1999, pre-seat belt law (PRBL) period. Data collected included demographic variables, seat belt use and position of the occupants in the vehicle. RESULTS: Of the 277 patients who were eligible for inclusion, data were complete in 258 subjects, 87 in the PRBL period and 171 in the POBL period. The prevalence of seat belt use was 47% (PRBL) and 63% (POBL) respectively. There was no significant gender difference at each period. The odds of wearing seat belt in the rear of a motor vehicle were significantly lower than that of a driver (Table 3, OR 0.19, 95% CI 0.07, 0.48). Adjusting for age, gender and position in vehicle exposure, there was about 100% increase in the odds of seat belt use during the post seat belt law era (OR = 2.09, 95% CI 1.21, 3.61). CONCLUSION: It is concluded from this hospital-based study that the mandatory seat belt law legislature was associated with increased seat belt use in motor vehicle accident victims. However, current data from the Road Traffic Agency indicate that there is still an alarming number of fatalities. This clearly suggests that additional public health measures are needed to address the epidemic of motor vehicle trauma in Jamaica.

Association between exposure/non-exposure to the mandatory seat belt law with regards to compliance in vehicle accident victims a hospital review / Asociación entre exposición/no exposición a la ley obligatoria de cinturón de seguridad en relación con su cumplimiento en el caso de víctimas de accidentes vehiculares ­ un estudio basado en datos de hospital

OBJECTIVE: Injuries sustained in motor vehicle accidents (MVAs) are a major challenge to the Jamaican healthcare system. In November 1999, Jamaica enacted legislation to make seat belt usage in motor vehicles compulsory. The effect of this policy change on seat belt usage is unclear. This study therefore sought to determine the prevalence of seat belt usage and to determine the association between exposure/non-exposure to the mandatory seat belt law and seat belt use in subjects who presented to the Accident and Emergency Department (A&E) of the University Hospital of the West Indies (UHWI) as a result of motor vehicle accidents. METHODS: Subjects were recruited from June to November 2003, post-seat belt law (POBL) period, and May to October 1999, pre-seat belt law (PRBL) period. Data collected included demographic variables, seat belt use and position of the occupants in the vehicle. RESULTS: Of the 277 patients who were eligible for inclusion, data were complete in 258 subjects, 87 in the PRBL period and 171 in the POBL period. The prevalence of seat belt use was 47% (PRBL) and 63% (POBL) respectively. There was no significant gender difference at each period. The odds of wearing seat belt in the rear of a motor vehicle were significantly lower than that of a driver (Table 3, OR 0.19, 95% CI 0.07, 0.48). Adjusting for age, gender and position in vehicle exposure, there was about 100% increase in the odds of seat belt use during the post seat belt law era (OR = 2.09, 95% CI 1.21, 3.61). CONCLUSION: It is concluded from this hospital-based study that the mandatory seat belt law legislature was associated with increased seat belt use in motor vehicle accident victims. However, current data from the Road Traffic Agency indicate that there is still an alarming number of fatalities. This clearly suggests that additional public health measures are needed to address the epidemic of motor vehicle trauma in Jamaica.

Objetivo: Las heridas producidas en accidentes en vehículos motorizados (AVM) constituyen uno de los principales desafíos para el sistema de atención a la salud en Jamaica. En noviembre de 1999, Jamaica aprobó una legislación que obligada al uso del cinturón de seguridad en vehículos motorizados. El efecto de este cambio de política sobre el uso del cinturón de seguridad no está claro. Por lo tanto, este estudio busca determinar la prevalencia del uso del cinturón de seguridad y determinar la asociación entre exposición/no exposición a la ley obligatoria de cinturón de seguridad y el uso del cinturón de seguridad en sujetos que acudieron al Departamento de Accidentes y Emergencia (A&E) del Hospital Universitario de West Indies (HUWI) como resultado de un accidente vehicular. Métodos: Los sujetos fueron reclutados de junio a noviembre de 2003, período posterior a la ley de cinturón de seguridad (PLCS), y de mayo a octubre de 1999, período anterior a la ley de cinturón de seguridad (ALCS) Los datos recopilados incluyeron las variables demográficas, el uso de cinturón de seguridad, y la posición de los ocupantes del vehículo. Resultados: De los 277 pacientes que eran elegibles para ser incluidos, se completaron los datos de 258 sujetos, 87 en el período ALCS y 717 en el período PLCS. La prevalencia del uso del cinturón de seguridad fue 47% (ALCS) y 63% (PLCS) respectivamente. No hubo diferencia significativa de género en ninguno de los períodos. Las probabilidades de uso del cinturón de seguridad fueron significativamente más bajas para los ocupantes del asiento trasero que para el conductor del auto (Tabla 3, OR 0.19, 95% CI 0.07, 0.48). Ajustando por edad, género y posición en exposición vehicular, hubo un aumento de alrededor del 100% en las probabilidades de uso del cinturón de seguridad durante la era posterior a la ley del uso del cinturón de seguridad (OR = 2.09, 95% CI 1.21, 3.61). Conclusión: A partir de este estudio basado en datos de hospital, se llegó a la conclusión de que la legislación de la ley del uso obligatorio del cinturón de seguridad, estuvo asociada con el aumento del uso del cinturón de seguridad en víctimas de accidentes con vehículos motorizados. Sin embargo, los datos actuales de la Agencia del Tráfico de Carreteras, indican que existe todavía un número alarmante de casos fatales. Esto sugiere a todas luces la necesidad de medidas de salud pública adicionales para abordar la epidemia de traumas por accidentes de vehículos en Jamaica

Are current processes for nuclear emergency management in Europe adequate?

We describe the results of process mapping of nuclear emergency management procedures in four European countries. We find clear differences and explore these in relation to their suitability for building a shared understanding across the emergency management team of the evolving situation and a balanced appreciation of the uncertainties. Our findings indicate that there are some issues that cause concern in that the procedures may run smoothly and efficiently but they may also risk underestimating uncertainty or ignore key issues that have only been identified by a minority of experts or models. We are concerned that they do not facilitate the building of shared mental models that the literature such as that on highly reliable organisations has shown is important.

Effect of health lifestyle pattern on dietary change.

PURPOSE: To examine the effect of lifestyle on the effectiveness of a low-intensity dietary intervention. DESIGN: A secondary data analysis was performed using data from the Eating Patterns Study, a randomized controlled trial that found that self-help materials with physician advice was effective in changing dietary intake and behavior. SETTING: Primary care clinics in a large health maintenance organization. SUBJECTS: A total of 2111 patients with a routine scheduled appointment with their primary care physicians. MEASURES: Participants were grouped into one of six health lifestyle patterns based on similarities in baseline measures of alcohol intake, smoking, diet quality, and exercise. Within each lifestyle pattern, changes from baseline in usual fat and fiber intake (based on a food frequency) and a fat and fiber behavior score were compared at 3 months and 12 months for intervention vs. control participants. INTERVENTION: Self-help materials delivered by a physician with advice to change diet. RESULTS: Intervention participants in the fitness lifestyle group made the largest changes relative to controls for each dietary outcome at 3 and 12 months. For intervention participants defined by their alcohol intake or current smoking, either no changes in diet were observed compared with controls, or early changes were not sustained over time. Intervention-control comparisons within the remaining lifestyle patterns showed smaller dietary changes compared with the fitness lifestyle. This finding was similar to previously published results. CONCLUSIONS: This randomized controlled trial had limited power to detect subgroup differences; however, these results suggest that lifestyle patterns may be useful in the development of effective, targeted interventions to change behavior.

Performance-related pay in health care.

OBJECTIVE: Performance-related pay (PRP) has been widely extended within the British public sector in the last 15-20 years, mostly because of pressure from central government. Its penetration in the National Health Service (NHS) has not so far been very deep but it has been sufficient to permit preliminary judgements on its likely impact. METHODS: Review of published accounts of the extent of use of PRP in the NHS and its impact, plus two case studies. RESULTS: There have been few rigorous studies reported. PRP has been introduced for a variety of reasons: an incentive to motivate staff; to enhance staff recruitment and retention; to signal a change in organizational culture; to control staff costs; to reduce the power of trades unions; to reinforce staff development policies. Very few NHS provider organizations have implemented PRP. Despite this, senior managers see real merit in it in improving staff performance and delivering a clear message about the importance of organizational performance. Employees are much more skeptical, seeing PRP as having no effect or being detrimental. CONCLUSIONS: PRP has had, at most, only a very modest beneficial impact in the British NHS. In the absence of better evidence, it would be sensible for government to continue to encourage local initiatives rather than propose a mandatory national scheme. It would also be prudent to subject local schemes to rigorous evaluation.

Pricing and promotion effects on low-fat vending snack purchases: the CHIPS Study.

OBJECTIVES: This study examined the effects of pricing and promotion strategies on purchases of low-fat snacks from vending machines. METHODS: Low-fat snacks were added to 55 vending machines in a convenience sample of 12 secondary schools and 12 worksites. Four pricing levels (equal price, 10% reduction, 25% reduction, 50% reduction) and 3 promotional conditions (none, low-fat label, low-fat label plus promotional sign) were crossed in a Latin square design. Sales of low-fat vending snacks were measured continuously for the 12-month intervention. RESULTS: Price reductions of 10%, 25%, and 50% on low-fat snacks were associated with significant increases in low-fat snack sales; percentages of low-fat snack sales increased by 9%, 39%, and 93%, respectively. Promotional signage was independently but weakly associated with increases in low-fat snack sales. Average profits per machine were not affected by the vending interventions. CONCLUSIONS: Reducing relative prices on low-fat snacks was effective in promoting lower-fat snack purchases from vending machines in both adult and adolescent populations.

Decision support in nuclear emergencies.

In a nuclear emergency, protective actions such as evacuation, sheltering and food bans can be taken to mitigate the consequences of any release of radioactivity. Within the RODOS project, an evaluation framework has been developed to support the assessment of the costs and benefits of potential actions. In order to help the decision makers gain insight into the decision problem and clarify their preferences, guidance can be given in three stages. First, the search of feasible portfolios of protective actions is seen as a constraint satisfaction problem; only those portfolios that satisfy constraints depending on factors such as feasibility are worth further evaluation. Second, the portfolios are ranked based on their consequences and the preferences of the decision makers using either a multi-attribute value or utility function. Third, a natural language report explaining the ranking is produced to help the decision makers gain insight into the decision problem and refine the decision parameters. An intelligent decision system has been developed to demonstrate the feasibility of the framework.

Immunohistologic assessment of technetium-99m-MIBI uptake in benign and malignant breast lesions.

UNLABELLED: This study was undertaken to assess the relationship between the degree of 99mTc-MIBI uptake in breast lesions and the following histologic factors: neovascularity, desmoplastic reaction, cellular proliferation and mitochondrial density. METHODS: Forty-two patients who previously underwent MIBI breast imaging (4 false-negative, 12 false-positive, 15 true-negative, 11 true-positive) were studied. Immunohistochemical staining was performed for neovascularity (Factor VIII antigen), desmoplasia (alpha-actin antigen), mitochondrial density (mitochondrial antigen) and cellular proliferation (MIB-1 antigen). The degree of microscopic staining was correlated with region of interest measurements of MIBI uptake on scintigraphy. RESULTS: There was a poor correlation between MIBI uptake and the degrees of neovascularity (r = 0.08, p > 0.05) and intracellular mitochondrial density (r = 0.04, p > 0.05) while there was a moderate correlation with cellular proliferation (r = 0.4, p < 0.05) and desmoplasia (r = 0.55, p < 0.001). CONCLUSION: The degree of MIBI uptake in breast lesions is multifactorial, but it appears to be related more to the degree of desmoplastic activity and cellular proliferation than neovascularity and mitochondrial density.

Self-reported dieting: how should we ask? What does it mean? Associations between dieting and reported energy intake.

OBJECTIVES: To determine whether self-reports of dieting to control weight are associated with reported energy intake, how this association varies with the phrasing of questions on dieting behaviors, and whether this association differs by educational level and weight status among adult male and female respondents. METHODS: The study population included 996 women and 227 men, aged 20-45, who volunteered to participate in a weight gain prevention trial. Participants completed surveys at baseline regarding their dieting behaviors and nutritional intake. RESULTS: The association between self-reported dieting and energy intake varied according to the phrasing of the questions assessing dieting behaviors. Multi-item scales and nonambiguous single-item questions (e.g., "current dieting") were more strongly associated with reported energy intake than more general single-item questions (e.g., "doing anything to lose weight"). Overweight dieters reported lower energy intake than overweight nondieters. Among nonoverweight persons, associations between dieting and energy intake were not significant. The association between dieting and energy intake did not differ by educational level among women. Among men, dieting predicted lower energy intake in those with low educational levels, although the number of men with low educational levels who were dieting was small. Reported dieting was not associated with energy intake among men with higher educational levels. DISCUSSION: Associations between self-reports of dieting and reported energy intake vary according to the phrasing of specific questions about dieting, gender, education, and weight status. These factors should be taken into account in the design of instruments for measuring these behaviors and in the interpretation of results, especially across studies using different methodologies.

Correlates of changes in leisure time physical activity over 2 years: the Healthy Worker Project.

BACKGROUND: This study is the first to examine associations between concurrent changes in demongraphics, health behaviors, and physical activity in a free-living cohort of adults. METHODS: Surveys were conducted at 32 worksites (n = 3,672 workers) before and after a 2-year health promotion intervention. Associations between concurrent changes in sociodemographics, health, health behaviors, and physical activity were examined. Characteristics of individuals were also examined in four extreme physical activity change groupings: consistently very active, consistently very inactive, and changing from one extreme to the other over time. RESULTS: Among women, being married was associated with consistently low levels of physical activity, and increases in education were associated with increases in physical activity. Among both men and women, maintenance of single marital status was associated with increased physical activity levels, and increases in BMI were associated with decreases in physical activity. Increases in high-fat/calorie food intake were associated with increases in physical activity among men, but not among women. CONCLUSION: The observed associations indicate factors that may be important for understanding decreases in physical activity. The dynamic associations between changes in sociodemographics and physical activity demonstrate the need to examine changes in sociodemographics over time, rather than at only a single time point.

A pricing strategy to promote low-fat snack choices through vending machines.

OBJECTIVES: This study examined the role of price on purchases of low-fat snacks from vending machines. METHODS: Sales of low-fat and regular snacks were monitored in nine vending machines during a 4-week baseline, a 3-week intervention in which prices of low-fat snacks were reduced 50%, and 3 weeks postintervention. RESULTS: The proportion of low-fat snacks purchased was 25.7%, 45.8%, and 22.8% in the three periods, respectively. Total snack purchases did not vary by period. CONCLUSIONS: Reducing relative prices may be effective in promoting lower-fat food choices in the population. Vending machines may be a feasible method for implementing such nutrition interventions.

Applicants to B.Sc.N., R.N., and R.P.N. nursing programs: differences and predictors.

We surveyed 205 applicants to three types of nursing programs (B.Sc.N., diploma-R.N., and diploma-R.N.A.) offered in Toronto, Ontario. Applicants were predominately white, unmarried women living within commuting distance of the institutions to which they applied. Applicants to practical nursing programs tended to be older than applicants to B.Sc.N. and diploma-R.N. programs, be married, have at least one dependant, come from blue-collar families, be out of school longer, and submit fewer applications. Applicants with dependants were 11 times more likely to choose R.P.N. over R.N. programs. Recency of graduation and high school average were predictive of choosing B.Sc.N. over R.N. programs. While this 1992 cohort had some appreciation for the challenges facing the nursing profession, most applicants still expected to secure full-time employment in acute care post-graduation. The data provide an important benchmark for comparing current and future cohorts of applicants with respect to socio-demographic characteristics and expectations of nursing as a career choice.

Ethnic/racial and socioeconomic differences in dieting behaviors and body image perceptions in adolescents.

This study examined differences in perceptions of body weight, dieting, unhealthy eating behaviors, and weight control methods among adolescent males and females of various racial/ethnic and socioeconomic (SES) subgroups. Data were derived from a comprehensive health survey administered to 36,320 students in grades 7 through 12 in Minnesota. Differences among ethnic/racial and SES groups were assessed using multivariate logistic regression controlling for grade and body mass index (BMI). Results showed that unhealthy weight control behaviors are not confined to upper SES white females. Compared to white females, Hispanic females reported greater use of diuretics; Asians reported more binge eating; and blacks reported higher rates of vomiting. Black and American Indian females were more likely to be satisfied with their body. Among males and females, higher SES was associated with greater weight satisfaction and lower rates of pathological weight control behaviors. Findings from this study suggest that future research should focus on the validity of self-reports of dieting and weight control behaviors in different ethnic subgroups.