A continuum-based outcome approach to measuring performance in HIV/AIDS case management.

This methods paper is third in a series addressing client outcomes in HIV/AIDS case management. After introducing earlier work the authors outline their effort to consolidate numerous discrete outcome measures and to establish each outcome indicator along a continuum scale that can be self-abstracted by HIV/AIDS service providers. The paper includes in-depth discussion of challenges and benefits derived from this type of outcome measurement process. Key lessons learned from a pilot study are offered for those considering development of similar client outcomes assessment programmes. The paper concludes with several opportunities for future research for those desiring to work in this relatively uncharted domain.

Physical stability of salmon calcitonin spray-dried powders for inhalation.

The effects of excipient crystallinity and water content on the physical stability of salmon calcitonin (sCT) in a spray-dried powder for inhalation have been investigated. sCT was dissolved in water with and without mannitol and then spray dried using a Büchi 190 spray dryer. The spray dried powders were stored for 5 days at 0, 29, 51, 58, 69, and 84% relative humidity at ambient temperature. The crystalline content, water content, secondary structure, and aggregation rates were determined for each powder immediately following spray drying and after storage at various relative humidities. In addition, the water sorption isotherms and reactivity to water vapor were determined using DVS and isothermal calorimetry, respectively. No sCT aggregation occurred during the spray drying process. Crystallinity depended on the amount of mannitol in the formulation. Powders containing up to 50% mannitol were fully amorphous, and those containing 70 and 90% mannitol contained some crystalline polyol. The powders remained aggregate free for over 2 years when stored below the critical RH (e.g., <20% for the powder containing 30% mannitol). Above this RH, sCT aggregation increased as a function of time. The amount of aggregate observed correlates with the amount of intermolecular beta-sheet formed, determined by FTIR. The sCT aggregation rate in powders containing 70% mannitol was significantly lower than that in powders containing 30% mannitol at all RH tested, presumably because of a higher ratio of amorphous mannitol to sCT, which inhibits the formation of beta-sheet structure. Moisture-induced crystallization of mannitol was observed in all powders stored at RH >50%. The moisture induced thermal activity trace (MITAT) offers a useful description on the physical stability of the spray dried powders. In conclusion, spray drying sCT and sCT/mannitol mixtures yields dry powders that contain physically intact peptide. In addition, sCT aggregation and mannitol crystallization in spray dried powders can be prevented during long-term storage if stored in low humidity environments, which can be easily assessed by MITAT.

Quantification of 2'-fluoro-2'-deoxyuridine and 2'-fluoro-2'-deoxycytidine in DNA and RNA isolated from rats and woodchucks using LC/MS/MS.

Apatmers are synthesized using 2'-fluoropyrimdines in place of normal pyrmidines to stabilize them against enzymatic degradation, and thereby improve their therapeutic efficacy. Despite this stabilizing effect, the apatmers can still be degraded by nucleases in the blood. Primer template extension studies have demonstrated that mammalian DNA polymerases can incorporate these 2'-fluoropyrimidines into growing strands of DNA. The toxicologic effects of these compounds have been examined in rats and woodchucks, animals known to be susceptible to the toxic effects of other modified pyrimidines. Whether these nucleosides can be incorporated into DNA in vivo has not been established. These studies report the development of methodologies and the results of studies designed to determine if and to what extent 2'-fluoropyrimidines are incorporated into tissue DNA following long-term treatment. Rats were dosed intravenously with either 2'-fluorouridine (2'-FU) or 2'-fluorocytidine (2'-FC) at doses of 5, 50, and 500 mg/kg/day for 90 days. Woodchucks were dosed intravenously with either 2'-FU or 2'-FC at doses of 0.75 or 7.5 mg/kg/day for 90 days. The amounts of 2'-FU or 2'-FC in DNA and RNA were quantified using newly developed LC/MS/MS methodologies. Administration of 2'-FU to rats and woodchucks resulted in incorporation of the compound into DNA from liver, spleen, testis, muscle, and kidney. Incorporation also occurred in RNA from rat liver (only tissue examined). Similarly, administration of 2'-FC to rats and woodchucks resulted in incorporation into liver DNA (only tissue examined). These data demonstrate that 2'-fluoropyrimidines are incorporated into DNA and RNA of various tissues of rats and woodchucks following long-term administration.

Development and implementation of an HIV/AIDS case management outcomes assessment programme.

The Case Management Section of the New York State Department of Health AIDS Institute coordinates the provision of case management services for people living with HIV/AIDS throughout the state. The Community Follow-Up Program (CFP), providing intensive case management for HIV-positive individuals and their families, operates under the auspices of the Case Management Section. This article focuses on a public/private outcomes assessment partnership, sponsored by the Case Management Section, and developed in conjunction with a team of CFP programme managers from across the state. The process used to develop outcome indicators and measures is described; challenges encountered along the way are detailed; and suggestions for other public/private partnerships are outlined. Results from two years of outcomes data collection are also presented. The article concludes that the inclusion of providers in the identification and measurement of desired outcomes can help overcome provider resistance to outcomes assessment and can help ensure that outcomes data are used to improve programme performance.

Outcomes of HIV/AIDS case management in New York.

The purpose of this study was to examine HIV case management (CM) outcomes in New York State. The results presented here are part of a larger study that explored: client needs identified during CM, success in arranging needs, other case managers used by the client, coordination between multiple case managers, client satisfaction with CM, and the correlation between health care costs and CM. This paper focuses on the linkage of clients with services. Twenty-eight agencies and 588 clients participated in the study. Each client's chart was reviewed; clients and case managers were interviewed. Almost 9,000 client needs were identified; 79.3% of these needs were for services. Over 72% of needed services were arranged for clients. However, of the services arranged, 12.9% were never utilized. Success in arranging services did not vary based on client demographics; client utilization of services, once arranged, varied based on only one demographic factor (clients who lived outside of New York City had higher utilization rates than those who lived in the city, p < or = 0.05). Services provided directly by the CM agency were arranged and utilized more frequently than services provided by another agency (p < or = 0.05). Medical needs were arranged and utilized at a higher rate-and legal needs at a lower rate-than other services, regardless of where the service was provided (p < or = 0.05). On average it took 2.3 months to arrange a service; however it took less time to arrange medical services and more time to arrange legal services (p < or = 0.05). Females, individuals whose mode of HIV transmission was heterosexual contact, clients whose children were living with them, the inadequately housed, and those without a high school diploma had significantly more needs than other clients (p < or = 0.05). Our study supports CM models that provide intensive services to women with children; the provision of multiple services, in addition to CM, within a single agency; and the need for case manager training on how to work with clients to increase service utilization.

Cultural analysis of an organ procurement organization.

Organ procurement organizations are a critical link in the acquisition, placement, and transport of human organs for transplantation. Employed within the organ procurement organizations are organ transplant coordinators and support staff who constitute the front line in the challenge to diminish the gap between the supply and demand for organs. Responsibilities are emotionally and physiologically demanding as employees regularly face death and grieving families with empathy and commitment. This study describes and interprets dominant themes embedded in the culture of one such organ procurement organization, geographically located in northeastern United States. The authors used ethnographic research methods to understand the shared meaning system of the members of this organization. Identified themes included coping and sharing, conflicting priorities and uncertainty, and mission and reward. The influence of each theme on the organization is discussed with prescriptive implications for managerial practice.

Primary pulmonary hypertension.

Primary pulmonary hypertension (PPH) is a condition characterized by sustained elevation of pulmonary artery pressure (PAP) without demonstrable cause. The most common symptom at presentation is dyspnea. Other complaints include fatigue, chest pain, syncope, leg edema, and palpitations. Right heart catheterization is diagnostic, showing a mean PAP >25 mmHg at rest and >30 mmHg during exercise, with a normal pulmonary capillary wedge pressure. In the National Institutes of Health-PPH registry, the median survival period was 2.8 years. Treatment is aimed at lowering PAP, increasing cardiac output, and decreasing in situ thrombosis. Vasodilators have been used with some success in the treatment of PPH. They include prostacyclin, calcium-channel blockers, nitric oxide and adenosine. Anticoagulation has also been advised for the prevention of deep vein thrombosis, pulmonary embolism, and in situ thromboses of the lungs. New drug treatments under investigation include L-arginine, plasma endothelin-I, and bosentan. Use of oxygen, digoxin, and diuretics for symptomatic relief have also been recommended. Patients with severe PPH refractory to medical management should be considered for surgery.

Hospitals' vertical integration into skilled nursing: a rational approach to controlling transaction costs.

Using 1985 and 1988 American Hospital Association data, this study examines 1,523 hospitals nationwide and concludes that hospitals' ownership of skilled nursing facilities helps minimize the transaction costs associated with post-acute patient transfers while productively using empty hospital beds. Unfortunately, such ownership creates complex cost, quality, and accessibility trade-offs in terms of the skilled nursing care provided.

Predictors of California nursing facilities' acceptance of people with HIV/AIDS.

OBJECTIVE: To examine factors that might predict the provision of HIV/AIDS care among California nursing facilities (NFs) in 1990. STUDY DESIGN: Logistic regression to examine the probability that a NF had admitted a person with AIDS/HIV (PWA/H). Independent variables of key interest included whether the facility was hospital-based; whether it sustained a financial loss in FY 1990; whether it had a hospice; the percentage of its residents on Medicare; the percentage of its residents on MediCal; the number of PWA/Hs per elderly in the county where the facility was located; the ratio of home-based hospices to elderly in the county; and the ratio of NF beds to elderly in the county. DATA COLLECTION METHODS: Data on all California NFs, obtained from the Office of Statewide Health Planning and Development (OSHPD), were merged with state data on the cumulative incidence of AIDS cases by county; U.S. census data on the number of elderly by county; and home-based hospice data from the 1990 Case Management Resource Guide for California. PRINCIPAL FINDINGS: Of the 902 facilities examined, 7.65 percent served AIDS residents. The financial loss variable was not significant. The community-based hospice variable was significant and negative. All other key variables were significant and positive. CONCLUSIONS: This study (1) suggests that NFs respond to external pressures to provide AIDS care even in the absence of financial incentives or a positive financial margin; (2) supports concerns that competition may exist between the elderly and PWA/H for NF beds; (3) shows that NFs are less likely to provide care if substitute services are available; and (4) demonstrates that facilities capable of providing a higher level of clinical and psychosocial care may be particularly willing, perhaps able, to provide AIDS care.