Value-Based Integrated Case Management at Payor Level: Implementation and Impact.

PURPOSE OF STUDY: Case management is an ideal service for patients with health complexity. However, most case management models do not integrate medical and behavioral health training and interventions, and there are little data evaluating these models in privately insured populations. The purpose of this study was to evaluate impact of an integrated case management (ICM) service at the payor level. PRIMARY PRACTICE SETTING: Health care insurance company. METHODOLOGY AND SAMPLE: A multimethod observational study was conducted at a health care insurance company in the Pacific Northwest of the United States. We conducted focus groups of case managers, leaders, and administrators and statistical analyses of outcomes data. Measures included care quality data (discharge follow-up appointment, cost per case, depression and anxiety measures, customer experience and satisfaction, and audit scores) of members receiving ICM services and employee focus group data (acceptability, adoption, feasibility, appropriateness, fidelity, and sustainability) related to the practice of ICM. RESULTS: Care quality data suggest ICM reduces mental health symptoms and increases discharge follow-up appointments for members. Implementation challenges include new employee orientation to ICM model, traditional views of case management, performance evaluation, documentation, and information technology. Facilitators of implementation include training, autonomy, and leadership support. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Organizations should be aware both of the benefits and challenges related to implementing ICM. Open communication between case managers and leadership and an improvement-focused culture appear to be important elements of implementation success. Future research should examine the perspective of members receiving ICM services and the implementation of ICM into health care delivery systems.

Health needs of accompanied refugee and asylum-seeking children in a UK specialist clinic.

AIM: To identify health needs and healthcare access barriers of accompanied refugee and asylum-seeking (RAS) children in the North East of England, and pilot a new service model to address these. METHODS: Mixed-methods study (retrospective analysis of routinely collected service data, qualitative data from focus groups) of children who attended a hospital-based specialist clinic. RESULTS: Over two years, 80 children were referred to this service. Most frequent diagnoses (total n = 104) were anaemia (n = 17), neurodevelopmental (n = 12), respiratory (n = 12) and mental health (n = 9) conditions. Mild-moderate stunting (23%), overweight and obesity (41%), stunting with obesity (9%) and micronutrient deficiencies (vitamin D (66%), vitamin A (40%) and manifest (14%) or latent (25%) iron deficiency anaemia) were highly prevalent. 62% of children had experienced psychological trauma, and 39% had abnormal results in psychosocial wellbeing screening. 21% of children required secondary or tertiary care, 8% mental health referrals, and 47% were followed up in this specialist clinic. Focus groups with families and the community report unaddressed health needs and substantial barriers of access to health care. CONCLUSION: Refugee and asylum-seeking children have substantial health needs and healthcare access barriers that are not routinely addressed. The authors propose a service model for healthcare provision.

Patients' Experiences of Deciding Whether or Not to Accept Bone Conduction Hearing Implants: A Qualitative Investigation.

OBJECTIVES: Bone conduction hearing implants (BCHIs) are an effective option to rehabilitate hearing for people who cannot use conventional, air conduction hearing aids. However, the uptake of such devices in the United Kingdom is lower than might be expected, and the reasons for this are not fully understood. The present study used qualitative methods to explore decision-making about whether to accept or reject BCHIs. DESIGN: Semistructured telephone interviews were conducted with 17 BCHI candidates who had recently accepted or rejected BCHIs. RESULTS: A thematic analysis identified four overarching themes: participants wanted to look and feel normal; potential risks were weighed against rewards; participants felt that there was a "right time" to have a BCHI; and information from clinicians and BCHI users was treated differently. Participants' perceptions of normality were influential in the final decision, and the BHCI was seen either as a barrier or facilitator of this. Participants consistently weighed up potential advantages and disadvantages of BCHIs, with potential for hearing improvement typically used as a benchmark against which other factors were measured. Some participants who rejected BCHIs felt that they could reconsider having a BCHI when they felt the time was right for them. Participants highly valued advice from clinicians, but felt that their expertise lacked validity as clinicians typically did not have experience of using BCHIs themselves. CONCLUSIONS: The decision to accept or reject a BCHI was highly individual. Each participant considered a range of factors; the influence of each factor depended on the individual's perceptions and experiences. This work highlights the importance of clinical staff being able to explore the individual priorities and concerns of each patient to ensure that patients feel happy and confident with the decision that they make.

Adverse childhood experiences, childhood relationships and associated substance use and mental health in young Europeans.

BACKGROUND: Adverse childhood experiences (ACEs) can increase risks of health-harming behaviours and poor health throughout life. While increases in risk may be affected by resilience resources such as supportive childhood relationships, to date few studies have explored these effects. METHODS: We combined data from cross-sectional ACE studies among young adults (n = 14 661) in educational institutions in 10 European countries. Nine ACE types, childhood relationships and six health outcomes (early alcohol initiation, problem alcohol use, smoking, drug use, therapy, suicide attempt) were explored. Multivariate modelling estimated relationships between ACE counts, supportive childhood relationships and health outcomes. RESULTS: Almost half (46.2%) of participants reported ≥1 ACE and 5.6% reported ≥4 ACEs. Risks of all outcomes increased with ACE count. In individuals with ≥4 ACEs (vs. 0 ACEs), adjusted odds ratios ranged from 2.01 (95% CIs: 1.70-2.38) for smoking to 17.68 (95% CIs: 12.93-24.17) for suicide attempt. Supportive childhood relationships were independently associated with moderating risks of smoking, problem alcohol use, therapy and suicide attempt. In those with ≥4 ACEs, adjusted proportions reporting suicide attempt reduced from 23% with low supportive childhood relationships to 13% with higher support. Equivalent reductions were 25% to 20% for therapy, 23% to 17% for problem drinking and 34% to 32% for smoking. CONCLUSIONS: ACEs are strongly associated with substance use and mental illness. Harmful relationships are moderated by resilience factors such as supportive childhood relationships. Whilst ACEs continue to affect many children, better prevention measures and interventions that enhance resilience to the life-long impacts of toxic childhood stress are required.

Evaluating the effectiveness and reliability of the Vibrant Soundbridge and Bonebridge auditory implants in clinical practice: Study design and methods for a multi-centre longitudinal observational study.

BACKGROUND: The Vibrant Soundbridge middle ear implant and the Bonebridge bone conducting hearing device are hearing implants that use radio frequency transmission to send information from the sound processor to the internal transducer. This reduces the risk of skin problems and infection but requires a more involved surgical procedure than competitor skin penetrating devices. It is not known whether more complex surgery will lead to additional complications. There is little information available on the reliability of these systems and adverse medical or surgical events. The primary research question is to determine the reliability and complication rate for the Vibrant Soundbridge and Bonebridge. The secondary research question explores changes in quality of life following implantation of the devices. The tertiary research question looks at effectiveness via changes in auditory performance. METHOD: The study was designed based on a combination of a literature search, two clinician focus groups and expert review.A multi-centre longitudinal observational study was designed. There are three study groups, two will have been implanted prior to the start of the study and one group, the prospective group, will be implanted after initiation of the study. Outcomes are surgical questionnaires, measures of quality of life, user satisfaction and speech perception tests in quiet and in noise. CONCLUSION: This is the first multi-centre study to look at these interventions and includes follow up over time to understand effectiveness, reliability, quality of life and complications.

Inpatient infliximab is ineffective at preventing colectomy for steroid refractory extensive colitis.

BACKGROUND: Despite data suggesting safety and efficacy in ulcerative colitis patients treated with inpatient infliximab, prior studies did not focus on patients with extensive colitis, the group at highest risk for requiring surgery. METHODS: This was a single center, retrospective study (2008-2015) of consecutive patients who required admission because of severe extensive ulcerative colitis defined by preoperative symptoms and computed tomography scans and postoperative histology. Patients admitted for high-dose steroids were compared with steroid refractory inpatients provided with one or two infusions of infliximab. The primary study outcome was colectomy rates; secondary outcomes included mean length of stay and 60-d complication rates. RESULTS: A total of 174 patients required admission with steroids for extensive ulcerative colitis. Of these, 19 (10%) also received infliximab. Among the subjects treated with infliximab, 15 (78%) required total colectomy during that admission versus 81 (52%) who received steroids alone (P = 0.03). Postoperative readmission rates, surgical-site infections, return to the operating room, and all-complication rates were similar between the cohorts (P > 0.05). CONCLUSIONS: For steroid refractory extensive ulcerative colitis, inpatient infliximab did not lower colectomy rates or increase postoperative complications compared with patients treated with steroids alone.

Update on medical and surgical options for patients with acute severe ulcerative colitis: What is new?

Acute severe ulcerative colitis (UC) is a highly morbid condition that requires both medical and surgical management through the collaboration of gastroenterologists and colorectal surgeons. First line treatment for patients presenting with acute severe UC consists of intravenous steroids, but those who do not respond require escalation of therapy or emergent colectomy. The mortality of emergent colectomy has declined significantly in recent decades, but due to the morbidity of this procedure, second line agents such as cyclosporine and infliximab have been used as salvage therapy in an attempt to avoid emergent surgery. Unfortunately, protracted medical therapy has led to patients presenting for surgery in a poorer state of health leading to poorer post-operative outcomes. In this era of multiple medical modalities available in the treatment of acute severe UC, physicians must consider the advantages and disadvantages of prolonged medical therapy in an attempt to avoid surgery. Colectomy remains a mainstay in the treatment of severe ulcerative colitis not responsive to corticosteroids and rescue therapy, and timely referral for surgery allows for improved post-operative outcomes with lower risk of sepsis and improved patient survival. Options for reconstructive surgery include three-stage ileal pouch-anal anastomosis or a modified two-stage procedure that can be performed either open or laparoscopically. The numerous avenues of medical and surgical therapy have allowed for great advances in the treatment of patients with UC. In this era of options, it is important to maintain a global view, utilize biologic therapy when indicated, and then maintain an appropriate threshold for surgery. The purpose of this review is to summarize the growing number of medical and surgical options available in the treatment of acute, severe UC.

Predicting body appreciation in young women: An integrated model of positive body image.

This study examined a range of predictors, based on previous theoretical models, of positive body image in young adult women. Participants were 266 women who completed an online questionnaire measuring body appreciation, activity participation, media consumption, perceived body acceptance by others, self-compassion, and autonomy. Potential mechanisms in predicting body appreciation assessed were self-objectification, social appearance comparison, and thin-ideal internalisation. Results indicated that greater perceived body acceptance by others and self-compassion, and lower appearance media consumption, self-objectification, social comparison, and thin-ideal internalisation were related to greater body appreciation. An integrated model showed that appearance media (negatively) and non-appearance media and self-compassion (positively) were associated with lower self-objectification, social comparison, and thin-ideal internalisation, which in turn related to greater body appreciation. Additionally, perceived body acceptance by others was directly associated with body appreciation. The results contribute to an understanding of potential pathways of positive body image development, thereby highlighting possible intervention targets.

Predictors and health-related outcomes of positive body image in adolescent girls: A prospective study.

This study aimed to investigate prospective predictors and health-related outcomes of positive body image in adolescent girls. In so doing, the modified acceptance model of intuitive eating was also examined longitudinally. A sample of 298 girls aged 12 to 16 years completed a questionnaire containing measures of body appreciation, potential predictors, and a range of health outcomes, at 2 time points separated by 1 year. Longitudinal change regression models showed that perceived body acceptance by others (positively), self-objectification and social comparison (negatively), and body appreciation (positively) prospectively predicted intuitive eating 1 year later, consistent with the acceptance model of intuitive eating. Perceived body acceptance by others was the only proposed predictor to prospectively predict an increase in body appreciation over time. Time 1 body appreciation prospectively predicted a decrease in dieting, alcohol, and cigarette use, and an increase in physical activity 1 year later. In particular, girls with low body appreciation were more likely than girls with high body appreciation to take up alcohol and cigarette use between time points. The results highlight body appreciation as an important target for interventions designed to prevent or delay the uptake of alcohol and cigarette consumption among girls. More broadly, they suggest that a positive body image can confer considerable benefit for adolescent girls.

Positive body image and young women's health: Implications for sun protection, cancer screening, weight loss and alcohol consumption behaviours.

This study examined the link between positive body image and a range of health behaviours. Participants were 256 women who completed an online questionnaire measuring body appreciation, body dissatisfaction, sun protection, cancer screening, seeking medical attention, weight-loss behaviour and alcohol and tobacco consumption. Results indicated that body appreciation was positively related to sun protection, skin screening and seeking medical attention and negatively related to weight-loss behaviour. Body appreciation explained unique variance, over and above body dissatisfaction, in sun protection, skin screening and weight-loss behaviour. These results have implications for interventions to improve adherence to health behaviours.

The protective role of body appreciation against media-induced body dissatisfaction.

This study aimed to examine the protective role of positive body image against negative effects produced by viewing thin-idealised media. University women (N=68) completed trait measures of body appreciation and media protective strategies. At a subsequent session, participants viewed 11 thin-ideal advertisements. Body dissatisfaction was assessed before and after advertisement exposure, and state measures of self-objectification, appearance comparison, and media protective strategies were completed. Results indicated that body appreciation predicted less change in body dissatisfaction following exposure, such that participants with low body appreciation experienced increased body dissatisfaction, while those with high body appreciation did not. Although state appearance comparison predicted increased body dissatisfaction, neither state self-objectification nor appearance comparison accounted for body appreciation's protective effect. Trait and state media protective strategies positively correlated with body appreciation, but also did not account for body appreciation's protective effect. The results point to intervention targets and highlight future research directions.

Predictors of intuitive eating in adolescent girls.

PURPOSE: To examine proposed predictors of intuitive eating, including social appearance comparison, and to test a modified acceptance model of intuitive eating in adolescent girls. METHODS: Participants were 400 adolescent girls aged 12-16 years who completed measures of body acceptance by others, self-objectification, social appearance comparison, body appreciation, and intuitive eating. RESULTS: Correlations showed that all proposed predictors were related to intuitive eating in the expected direction. In particular, social appearance comparison was negatively related to body appreciation and intuitive eating. After controlling for other predictors, social appearance comparison was shown to explain unique variance in intuitive eating. Using structural equation modeling, an integrated modified acceptance model of intuitive eating yielded an overall good fit to the data. Mediation analyses showed that there was a significant indirect effect of body acceptance by others on both body appreciation and intuitive eating through social appearance comparison and self-objectification. CONCLUSIONS: The findings extend the acceptance model of intuitive eating to adolescent girls but also identify social comparison as an important mechanism in this process. Practically, the findings highlight several areas that may be targeted to foster adaptive eating patterns in girls.

The role of skin trauma in the distribution of morphea lesions: a cross-sectional survey of the Morphea in Adults and Children cohort IV.

BACKGROUND: Skin trauma may play a role in the development of morphea lesions. The association between trauma and the distribution of cutaneous lesions has never been examined to our knowledge. OBJECTIVE: We sought to determine whether patients enrolled in the Morphea in Adults and Children (MAC) cohort exhibit skin lesions distributed in areas of prior (isotopic) or ongoing (isomorphic) trauma. METHODS: This was a cross-sectional analysis of the MAC cohort. RESULTS: Of 329 patients in the MAC cohort, 52 (16%) had trauma-associated lesions at the onset of disease. Patients with lesions in an isotopic distribution had greater clinical severity as measured by a clinical outcome measure (mean modified Rodnan Skin Score of 13.8 vs 5.3, P = .004, 95% confidence interval 3.08-13.92) and impact on life quality (mean Dermatology Life Quality Index score 8.4 vs 4.1, P = .009, 95% confidence interval 1.18-7.50) than those with an isomorphic distribution. Most frequent associated traumas were chronic friction (isomorphic) and surgery/isotopic. LIMITATIONS: Recall bias for patient-reported events is a limitation. CONCLUSION: Of patients in the MAC cohort, 16% developed initial morphea lesions at sites of skin trauma. If these findings can be confirmed in additional series, they suggest that elective procedures and excessive skin trauma or friction might be avoided in these patients.

Alcohol and young people: what the legislation says about access and secondary supply.

ISSUE: The rationale and potential impact of Australia's recent legislative changes regulating secondary supply of alcohol to minors, particularly on private premises. APPROACH: An examination of similarities and differences between state and territory liquor licensing legislation regulating secondary supply of alcohol to minors was undertaken. KEY FINDINGS: The Northern Territory, New South Wales, Queensland, Tasmania and Victoria prohibit supply of alcohol to minors on private premises, except by parents/guardians/authorised persons. Northern Territory, Queensland and Tasmanian legislation also prescribes that supply must occur responsibly and under supervision. Elsewhere, alcohol supply to minors on private premises is unregulated. These legislative changes reflect the 'familialisation' of adolescent drinking. IMPLICATIONS: Recent legislative amendments regulating secondary supply on private premises may indicate growing awareness of adolescent alcohol-related harms and signal a shift in community norms. However, sociocultural factors, misunderstanding and challenges in enforcing the legislation may limit compliance. CONCLUSIONS: Changes in secondary supply legislation need effective dissemination as divergence between states and territories may result in confusion about legal responsibilities. A national approach may be warranted to help set community boundaries for young people's drinking.

A pilot study to investigate the efficacy of tobramycin-dexamethasone ointment in promoting wound healing.

INTRODUCTION: The standard postsurgical treatment of wounds after dermatologic procedures is currently limited. Topical corticosteroids have been used successfully in postoperative management of ophthalmologic surgeries that involve the skin of the eyelid. In particular, tobramycin 0.3%/dexamethasone 0.1% ophthalmic ointment is considered the "gold standard" of steroid-antibiotic fixed combinations and is marketed worldwide as an agent used to control postsurgical inflammation and prevent postsurgical infection. The purpose of this study is to evaluate both the efficacy and safety of tobramycin-dexamethasone ointment for the postsurgical management of Mohs or dermatologic surgery in comparison to white petrolatum. METHODS: The authors employed a half-scar study in which patients who underwent skin cancer removal surgery were given tobramycin-dexamethasone ointment and white petrolatum to apply to each half of their wound for 2 weeks. The study was double blinded, and physicians and the patients independently evaluated the scars for cosmetic appearance at 2 and 6 weeks postoperatively. The evaluation criteria included judging which side of the wound looked better based on color, thickness, and discomfort. RESULTS: Eighteen patients were enrolled, of which 13 patients completed the three phases of the study. After 6 weeks the wounds did not show a statistically significant difference in color, thickness, or discomfort on either side. CONCLUSION: Results obtained to date suggest that the application of tobramycin-dexamethasone ointment to wounds after dermatologic surgery does not promote better wound healing than white petrolatum. These findings indicate that a topical steroid and antibiotic ointment may not be an effective intervention in improving postoperative outcomes in dermatologic surgeries.

Clothing choices, weight, and trait self-objectification.

The present study aimed to assess the link between clothing choice and aspects of body image. Participants were 112 female undergraduate students who completed a questionnaire containing a measure of clothing functions, as well as BMI, self-classified weight, and trait self-objectification. Results indicated that BMI and self-classified weight were positively correlated with the choice of clothes for camouflage. Self-objectification was positively correlated with choice of clothes for fashion, and negatively correlated with choosing clothes for comfort. It was concluded that clothing represents an important but neglected aspect of contemporary women's management of their body's appearance.