Social health maintenance organizations' service use and costs, 1985-89

Presented in this article are aggregate utilization and financial data from the four social health maintenance organization (S/HMO) demonstrations that were collected and analyzed as a part of the national evaluation of the S/HMO demonstration project conducted for the Health Care Financing Administration. The S/HMOs, in offering a $6,500 to $12,000 chronic care benefit in addition to the basic HMO benefit package, had higher start up costs and financial losses over the first 5 years than expected, and controlling costs continues to be a challenge to the sites and their sponsors.     

Atraumatic joint and limb pain in the elderly

Patients who visit the emergency department often have complaints of joint and limb pain. The differential diagnosis, clinical presentation, and treatment choices can be vastly different in the young- or middle-aged population compared with the elderly population, and the concerns of each group must be addressed. The emergency physician is in a unique position in that they are frequently the first to see these individuals and have the opportunity to intervene before permanent disability ensues. Some of the more common etiologies of atraumatic joint and limb pain, including crystal deposition diseases such as gout and pseudogout, osteoarthritis, septic arthritis, and inflammatory arthritides such as rheumatoid arthritis will be addressed in this article. In addition,several arthritides specific to the elderly population such as poly-myalgia rheumatica and associated giant cell arteritis will be covered. Finally a discussion of cervical and lumbar disc disease, as well as gait disorders, and their impact on the elderly, will be presented.     

Variation by disability in state predictors of Medicaid 1915c waiver use and expenditures

PURPOSE: States are increasingly using the Medicaid 1915c waiver program to provide community-based long-term care. A substantially greater share of long-term-care dollars supports community-based care for individuals with intellectual and developmental disabilities, relative to older and working-age persons with primarily physical disabilities. DESIGN AND METHODS: We used state-level data for the period from 1992 to 2001 to estimate fixed-effects panel models. We compared state predictors of waiver utilization and expenditures for waivers serving both older and working-age individuals (O/WAIs) relative to waivers serving individuals with intellectual and developmental disabilities (IDDs). RESULTS: We found community-based-care capacity to predict use and expenditures for both target groups. Although regulation of institutional supply was positively related to expenditure measures for IDDs, it was not related to use or expenditures for O/WAIs. Demand variables (e.g., the size of a state's African American population) predicted use and expenditures for IDD waivers, but they were less consistent for O/WAI waivers. State resources were a robust predictor of use and expenditures for both groups. IMPLICATIONS: Increased community-based-care capacity appears to be an important factor in efforts to expand the availability of Medicaid community-based care. Federal policies that address state resource issues may also spur growth in community-based long-term care.     

Maternal attributions and expressed emotion as predictors of attendance at parent management training

BACKGROUND: The effectiveness of parent management training (PMT) as a treatment for child behaviour problems is reduced by high attrition rates. One difficulty with engaging mothers is that, by definition, PMT is directed at the parent, yet many parents believe the cause of the problem lies within the child. Hence the model of therapy offered contradicts their understanding about the cause and nature of the problem. Moreover, the emotional consequence of holding child-responsibility causal attributions is associated with high expressed emotion (EE), a known predictor of poor compliance with therapy in other child psychiatric disorders. METHODS: Seventy-five consecutive referrals of mothers to a PMT programme were recruited. EE was assessed using the Camberwell Family Interview methodology. Spontaneous causal attributions about their child's problem behaviour were collected from the same interview material and independently coded using the Leeds Attributional Coding System. Attendance data at the PMT programme was collected following completion of programmes. RESULTS: Contrary to expectations, mothers who made child-responsibility attributions and were highly critical about their child's behaviour were no more likely than non-blaming, low EE parents to drop out prematurely from a course of PMT. However, expressing an understanding of their own role in managing their child's behaviour was predictive of attendance. Two factors were, however, more closely associated with greater attrition: having been offered a clinical diagnosis and being from a lower socio-economic family. CONCLUSIONS: Socio-economic factors should be viewed as barriers to uptake of services and successful strategies for increasing engagement of families are likely to be economical rather than psychological. However, although the causal attributions mothers make about their child's behaviour did not predict whether they were likely to attend PMT, an exploratory analysis found evidence to suggest that successful engagement with PMT begins early in the referral process and that referring clinicians should ensure treatment options are aligned with diagnoses provided.     

Assessment of sub-division of plantar pressure measurement in children

Methods for the measurement of plantar pressure are poorly defined particularly when describing sub-sections of the plantar surface of the foot in the presence of deformity. The aim of this study was to assess foot pressure measurement in healthy children, using an automatic technique of sub-area definition that has the potential for objective evaluation of treatment of foot deformity. Twelve healthy children were examined on three occasions. Plantar pressure data were collected and time synchronised with force plate and stereophotogrammetric data. The footprint was divided into five sub-sections by using the position of the markers on the foot at mid-stance projected onto the pressure footprint. Repeatability for peak pressure and peak force was assessed. Automatic sub-area definition based on marker placement was found to be reliable in healthy children. A comparison of results revealed that peak vertical force was a more consistent measure than peak pressure for each of the five sub-areas. This suggests that force may be a more appropriate measurement for outcome studies.