Cynthia A. Loveland Cook

The effects of travel barriers and age on the utilization of alcoholism treatment aftercare

OBJECTIVE The objective of this research was to ascertain whether geographical accessibility (in conjunction with other patient characteristics) reduced the probability of participating in alcoholism aftercare treatment. METHODS A sample of 4,621 United States male veterans discharged with an outpatient appointment from one of 33 Department of Veterans Affairs inpatient Alcohol Dependency Treatment Programs was identified. The outpatient records of each patient were obtained to determine whether aftercare services were utilized following discharge. Binary choice analysis was used to model the decision to enter aftercare treatment as a function of travel distance, age, marital status, ethnicity, severity of illness, and urbanization. RESULTS Travel barriers significantly reduced aftercare participation, especially for elderly and rural veterans. Both younger and older veterans were less likely to keep their aftercare appointment than middle-aged veterans. Married patients were more likely to utilize outpatient services than unmarried patients. Ethnic status, severity of illness, and urban size all negatively affected the likelihood of appointment attendance. CONCLUSIONS The results obtained from this analysis can be effectively used to identify which patients are not likely to enter aftercare alcoholism treatment. The discharge plans of patients at risk for appointment noncompliance should be given special attention since aftercare has been shown to improve treatment outcome. Moreover, because alcoholism treatment reduces the utilization of other medical services, promoting continuity of care should help lower the overall costs of providing health care to alcoholic patients.

Risk factors for AMA discharge from VA inpatient alcoholism treatment programs

This study was designed to identify those risk factors associated with discharge from inpatient alcoholism treatment against medical advice (AMA) and the underlying reasons for these discharges. Data on the characteristics of patients and their index hospitalization were obtained from the systematic review of medical records for 186 alcoholics who were discharged AMA and 201 alcoholics who completed treatment. Comorbid medical diagnosis reduced the risk of AMA discharge by one quarter, whereas court referral to treatment reduced the risk by one half. A college education, vocational or other training, being employed, and having a history of previous AMA discharges significantly increased the risk. The most common reasons for AMA discharge, as perceived by treatment providers, were psychosocial problems, difficulties in the treatment program, and lack of interest in treatment. The clinical implications of these findings for the inpatient treatment of alcoholics are discussed.

Radiation Exposure and Cost Influence Physician Medical Image Decision Making A Randomized Controlled Trial

Background: It is estimated that 20%–40% of advanced medical imaging in the United States is unnecessary, resulting in patient overexposure to radiation and increasing the cost of care. Previous imaging utilization studies have focused on clinical appropriateness. An important contributor to excessive use of advanced imaging may be a physician “knowledge gap” regarding the safety and cost of the tests. Objectives: To determine whether safety and cost information will change physician medical image decision making. Research Design: Double-blinded, randomized controlled trial. Following standardized case presentation, physicians made an initial imaging choice. This was followed by the presentation of guidelines, radiation exposure and health risk, and cost information. Results: Approximately half (57 of 112, 50.9%) of participants initially selected computed tomography (CT). When presented with guideline recommendations, participants did not modify their initial imaging choice (P=0.197). A significant reduction (56.3%, P<0.001) in CT ordering occurred after presentation of radiation exposure/health risk information; ordering changed to magnetic resonance imaging or ultrasound (US). A significant reduction (48.3%, P<0.001) in CT and magnetic resonance imaging ordering occurred after presentation of Medicare reimbursement information; ordering changed to US. The majority of physicians (31 of 40, 77.5%) selecting US never modified their ordering. No significant relationship between physician demographics and decision making was observed. Conclusions: This study suggests that physician decision making can be influenced by safety and cost information and the order in which information is provided to physicians can affect their decisions.

Complementary alternative medicine in health and mental health: implications for social work practice.

ABSTRACT This article describes the increasing use of complementary alternative medicine (CAM) in this country and its implications for social work practice, education, research and policy in the health care field. Descriptive examples of CAM treatment modalities are provided along with their underlying rationale, common uses and available empirical support. It is concluded that patients will be better served by social workers who have knowledge of CAM treatment modalities. Furthermore, the need for further research on the efficacy of many CAM treatments and the certification of CAM treatment providers is discussed.

A randomized trial of two quality improvement strategies implemented in a statewide public community-based, long-term care program.

Background. It has not been demonstrated that the implementation of computerized quality improvement strategies can improve client-centered outcomes in public community based, long-term care (CBLTC) programs. Objectives. To test and evaluate 2 innovative computer-assisted, client-centered quality improvement strategies for public community-based, long-term care. The first strategy, the Normative Treatment Planning (NTP) program, assesses needs, prescribes services, and evaluates outcomes. The second strategy, the Client Feedback System (CFS) program, provides service vendors with feedback on client perceptions of services. Research Design. A 2 × 2 factorial design with the 2 strategies using cluster randomization. Subjects. A total of 2222 clients (86% of eligible program clients) enrolled in Indiana’s state case management program and/or the Medicaid home and community-based services waiver program for the aged and disabled as of January 1, 1995. Measures. Outcomes of needs met and client satisfaction were measured through telephone surveys every 6 months for 2 years. Results. A total of 1006 participants (45%) completed the 2-year evaluation study. For the group using only the NTP program, perception of needs met and client satisfaction were significantly better than the control group over the 2 years. During this period, the group using only the CFS program had significantly better client satisfaction than the control group. However, the effect sizes of the significant differences were small, and no statistically significant effects were found for the group using both programs. Conclusions. Client-centered quality improvement strategies can be implemented to enable public CBLTC programs to meet client needs better and increase client satisfaction.

Practicing social justice: Community-based research, education, and practice

Summary The Center for Social Justice Research and Education at Saint Louis University has implemented a model of collaborative research and education among social work practitioners, university faculty and students. The partnerships promote creative practice of social justice in the community. Social workers in community agencies articulate the relevant practice problems for students and faculty; faculty offer methodological and resource assistance to practitioners; students learn social justice best at the intersection of the perspectives of university and community. Steps in the implementation of the model and examples of the collaboration are described.

Complementary Alternative Medicine: Implications for Family Therapy

This article considers the fit between family therapy and complementary alternative medicine (CAM). Descriptions of and research results on a variety of CAM practices are provided, as are implications for practice, education, research, and policy. It is concluded that the two fields mesh easily and that clients might be better served if their therapists had knowledge of CAM. At the same time, therapists are cautioned regarding the need for both further study and appropriate regulation of alternative practices.

Collaborative QI in Community-Based Long Term Care

BACKGROUND In a statewide demonstration project funded by The Robert Wood Johnson Foundation, the state of Indiana, vendors, clients and Indiana University researchers began working together in 1992 to use quality improvement (QI) techniques to improve the delivery of community-based long term care services. QI STRATEGIES: These collaborators, working with state Area Agencies on Aging (AAAs) case managers, are implementing two strategies--Normative Treatment Planning (NTP), which standardizes the clinical assessment of client needs and the prescription of services by case managers, and the Client Feedback System (CFS), a systematic method for obtaining feedback from long term care clients on the quality of in-home services. CURRENT STATUS This community-based long term care project has been implemented in AAAs throughout the state of Indiana. In January 1995 the states 16 AAAs were randomly assigned to four experimental or control groups to assess the projects effectiveness. In the interim, clients are surveyed by telephone every six months to evaluate their satisfaction with services and clinical needs. LESSONS LEARNED The experience suggests several lessons: (1) build on existing and successful activities; (2) involve a wide range of participants, not just innovators; (3) obtain buy-in from trade and professional associations that represent program participants; (4) turn national attention given to the program into an asset; (5) conduct separate data collection to evaluate an interventions success; (6) visit the field often; (7) pay as much attention to program implementation as to development; and (8) provide ongoing, informal educational opportunities for the field. SUMMARY AND CONCLUSIONS This project has resulted in significant movement toward a shared quality improvement vocabulary, information system, and a shared vision of high-quality home care.

Relationship Between Alcoholism Treatment and Health Care Utilization

The cost of health care for alcoholism continues to be extremely high, both for direct treatment of the disease, such as detoxification and rehabilitation services, and for care of alcohol-related illnesses, such as liver cirrhosis and accidents. In 1985 alone, the direct health care costs for alcohol abuse, including hospital and nursing home care, physician and other professional services, and prescription drugs, amounted to

Youth who murder and societal responsibility: An issue of social justice

6.8 billion, of which