Kevin D. Frick

A Social Model for Health Promotion for an Aging Population: Initial Evidence on the Experience Corps Model

This report evaluates whether a program for older volunteers, designed for both benerativity and health promotion, leads to short-term improvements inmultiple behavioral risk factors and positive effects on intermediary risk factors for disability and other morbidities. The Experience Corps® places older volunteers in public elementary schools in roles designed to meet schools’ needs and increase the social, physical, and cognitive activity of the volunteers. This article reports on a pilot randomized trial in Baltimore, Maryland. The 128 volunteers were 60–86 years old; 95% were African American. At follow-up of 4–8 months, physical activity, strength, people one could turn to for help, and cognitive activity increased significantly, and walking speed decreased significantly less, in participants compared to controls. In this pilot trial, physical, cognitive, and social activity increased, suggesting the potential for the Experience Corps to improve health for an aging population and simultaneously improve educational outcomes for children.

A Behavioral Weight-Loss Intervention in Persons with Serious Mental Illness

BACKGROUND Overweight and obesity are epidemic among persons with serious mental illness, yet weight-loss trials systematically exclude this vulnerable population. Lifestyle interventions require adaptation in this group because psychiatric symptoms and cognitive impairment are highly prevalent. Our objective was to determine the effectiveness of an 18-month tailored behavioral weight-loss intervention in adults with serious mental illness. METHODS We recruited overweight or obese adults from 10 community psychiatric rehabilitation outpatient programs and randomly assigned them to an intervention or a control group. Participants in the intervention group received tailored group and individual weight-management sessions and group exercise sessions. Weight change was assessed at 6, 12, and 18 months. RESULTS Of 291 participants who underwent randomization, 58.1% had schizophrenia or a schizoaffective disorder, 22.0% had bipolar disorder, and 12.0% had major depression. At baseline, the mean body-mass index (the weight in kilograms divided by the square of the height in meters) was 36.3, and the mean weight was 102.7 kg (225.9 lb). Data on weight at 18 months were obtained from 279 participants. Weight loss in the intervention group increased progressively over the 18-month study period and differed significantly from the control group at each follow-up visit. At 18 months, the mean between-group difference in weight (change in intervention group minus change in control group) was -3.2 kg (-7.0 lb, P=0.002); 37.8% of the participants in the intervention group lost 5% or more of their initial weight, as compared with 22.7% of those in the control group (P=0.009). There were no significant between-group differences in adverse events. CONCLUSIONS A behavioral weight-loss intervention significantly reduced weight over a period of 18 months in overweight and obese adults with serious mental illness. Given the epidemic of obesity and weight-related disease among persons with serious mental illness, our findings support implementation of targeted behavioral weight-loss interventions in this high-risk population. (Funded by the National Institute of Mental Health; ACHIEVE ClinicalTrials.gov number, NCT00902694.).

Global vision impairment due to uncorrected presbyopia.

OBJECTIVES To evaluate the personal and community burdens of uncorrected presbyopia. METHODS We used multiple population-based surveys to estimate the global presbyopia prevalence, the spectacle coverage rate for presbyopia, and the community perception of vision impairment caused by uncorrected presbyopia. For planning purposes, the data were extrapolated for the future using population projections extracted from the International Data Base of the US Census Bureau. RESULTS It is estimated that there were 1.04 billion people globally with presbyopia in 2005, 517 million of whom had no spectacles or inadequate spectacles. Of these, 410 million were prevented from performing near tasks in the way they required. Vision impairment from uncorrected presbyopia predominantly exists (94%) in the developing world. CONCLUSIONS Uncorrected presbyopia causes widespread, avoidable vision impairment throughout the world. Alleviation of this problem requires a substantial increase in the number of personnel trained to deliver appropriate eye care together with the establishment of sustainable, affordable spectacle delivery systems in developing countries. In addition, given that people with presbyopia are at higher risk for permanently sight-threatening conditions such as glaucoma and diabetic eye disease, primary eye care should include refraction services as well as detection and appropriate referral for these and other such conditions.

A prospective evaluation of a protocol for magnetic resonance imaging of patients with implanted cardiac devices

BACKGROUND Magnetic resonance imaging (MRI) is avoided in most patients with implanted cardiac devices because of safety concerns. OBJECTIVE To define the safety of a protocol for MRI at the commonly used magnetic strength of 1.5 T in patients with implanted cardiac devices. DESIGN Prospective nonrandomized trial. (ClinicalTrials.gov registration number: NCT01130896) SETTING: One center in the United States (94% of examinations) and one in Israel. PATIENTS 438 patients with devices (54% with pacemakers and 46% with defibrillators) who underwent 555 MRI studies. INTERVENTION Pacing mode was changed to asynchronous for pacemaker-dependent patients and to demand for others. Tachyarrhythmia functions were disabled. Blood pressure, electrocardiography, oximetry, and symptoms were monitored by a nurse with experience in cardiac life support and device programming who had immediate backup from an electrophysiologist. MEASUREMENTS Activation or inhibition of pacing, symptoms, and device variables. RESULTS In 3 patients (0.7% [95% CI, 0% to 1.5%]), the device reverted to a transient back-up programming mode without long-term effects. Right ventricular (RV) sensing (median change, 0 mV [interquartile range {IQR}, -0.7 to 0 V]) and atrial and right and left ventricular lead impedances (median change, -2 Ω [IQR, -13 to 0 Ω], -4 Ω [IQR, -16 to 0 Ω], and -11 Ω [IQR, -40 to 0 Ω], respectively) were reduced immediately after MRI. At long-term follow-up (61% of patients), decreased RV sensing (median, 0 mV, [IQR, -1.1 to 0.3 mV]), decreased RV lead impedance (median, -3 Ω, [IQR, -29 to 15 Ω]), increased RV capture threshold (median, 0 V, IQR, [0 to 0.2 Ω]), and decreased battery voltage (median, -0.01 V, IQR, -0.04 to 0 V) were noted. The observed changes did not require device revision or reprogramming. LIMITATIONS Not all available cardiac devices have been tested. Long-term in-person or telephone follow-up was unavailable in 43 patients (10%), and some data were missing. Those with missing long-term capture threshold data had higher baseline right atrial and right ventricular capture thresholds and were more likely to have undergone thoracic imaging. Defibrillation threshold testing and random assignment to a control group were not performed. CONCLUSION With appropriate precautions, MRI can be done safely in patients with selected cardiac devices. Because changes in device variables and programming may occur, electrophysiologic monitoring during MRI is essential.

A Review of Health-Related Workplace Productivity Loss Instruments

The objective of this review was to identify health-related workplace productivity loss survey instruments, with particular emphasis on those that capture a metric suitable for direct translation into a monetary figure.A literature search using Medline, HealthSTAR, PsycINFO and Econlit databases between 1966 and 2002, and a telephone-administered survey of business leaders and researchers, were conducted to identify health-related workplace productivity measurement survey instruments. This review was conducted from the societal perspective. Each identified instrument was reviewed for the following: (i) reliability; (ii) content validity; (iii) construct validity; (iv) criterion validity; (v) productivity metric(s); (vi) instrument scoring technique; (vii) suitability for direct translation into a monetary figure; (viii) number of items; (ix) mode(s) of administration; and (x) disease state(s) in which it had been tested.Reliability and validity testing have been performed for 8 of the 11 identified surveys. Of the 11 instruments identified, six captured metrics that are suitable for direct translation into a monetary figure. Of those six, one instrument measured absenteeism, while the other five measured both absenteeism and presenteeism. All of the identified instruments except for one were available as paper, self-administered questionnaires and many were available in languages other than English.This review provides a comprehensive overview of the published, peerreviewed survey instruments available to measure health-related workplace productivity loss. As the field of productivity measurement matures, tools may be developed that will allow researchers to accurately calculate lost productivity costs when performing cost-effectiveness and cost-benefit analyses. Using data captured by these instruments, society and healthcare decision makers will be able to make better informed decisions concerning the value of the medications, disease management and health promotion programmes that individuals receive.

Hospital at Home: Feasibility and Outcomes of a Program To Provide Hospital-Level Care at Home for Acutely Ill Older Patients

Context Hospital care for older people often means iatrogenic complications and a decline in function. Home hospital care might reduce these adverse outcomes. Content Patients were 65 years of age or older and required hospital care for pneumonia, heart failure, chronic obstructive pulmonary disease, or cellulitis. In phase I, they were hospitalized. In phase II, they could choose home hospital care (continuous nursing care followed by at least daily visits from a nurse and a physician). Sixty percent of patients chose home hospital care. Patients who received this type of care had shorter stays; fewer procedures, consultations, and indwelling devices; less delirium; greater satisfaction; and similar functional outcomes. Cautions The study was nonrandomized, and data were missing. Conclusion Home hospital care may be a good alternative for selected patients. The Editors Although the acute care hospital is the standard venue for providing acute medical care, it is expensive and may be hazardous for older persons, who commonly experience functional decline, iatrogenic illness, and other adverse events during care (1-3). Providing acute hospital-level care in a patients home is an alternative to hospital care (4, 5). Although several hospital-at-home models have been studied, there is controversy regarding the effectiveness of this method. In part, this reflects heterogeneity among hospital-at-home models (6). A recent Cochrane review examined surgical and medical early hospital discharge models, terminal care, and admission avoidance, that is, substitutive models. Overall, no differences were found in health outcomes. Patients, but not caregivers, had increased satisfaction with hospital-at-home care, and there was some evidence that substitutive models may be cost-effective (7). However, with some exceptions (8), most of these models would be difficult to distinguish from augmented skilled nursing services, community-based long-term care, or home-based primary care services in the United States. In addition, most studies have been done in countries with single-payer national health insurance systems (7-14). Previous research in the United States has been limited to a pilot study of a physician-led substitutive hospital-at-home model for older persons with acute medical illness (15). The aim of our study was to evaluate the safety, efficacy, clinical and functional outcomes, patient and caregiver satisfaction, and costs of providing acute hospital-level care in a hospital at home that substituted entirely for admission to an acute care hospital for older persons. Methods Patients The target sample was community-dwelling persons, age 65 years and older, who lived in a catchment area and who, in the opinion of a physician not involved in the study, required admission to an acute care hospital for 1 of 4 target illnesses: community-acquired pneumonia, exacerbation of chronic heart failure, exacerbation of chronic obstructive pulmonary disease, or cellulitis. Patients were required to meet validated criteria of medical eligibility for hospital-at-home care (16), which were designed to identify patients who would be medically suitable for this type of treatment. The most common reasons for medical ineligibility were uncorrectable hypoxemia (oxygen saturation <90%), suspected myocardial ischemia, and presence of an acute illness, other than the target illness, for which the patient was required to be hospitalized. Study Design This study was a prospective quasi-experiment conducted in 2 consecutive 11-month phases. During the acute care hospital observation phase (1 November 1990 to 30 September 2001), eligible patients were identified and followed through usual hospital care. Study coordinators verified the patients eligibility for hospital-at-home care using a standard protocol at the time of enrollment. During this observation phase of the study, most patients were identified the morning after admission. These patients made up the acute hospital observation comparison group. During the intervention phase (1 November 2001 to 30 September 2002), eligible patients were identified at the time of admission and were offered the option of receiving their care in hospital at home rather than in the acute care hospital. Patients who chose hospital-at-home treatment were never admitted to the acute care hospital but received treatment, after initial evaluation (usually in the emergency department), in their home. The intervention group comprised all patients eligible for hospital-at-home care, irrespective of where they were treated. Approval The institutional review boards from each study site, the coordinating center, and officials at the Center for Health Plans and Providers at the Centers for Medicare & Medicaid Services (CMS) gave their approval for the study. All participants provided informed written consent. Study Sites The study was conducted in 3 Medicare managed care (Medicare + Choice) plans at 2 sites and at a Veterans Administration medical center. Univera Health and Independent Health, in Buffalo, New York, are Medicare + Choice plans that operate in an independent practice association model. These 2 plans collaborated to provide hospital-at-home care and made up 1 study site (site 1). The Fallon Health Care System (site 2), in Worcester, Massachusetts, operates a not-for-profit Medicare + Choice plan, and the Fallon Clinic, a for-profit multispecialty physician group, provides care on a capitated basis to Medicare + Choice beneficiaries. The Portland, Oregon, Veterans Administration Medical Center (site 3) is a quaternary care and teaching facility. Assessments Age, gender, and primary diagnosis were obtained for all eligible patients. Informed written consent was required for all additional data collection: medical record review, cost data review, and interviews. Staff trained at the coordinating center used standard procedures outlined in a detailed training manual to conduct all interviews, assessments, and medical record reviews. At baseline, interrater reliability was verified among the staff. Quality checks of medical record reviews were done midway through the study. Interrater reliability for ratings on the components of the daily patient interview was confirmed in 13 paired observations ( = 0.91). Interrater reliability among study sites was similar. Medical Record Reviews Medical records were abstracted by using a standardized instrument that captured illness acuity, health status, medication use, results of laboratory tests, treatments, the hospital course and complications, health outcomes, and whether treatment standards were met. Illness acuity was determined by using the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (17). Health status was measured by using clinical indicators appropriate to the diagnoses, a checklist of chronic medical conditions, and the Charlson comorbidity index (18). Medication use was defined as the number of prescribed medications taken on a daily basis at the time of admission. Diagnostic and therapeutic interventions were categorized as potentially difficult or not difficult to do in the home. The patients clinical course was characterized according to whether emergency situations (those that required physician evaluation within 30 minutes, such as the development of acute shortness of breath) or critical complications (death, transfer to intensive care setting, intubation, or myocardial infarction) occurred. Clinical care was examined with regard to completion of illness-specific standards of care (19-21). Eligible patients who consented to participate completed a baseline interview that included demographic information, self-reported health status, assessment of sleep, Katz activities (22), Lawton instrumental activities of daily living (23), continence, mobility, the Geriatric Depression Scale (24), Jaeger vision test, the Mini-Mental State Examination (MMSE) (25), the Digit Span Test (26), and evaluation by the Confusion Assessment Method (CAM) (27). Subsequently, patients were evaluated daily until discharge by using a structured interview consisting of the MMSE, Digit Span Test, and CAM rating. A family member, caregiver, or person who knew the patient well was interviewed at the time of admission to complete the modified Blessed Dementia Rating Scale (28). At 2 weeks after admission, patients and family members were interviewed by telephone to obtain the patients current functional status and to assess his or her satisfaction with care. Intervention: The Hospital-at-Home Model of Care The hospital-at-home model of care has been described previously (15). Briefly, a patient requiring admission to the acute care hospital for a target illness was identified in an emergency department or ambulatory site and his or her eligibility status was determined. Nonstudy medical personnel, usually emergency department physicians, made the decision to hospitalize the patient. All patients who were offered but who declined hospital-at-home care were admitted to the acute care hospital. After informed consent was obtained, the patient was transported home by an ambulance. Patients were evaluated by the hospital-at-home physician either in the emergency department or shortly after arriving at home. Patients who required oxygen therapy were sent home with a portable oxygen apparatus pending delivery of home oxygen therapy. The hospital-at-home nurse met the ambulance at the patients home. The patient had subsequent direct one-on-one nursing supervision for an initial period of at least 8 hours at site 3 and for a period of 24 hours at sites 1 and 2. When direct nursing supervision was no longer required, the patient had intermittent nursing visits at least daily. The hospital-at-home physician made at least daily home visits and was available 24 hours a day for urgent or emergent visits. Nursing and other care components, such as durable medical equipme

Decrease in Rate of Myopia Progression with a Contact Lens Designed to Reduce Relative Peripheral Hyperopia: One-Year Results

PURPOSE To determine whether a novel optical treatment using contact lenses to reduce relative peripheral hyperopia can slow the rate of progress of myopia. METHODS Chinese children, aged 7 to 14 years, with baseline myopia from sphere -0.75 to -3.50 D and cylinder ≤1.00 D, were fitted with novel contact lenses (n = 45) and followed up for 12 months, and their progress was compared with that of a group (n = 40) matched for age, sex, refractive error, axial length, and parental myopia wearing normal, single-vision, spherocylindrical spectacles. RESULTS On adjusting for parental myopia, sex, age, baseline spherical equivalent (SphE) values, and compliance, the estimated progression in SphE at 12 months was 34% less, at -0.57 D, with the novel contact lenses (95% confidence interval [CI], -0.45 -0.69 D) than at -0.86 D, with spectacle lenses (95% CI, -0.74 to -0.99 D). For an average baseline age of 11.2 years, baseline SphE of -2.10 D, a baseline axial length of 24.6 mm, and 320 days of compliant lens wear, the estimated increase in axial length (AL) was 33% less at 0.27 mm (95% CI, 0.22-0.32 mm) than at 0.40 mm (95% CI, 0.35-0.45 mm) for the contact lens and spectacle lens groups, respectively. CONCLUSIONS The 12-month data support the hypothesis that reducing peripheral hyperopia can alter central refractive development and reduce the rate of progress of myopia. (chictr.org number, chiCTR-TRC-00000029 or chiCTR-TRC-00000032.).

Potential lost productivity resulting from the global burden of uncorrected refractive error

OBJECTIVE To estimate the potential global economic productivity loss associated with the existing burden of visual impairment from uncorrected refractive error (URE). METHODS Conservative assumptions and national population, epidemiological and economic data were used to estimate the purchasing power parity-adjusted gross domestic product (PPP-adjusted GDP) loss for all individuals with impaired vision and blindness, and for individuals with normal sight who provide them with informal care. FINDINGS An estimated 158.1 million cases of visual impairment resulted from uncorrected or undercorrected refractive error in 2007; of these, 8.7 million were blind. We estimated the global economic productivity loss in international dollars (I

Screening for Sudden Cardiac Death in the Young: Report From a National Heart, Lung, and Blood Institute Working Group

) associated with this burden at I

Preventive Care for Colorectal Cancer Survivors: A 5-Year Longitudinal Study

427.7 billion before, and I