Public-private partnerships: working at the local level to increase the quality and number of medical homes for Medicaid children

We have described a process in which one state's public health leaders provided a large degree of flexibility at the community level to improve pediatric health care access for children in need. This "room-to-wiggle" allowed program providers to tailor their programs to the specific needs of their communities while remaining faithful to the statewide goals. Among the most promising outcomes of the coordinated efforts to forge public-private partnerships is the continuation of the relationships that developed in the process and the further collaborations they have spawned.

Note on ambient noise levels in head start speech-language therapy rooms

Only one speech-language therapy room of ten at preschool Head Start centers met the American Speech-Language-Hearing Association's (ASHA) requirements for ambient noise levels in educational settings. Preschoolers with speech-language disorders need ideal circumstances for therapy, which may be achieved through environmental changes or assistive listening devices.

Case control study of risk factors for toxic mastitis in 26 dairy herds

A retrospective case control study of farm level risk factors for toxic mastitis was carried out in November and December 1996. Twenty-six farms from mid-Somerset were visited: 13 case farms (had had a cow with toxic mastitis in the previous year) and 13 geographically matched controls (no case of toxic mastitis). The farmers were interviewed and the buildings were examined. Information was collected on the type and quality of housing, usual milking routines, milk quality and mastitis prevalence in the previous year. All the data were collected on to pretested recording sheets and loaded into a database. Simple and complex analysis was done. The following variable were significantly (P < 0.05) associated with an increased risk of toxic mastitis in the simple analysis: housing cows in October rather than November; a low number of calving boxes per cow; a high proportion of cows with intermediate body condition and low herd bulk milk somatic cell counts (HBMSCC). In the final model low HBMSCC and a high proportion of cows with intermediate body condition remained significant. The authors conclude that, despite the small size sample, the results of this study are consistent, plausible and support the information from previous experimental and observational studies about the role of somatic cell counts in toxic mastitis.

Understanding and controlling the scarring response: the contribution of histology and microscopy

In response to injury, the body usually initiates a full and swift wound healing response resulting in reconstructed, repaired tissue. In certain instances, due to a variety of factors, this may not happen, an example being chronic granulating venous leg ulcers. At the other extreme, the wound may heal excessively, producing disabling hypertrophic scarring such as can occur following large, deep burn injuries. Our group is interested in the surgical treatment of the eye disease glaucoma. As will be explained, the successful surgical treatment of this disease depends on a reduced scarring response at the end of wound healing. The purpose of this article is to give an overview of our microscopic and histological experimental work which has furthered our understanding of tissue repair, particularly the scarring response and its potential modification for successful glaucoma surgery.

Ocular morbidity following renal transplantation

BACKGROUND

Long-term visual outcome following renal transplantation is poorly documented in medical literature. The purpose of this study was to determine the ocular morbidity in a group of renal transplant patients receiving immunosuppressive therapy.

METHODS

Patients who had undergone renal transplantation were identified from the renal outpatient register, and patients who were at least 8 years posttransplantation were included in the study. Ocular examination was on average 14.6 years post-surgery. There were 43 males and 28 females, with ages ranging from 29 to 74 years. The patients had undergone renal transplantation between March 1968 and September 1986. The ophthalmic examinations were carried out over a 15-month period in a research clinic.

RESULTS

Visual acuity was greater than or equal to 6/9 in 75% of the eyes. 10% of eyes had visual acuities of less than 6/24. Four eyes had central/branch retinal-vein occlusions; four eyes had posterior subcapsular lens opacities; three eyes had optic atrophy; one eye had complications of proliferative diabetic retinopathy; one eye had diabetic maculopathy and one eye had a central retinal artery occlusion. Only five eyes had irreversible visual loss resulting in visual acuities of less than 6/60.

CONCLUSION

The incidence of sight-threatening complications in long-term survivors of renal transplantation was low. The results indicate that long-term prognosis for normal vision in patients who have undergone renal transplantation is good. Regular ophthalmic examinations are recommended for early detection of sight-threatening complications.

The role of staphylococcal superantigens in the pathogenesis of marginal keratitis

Previous studies have demonstrated an increased incidence of delayed-type hypersensitivity to staphylococcal antigens in patients with blepharitis, but this does not predict subsequent development of marginal keratitis (MK). Superantigens are potent immune-modifying molecules produced by pathogenic organisms including Staphylococcus aureus. To study whether staphylococcal superantigens play a role in the development of MK, conjunctival and lid margin cultures were taken from 26 subjects with MK and 24 controls. Four of 8 eyes with their first episode of MK grew strains of S. aureus, of which only one was superantigen-producing. None of the subjects with recurrent MK and only one control grew S. aureus. We conclude that staphylococcal superantigens are unlikely to play a central role in the development of MK. The absence of S. aureus on the lids of subjects with recurrent MK may reflect an alteration in lid flora due to previous topical antibiotic and steroid treatment.

Nursing home care quality: a multidimensional theoretical model

This exploratory study was undertaken to discover the defining dimensions of nursing home care quality and to propose a conceptual model to guide nursing home quality research and the development of instruments to measure nursing home care quality. Three focus groups were conducted in three central Missouri communities. A naturalistic inductive analysis of the transcribed content was completed. Two core variables (interaction and odor) and several related concepts emerged from the data. Using the core variables, related concepts, and detailed descriptions from participants, three models of nursing home care quality emerged from the analysis: (1) a model of a nursing home with good quality care; (2) a model of a nursing home with poor quality care; and (3) a multidimensional model of nursing home care quality. The seven dimensions of the multidimensional model of nursing home care quality are: central focus, interaction, milieu, environment, individualized care, staff, and safety. To pursue quality, the many dimensions must be of primary concern to nursing homes. We are testing an instrument based on the model to observe and score the dimensions of nursing home care quality.

Verifying nursing home care quality using minimum data set quality indicators and other quality measures

Researchers, providers and government agencies have devoted time and resources to the development of a set of Quality Indicators derived from Minimum Data Set (MDS) data. Little effort has been directed toward verifying that Quality Indicators derived from MDS data accurately measure nursing home quality. Researchers at the University of Missouri-Columbia have independently verified the accuracy of QI derived from MDS data using four different methods; 1) structured participative observation, 2) QI Observation Scoring Instrument, 3) Independent Observable Indicators of Quality Instrument, and 4) survey citations. Our team was able to determine that QIs derived from MDS data did differentiate nursing homes of good quality from those of poorer quality.

Efficacy and safety of a new protocol for continuous infusion of midazolam and fentanyl and its effects on patient distress during electrophysiological studies

Electrophysiological studies are often distressing for patients. We devised a regime of continuous infusion of midazolam and fentanyl during electrophysiological studies without the presence of a specialist anaesthetist. The effects on key hemodynamic and respiratory variables and level of sedation were evaluated in detail in the first 775 patients. The safety of this practice was evaluated in 1,344 consecutive patients. Doses were calculated according to patients' weight and age. A mean total dose of 26 mg of midazolam and 115 mcg of fentanyl were infused. Satisfactory sedation was achieved in 97% of patients. The mean duration of procedure was 188 +/- 90 minutes. Complete amnesia of the procedure was obtained in 87% of patients. Sedation caused clinically insignificant changes in respiratory rate, oxygen saturation, end-tidal CO2 and blood pressure. There were no major complications related to sedation. Upper airway obstruction, usually minor, occurred in 42% and some restlessness in 20% of sedated patients. The assistance of a specialist anesthetist was required in 0.3% of sedated patients for management of restlessness, hypoventilation, or obstructive sleep apnea. The amount of distress experienced by sedated patients (n = 775) was significantly less compared to a previous series of nonsedated patients (n = 775) undergoing electrophysiological studies (P < 0.001). The degree of distress experienced by patients during electrophysiological studies can be reduced significantly by sedation with intravenous midazolam and fentanyl. Continuous infusion is an efficient, safe, and effective way of administering midazolam and fentanyl.

Setting thresholds for MDS (Minimum Data Set) quality indicators for nursing home quality improvement reports

BACKGROUND

Determining meaningful thresholds to reinforce excellent performance and flag potential problem areas is critical for quality improvement reports. Without thresholds, an organization may interpret its performance as superior to others because it is "better than average" and falsely assume it does not have care problems in certain areas.

SETTING THRESHOLDS

The Minimum Data Set (MDS) assessment instrument is mandated for use nationwide in all nursing homes participating in Medicaid or Medicare programs. Since 1993 a research team at the University of Missouri-Columbia has been developing and testing quality indicators (QIs) derived from MDS data as a foundation for quality improvement activities. In July 1996, a cross-section of 13 clinical care personnel from nursing homes participated on an expert panel for threshold setting for QIs derived from MDS assessment data. Panel members individually determined good and poor threshold scores for each QI, reviewed statewide distributions of MDS QIs, and, two weeks later, completed a follow-up Delphi round. Three members of the research team reviewed the results of the expert panel and set the final thresholds. With thresholds established for good and poor scores, MDS QI scores are reported to a sample of Missouri nursing homes using the thresholds.

CONCLUSIONS

To ensure that thresholds reflect current practice, threshold setting with another panel of experts will be repeated as needed, but at least biannually. The report format will be revised on the basis of user input, and a statewide study testing different educational support methods for quality improvement using MDS QIs is now underway.