Home phototherapy using fiberoptic lights for the treatment of newborn hyperbilirubinemia has proven to be safe and effective. The purpose of this study was to explore whether differences in the outcomes of duration, reduction of bilirubin levels, hyperbilirubinemia resolution, or readmission could be explained by initial bilirubin levels and variations in newborn clinical characteristics at the commencement of treatment. This retrospective chart review of 187 newborns, who had received home phototherapy, revealed hyperbilirubinemia resolved in 162 of the cases (86.6 percent). Seventeen (9.1 percent) required readmission to the hospital. The strongest predictor of treatment duration using birthweight, feeding type, age at admission, and bilirubin level at commencement of treatment as independent variables was the age of the newborn at admission (R2 =.03) followed by the bilirubin level at commencement of treatment (R2 = 0.10). No variables showed predictive power in relation to the absolute drop in bilirubin. Furthermore, those newborns whose hyperbilirubinemia resolved and those who required readmission showed no significant differences in relation to their clinical characteristics of birthweight, bilirubin level at commencement of treatment, or age at admission. When variables of absolute drop in bilirubin, bilirubin level at the completion of treatment, duration of treatment, gestational age, and age at admission were analyzed based on feeding type (bottle vs. breast), the only significantly different characteristic was the bilirubin level at the completion of treatment (p =.034). Bilirubin levels at the completion of treatment were on the average lower for bottle-fed newborns when compared to breast-fed newborns. Results suggest that the older the newborn at admission, the shorter the treatment duration, and the higher the bilirubin level on admission, the longer the duration of treatment. Findings also suggest pediatricians tolerate higher bilirubin levels at the completion of treatment for breast-fed newborns than for bottle-fed. This study illustrates implications for nursing and medical management of hyperbilirubinemia by providing information regarding the home phototherapy population, treatment outcomes, and highlighting the need for proper follow-up, documentation, and continued research of this potential public health problem.

Background. Ozone has been recognized as the most widespread and persistent urban pollution problem with demonstrated effects on health outcomes. However, there have been a limited number of studies using both temporal and spatial characteristics to study these relationships. Purpose. Using traditional statistics and geostatistics in combination with GIS, the association between ozone concentration and emergency department (ED) admissions for cardiovascular and respiratory conditions were examined at the ZIP code level. Methods. This study used multiple large datasets representing data for Maryland in the summer, 2002: (1) ozone data from the EPA, (2) weather factors from the National Climate Data Center, (3) socioeconomic status (SES) data from the Census 2000, and (4) ED visit data from the Maryland Health Services Cost Review Commission. Block kriging, a geostatistical technique, was applied to estimate daily ozone and weather factors (i.e., temperature and relative humidity) by ZIP-day level. These data were linked to aggregated ED visits. Poisson regression was used. Results. For 30 days of the 92-day study period, block kriged ozone concentration exceeded the EPA's national air quality standards for 8-hr ozone concentration, 85 parts per billion (ppb). A 10 ppb increment of 8-hr ozone as a 3-day average was associated with increased respiratory ED visits by 3.1% (95% CI: 1.8, 4.5) even after adjusting for weather factors, SES, and day of week. For cardiovascular ED visits, a 10 ppb increment of 1-hr ozone as a 5-day average increased by 4.7% (95% CI: 3.1, 6.3). Conclusion/Implication. Findings suggest that respiratory and cardiovascular ED visits increased even at lower ozone concentration than the EPA's air quality standards. As few studies examined the relationship between ozone and cardiovascular ED visits at a small area level, this study showed a statistical significance of ozone effects on increasing cardiovascular ED visits. Moreover, a limited number of studies have controlled for SES in examining relationship between air pollution and health, whereas this study adjusted for SES as a confounding factor of ozone effects on health outcomes. This study suggests that the integration of large datasets from discrete sources and the use of geostatistics and GIS can facilitate population health assessment. Future studies can use a similar approach to investigate other environmental risk factors and patient health outcomes at the population level.

Statement of the problem. The purpose of this study was to develop an instrument to measure the content and quality of prenatal care services in a population of low income women. Dimensions of performance as proposed by the Joint Commission on Accreditation of Healthcare Organizations were used to define the quality of prenatal care. The United States Public Health Service Expert Panel Guidelines on the Content of Prenatal Care were used as the standard for the content of care. Methods. The Content and Quality of Prenatal Care Measure (CQPM), a prenatal care record review measure, was developed in this study. An assessment of content validity and intra- and inter-rater reliability was completed. Data collected for the validity sample of 163 records at two county health department sites was scored by content area. The Adequacy of Prenatal Care Utilization Index (APNCU) developed by Kotelchuck was used to categorize each record in the validity sample. Criterion-related validity was assessed with ANOVA using the CQPM scores as the dependent variable and the APNCU groups as the independent variable and by discriminant function analysis using the CQPM content scores as predictors for group membership in APNCU groups. Results. The mean percent agreement for each of the content areas for intra- and inter-rater reliability ranged from 72% to 95% with medical risk assessment having the highest reliability and health promotion having the lowest. Intra and inter-rater percent agreement for items ranking the quality of care was 70% and 51.6%. A significant difference between the groups was found in ANOVA, F(3,157):16.23, p < .00001, confirming criterion-related validity. The discriminant function analysis found an overall Lambda =.451941 (chi2 = 110.79, df 15, p < .00001). The prediction equation accounted for 62% of grouped cases being correctly classified also confirming criterion-related validity. Discussion. These results show that the Content and Quality of Prenatal Care Measure is reliable and valid and may be used to monitor care provided to low income populations and to conduct research on the content of prenatal care. Further research on weighting each item score in the CQPM and the reliability of items for special populations may be indicated.

Available evidence does not indicate an increase in the rate of execution of advance directives (ADs) following implementation of the Patient Self-Determination Act (PSDA) on 12/1/91. Although the community is perceived as a more conducive context than a healthcare institution for the execution of ADs, the rate of AD execution also has remained static among community-dwelling adults following implementation of the PSDA. Little is known about the factors related to the execution or non-execution of ADs by community-dwelling adults. This study described the enabling, experiential, socio-spiritual, and demographic characteristics of community-dwelling adults who had executed ADs, i. e., terminal care documents and/or durable powers of attorney for health care, and of community-dwelling adults who had not executed ADs; investigated relationships among the characteristics and the execution or non-execution of ADs; and examined differences between executors and non-executors of ADs related to the characteristics. Data were collected by mail from a random sample of 530 residents of one Northeastern state, using a self-administered, 68-item researcher-constructed questionnaire. The response rate was 51% (n=210) after three mailings with 18.1% (n=38) having executed an advance directive (AD). The AD proportion was consistent with those reported in earlier studies of community-dwelling adults that have been conducted since the implementation of the PSDA. Major study variables included dimensions of personal autonomy and self-determination, concern for family, death anxiety, religiosity, familiarity with ADs, AD education, personal experience with the terminal illnesses or critical injuries of family members and/or friends, physician-initiated AD discussions, and concern about an executed AD having a negative impact on one's care. Significant differences between executors and non-executors of ADs on the study variables included executors being more familiar with ADs, F(1,205) = 65.69, p < .0001, reporting more AD education, Z = -5.82, p < .0001 having more experiences with the terminal illnesses or critical injuries of family members and/or friends, F(1,201) = 8.33, p = .0043, engaging in physician-initiated AD discussions more often, Z = -4.75, p < .0001, expressing greater concern about having an executed AD negatively impact one's care, F(1,202) = 5.20, p = .0236, having a higher degree of religiosity, F(1,180) = 6.41, p = .0122, and being older, F(1,207) = 24.06, p < .0001, than non-executors. Path analysis of variables with significant correlations indicated that physician-initiated discussions about ADs, familiarity with ADs, AD education, concern about the negative impact of an executed AD on one's care, concern for family, religiosity, age, and health status were effective predictors (p <= .05) of the execution of an AD, explaining 30% of the variance (R2adj). The findings suggest that being informed about ADs is fundamental to their subsequent execution. Information-building about ADs among autonomous individuals appears to be a process that is constituted by multiple factors, including familiarity with ADs, physician-initiated AD discussions, AD education, and experiences with the terminal illnesses or critical injuries of family members and/or friends. Furthermore, ongoing AD discussions between healthcare professionals and AD executors seem warranted to clarify patients' understanding of previously executed ADs.

People with developmental disabilities are recognized as a vulnerable population and are frequently at increased risk due to their physical, social, economic and societal disparities. Despite these vulnerabilities, the regulations that govern community-based residential settings for the developmentally disabled provide little oversight with regard to home environmental health hazards such as lead, mercury, carbon monoxide, pesticides, radon and volatile organic compounds. Minimal data are available about the environmental health risks experienced by people in residential settings for the developmentally disabled and about how the behaviors and choices of support staff affect the indoor air quality in these residences. This study assessed the home characteristics, household behaviors and practices that place people with developmental disabilities at health risk from environmental hazards in their homes. Homes (N=57) run by three major service providers of residential services for the developmentally disabled in Anne Arundel County, Maryland were selected using random stratified sampling for evaluation. A survey and a home environmental assessment conducted by an observational walk-through of each home were used to assess the presence of neurotoxicants such as lead and mercury in the home, protective devices such as carbon monoxide detectors and radon testing, and the use of behaviors and practices that contribute to indoor pollution from pesticides, environmental tobacco smoke and cleaning products.;Twenty-eight homes (49%) had at least one source of carbon monoxide exposure and 21 (72%) of these homes had no carbon monoxide detector. **Carbon monoxide detectors tended to be more likely in homes with than in homes without carbon monoxide sources. Radon was a concern. Fifty-six of 57 homes were not tested for radon. In 41 of the homes basements, where carbon monoxide and radon are likely to accumulate, were used as living space for staff and developmentally disabled residents. Forty-nine homes reported professional pesticide contracts and 56 homes contained products with volatile organic compounds. Regulation and education of providers is necessary to prevent environmental health risks in this vulnerable population. More research is needed to investigate the home environmental health risks of people with developmental disabilities and their staff living in residential settings.

African Americans have low rates of colorectal cancer (CRC) screening, and little is known about factors influencing their participation. This study sought to identify variables within the biopsychosocial (BPS) model's three factor groups (biological, psychosocial/behavioral, social) that predicted timely colorectal cancer (CRC) screening ('screening') in African American (AA) men and women aged ≥ 40 in Maryland. A secondary analysis of data from 580 AAs in the 2002 Maryland Cancer Survey (MCS) examined whether biological (age, gender, CRC family history), psychosocial/behavioral (mammogram and prostate specific antigen [PSA] screening history, body mass index, activity level, fruit/vegetable consumption, alcohol, smoking, cancer concern, cancer perceived risk, perception of familial cancer), and social (education, employment, insurance, access to healthcare provider [HCP], and HCP recommendation of fecal occult blood test and/or sigmoidoscopy/colonoscopy) factors predicted screening. Research question 1 examined individuals without CRC family history (N=473) using simultaneous, hierarchical block, and stepwise entry logistic regression analyses of individual and grouped variables. Recommendation of fecal occult blood test (OR 11.90, 95% CI: 6.84, 20.71) and sigmoidoscopy/colonscopy (OR 7.06, 95% CI 4.11, 12.14), moderate/vigorous activity (OR 1.70, 95% CI: 1.02, 2.82), and history of PSA screening (OR 2.81, 95% CI 1.01, 7.81) predicted screening, as did the social factor group. Research question 2 examined individuals with CRC family history (N=86) using the same models. Recommendation of sigmoidoscopy/colonscopy (OR 24.3, 95% CI 5.30, 111.34) and vigorous activity (OR 5.21, 95% CI: 1.09, 24.88) predicted screening, as did the social factor group. The study hypothesis proposing that CRC family history predicted screening when controlling for age, education, and insurance was not supported. Results suggest that HCP recommendation was the most important predictor of screening. The small sample of people with CRC family history and sample characteristics (e.g., insurance) that differed from Maryland demographics limit generalizability. Other potentially important variables (e.g., fatalism) were not in the MCS dataset and therefore could not be examined. Prospective research should examine additional possible predictors of screening, and socioeconomic and other variables that limit access to HCPs. Variables that influence HCPs' recommendations for screening and individuals' adherence to recommendations are also important to investigate.

Disruptive behaviors are a prevalent problem among hospitalized elderly patients and a challenge for today's policy-makers. This problem had not been studied in the two subacute care models: hospital and nursing home-based. This study reviewed the responses of 101 licensed nurses working in 8 JCAHO accredited subacute care programs, 5 hospital-based and 3 nursing home-based. A new scale was developed that provided a comprehensive inventory of interventions for the management of disruptive behaviors. The inventory utilized the following categories of management strategies: behavioral, functional, psychological, environmental, and medical (Beck et al., 1993; Taft et al., 1997). Nurses were asked to rate videotapes of the 4 most commonly occurring types of disruptive behaviors, physical aggression, verbal aggression, agitation, and wandering with respect to (a) the effort involved in behavior management; (b) tolerance toward the occurrence of the behavior; (c) frequency of occurrence and (d) the types of primary interventions (actual and ideal) most likely to be instituted in caring for elderly patients in their particular subacute care setting. Analysis of variance indicated no significant differences between the four types of behaviors with respect to perceived effort, although organizational tolerance for agitation-type behavior was significantly higher than for the other three types. Nursing home-based subacute nurses witnessed a greater frequency of physical aggression, verbal aggression, and agitation-related disruptive behaviors, but fewer occurrences of wandering than hospital-based subacute nurses. No significant differences were found between nurses' intervention selections by facility type nor actual and ideal determined by chi square analyses. Stepwise regression analyses were not statistically significant for demographic and professional characteristics of nurses nor type of facility to explain perceived effort, but did reveal there was a significant (R 2 = 0.049; p = 0.026) positive relationship between organizational tolerance and perceived effort for agitation. An important study finding consistent with the Omnibus Reconciliation Act of 1987 was that nurses in both hospital and nursing home-based subacute settings did not select physical or chemical restraints as a primary intervention for managing disruptive behaviors.

In recent years, providing care for individuals with severe mental illness has consumed increasing state and federal financial resources, with State Medicaid systems bearing the heaviest burden. Managed care strategies have been initiated by public mental health systems as a mechanism to control expenses. The state of Maryland implemented a mental health carve-out on July 1, 1997. The purpose of the present study is to describe the effects of the carve-out on access-to-care for individuals using emergency department services in one suburban health care system. Data for this study included all episodes of emergency crisis care in pre-implementation (1996-1997) and post-implementation (1998-1999) time periods. These data were examined within the context of the Behavioral Model of Health Service Use (Andersen, 1995) to describe the interrelationships among external environment, predisposing characteristics, and enabling resources on use of health services. Use of health services was operationalized by four outcomes: disposition, length of stay, number of visits, and recidivism. There were a total of 2986 episodes, initiated by 1928 individuals. Logistic regression demonstrated that when controlling for predisposing characteristics and enabling resources, the likelihood of inpatient admission did not change after initiation of the program. Moreover, there was not a significant change in the number of emergency visits. The assessment of recidivism demonstrated that only psychotic disorders (a predisposing characteristic) were a significant predictor of 30-day repeat visits. Multiple regression models examining the impact of the carve-out on length of stay demonstrated a significant increase in the emergency department length of stay (F = 5.47, p = .05) following the implementation of the carve-out. While benefits associated with improved coordination of services might be expected with the implementation of the carve-out, there was not a change in inpatient admissions, number of emergency visits, or recidivism. Additionally, there was a significant increase in the amount of time required to assess patients and to provide an appropriate disposition. The limited study sample and data prohibit generalizability. Considering that evaluations of mental health carve-outs are limited, this study reflects that anticipated benefits have not been experienced in emergency departments.

Background. For women with chronic conditions, care often concentrates on the underlying disorder to the exclusion of cancer screening recommendations. This occurs in the face of lengthening life spans for those with chronic illnesses. Research objective: This study investigated the relationship between chronic illness and the receipt of breast cancer screening services, while controlling for the influence of various established predictors of screening. Data source: Survey data from the 1996 Medical Expenditure Panel Survey (MEPS) Household component. Methods: The influence of chronic illness on the likelihood of having a clinical breast exam (CBE) or mammogram was estimated using logistic regression models. Since a gold standard for measurement of chronicity did not exist, three different measures--number of chronic diseases, Charlson Comorbidity Index, and the presence of mobility and cognitive limitations---were used. Population studied: Women forty years or older (N = 4169). Principal findings: Of the chronicity measures examined, only mobility and cognitive limitations were significant. Women with either limitation were 25 to 30% less likely to be screened even though they had more ambulatory care visits than those without limitations. Neither the number of chronic conditions nor the Charlson Comorbidity Index score were significant predictors of screening. Other significant predictors of screening included age, education, income, insurance, having a usual source of care, and living in a metropolitan statistical area. Conclusions: Although women with mobility and cognitive limitations use more health care services, they are less likely to be screened for breast cancer. A variety of factors including a disease-oriented healthcare system, care priorities, difficulty performing a CBE or mammogram, a lack of insurance, and provider and patient knowledge and attitudes about screening may lead to bias against screening women with mobility anal cognitive limitations. Implications for policy, delivery or practice. Physically inaccessible care sites, inadequate equipment, such as nonadjustable examining tables, and time pressures experienced by providers may impede efforts to provide comprehensive preventive care to women with chronic disabilities. Increasing health care coverage or geographic access may be inadequate if the knowledge and attitudes of providers and patients are not addressed.

The purpose of this study was to examine the factors that were most predictive of hospital admission for Congestive Heart Failure (CHF) patients admitted to a large urban home care organization. The Andersen Behavioral Model of Health Services Use served as the conceptual framework for the study. A retrospective design using administrative data from the OASIS instrument investigated client characteristics measured at admission (predisposing, enabling and need) and resource utilization that were predictive of hospital admission from a home health episode. This secondary data analysis included 710 CHF patients, of whom 150 or 21% were admitted to the hospital during a home health episode. A logistic hierarchical regression was performed to determine predictors of hospital admission. Four questions were tested to determine predictors. Three measures--increase in dyspnea, fewer physical therapy visits and higher visit intensity--predicted hospital admission. Chi-square and t-tests were conducted to determine if there was a difference between those hospitalized and those not hospitalized. Patients were more likely to be hospitalized if they: had Medicaid as their primary payer; had increased shortness of breath with activity; had a higher acuity level as measured by symptom control; required more assistance in upper body dressing; needed more assistance in ambulating; had difficulty transferring; were more dependent in all Activities of Daily Living; had significantly fewer physical therapy visits; and had a higher intensity of visits per day. The findings demonstrate the value of using OASIS for a specific disease, CHF, in examining the outcome of hospitalization from a home care agency. Findings provide information for nurses on the importance of the assessment of dyspnea during the first home care visit, the use of physical therapy services and the role of the visit intensity during a home care episode. Further research needs to explore the restrictive policies of the state Medicaid programs that may contribute to the significantly higher hospitalization rates of these CHF patients.