Extended Care Programs Research Articles

The Introduction of Extended Out‐of‐Home Care (OOHC) Until 21 Years in Australia: A Mapping of Policy, Legislation and Programs in Each Jurisdiction

ABSTRACTIt is increasingly recognised by global research that extending out‐of‐home care (OOHC) until at least 21 years of age is the policy reform most likely to advance improved outcomes for care leavers. In recent years, all eight Australian jurisdictions (States and Territories) have introduced forms of extended care programs. Yet, major variations remain between these jurisdictions in terms of the placement types covered, the levels of support and funding, and the terms and language used to describe their programs. This paper maps the existing policy developments in each jurisdiction and the level of program supports provided to care leavers aged 18–21 years. For each jurisdiction, we establish extended care eligibility and coverage, funding and adequacy, and the key terminology used. Our discussion of the commonalities and differences between the jurisdictions suggests that some sub‐groups of care leavers may need additional and specialised forms of support. They include most notably those exiting residential care and Aboriginal and Torres Strait Islander care leavers.

Homelessness and Housing Instability Among Care Leavers in Australia: Exploring Housing Pathways and Best Practice Housing Models

ABSTRACTA significant proportion of young people exiting Out‐of‐Home Care (OOHC) encounter substantial challenges in securing housing, often leading to homelessness within a few months after leaving care. All Australian jurisdictions have now approved extended care programs up to 21 years; however, none of them currently offer these young people guaranteed accommodation options. This study aims to explore the factors underlying poor housing outcomes among care leavers and to develop a best practice model that complements the extended care framework in Australia, thereby addressing or ameliorating homelessness issues among these young adults. A scoping review of 18 scholarly articles and seven grey literature reports supplemented by ancestral search forms the basis of a thematic analysis. This analysis reveals factors contributing to negative and positive housing outcomes for young people related to OOHC transitional processes in Australia and Organisation for Economic Co‐operation and Development (OECD) nations. It includes evaluations of the implementation of extended care and of housing programs in these countries. By analysing current extended care policies in each jurisdiction, as well as literature featuring good post‐care housing practices both locally and internationally, five key principles have been identified for a best practice model.

Design of Project STAR: A randomized controlled trial evaluating the impact of an adaptive intervention on long-term weight-loss maintenance

BackgroundWithout provision of additional intervention, most individuals regain weight after the end of weight-loss programs. Extended-care programs have been demonstrated to improve long-term weight-loss maintenance, but effects are modest. MethodsWe proposed to evaluate whether delivering extended-care telephone sessions on an ADAPTIVE (provided when individuals are deemed to be at high-risk for weight regain) versus STATIC (the once-per-month schedule typically used in extended-care programs) schedule improves weight regain after initial weight loss. Adults with obesity were initially recruited for a 16-week lifestyle weight-loss program, and those who lost ≥5 % of their initial weight were eligible for enrollment in the Project STAR maintenance trial. ResultsA total of 449 individuals (mean ± SD age = 49.5 ± 11.4 years, BMI = 35.7 ± 4.0 kg/m2, 83.5 % female, 23.4 % Black or African American, 9.8 % Hispanic) were recruited for the initial weight-loss program and lost an average of 6.4 ± 4.9 % of their initial body weight; 255 were randomized to the maintenance trial. There were no significant differences between participants randomized to the trial versus those who were not in terms of baseline weight, gender, race/ethnicity, education, or marital status, all ps > 0.05; however, participants who were randomized to the trial were older, p = .014, and reported higher incomes, p < .001. ConclusionResults from Project STAR will demonstrate whether providing extended-care intervention on an individually adaptable schedule improves long-term weight-loss maintenance. Moreover, the rich longitudinal dataset collected during the trial will serve as a foundation for building future predictive algorithms of weight regain and novel weight-maintenance interventions.

“… I still need to learn some things”: an interpretative phenomenological analysis of the lived experience of extended residential youth care in Denmark

ABSTRACT Youth residential home care is, in many countries, terminated at 18 years of age. However, current research suggests that leaving care at 18 is associated with several negative or suboptimal outcomes. Denmark has, in response to this, established an extension of care which can continue until the age of 23 years. This study aimed to provide a detailed understanding of the experiences of living in the Danish extended care program. This qualitative study explored the experiences of eight young adult residents (4 men and 4 women). Interpretative phenomenological analysis was used to analyze the residents’ accounts which constructed three group experiential themes: (1) “It was me; I just didn’t want to listen:” The experience of the transition to adulthood while in residential care. (2) “I still need to learn some things:” The experience of maturation in extended care. (3) “They don’t come running to me every day anymore:” The experience of preparing to transition out of extended care. This study has important implications for practice given the sample’s perceived inability to live independently outside of care at 18 years of age. The findings support current arguments for establishing an extended care system in countries which currently only offer juvenile residential care.

Equity and Inclusion for LGBTQ+ Residents: Lessons Learned from the Initial Long-Term Care Equality Index (LEI)

ObjectivesMost older adults with lesbian, gay, bisexual, queer, questioning, transgender, and related identities (LGBTQ+) are concerned about receiving lower-quality care and/or being mistreated in nursing homes. Older LGBTQ+ veterans may have additional reservations about care in Department of Veterans Affairs (VA) nursing homes (Community Living Centers [CLCs]) because of experience with past discriminatory military policies (eg, bans on participating in military service, Don't Ask Don't Tell). This article describes one of the first VA CLCs to participate in the Human Rights Campaign–developed Long-Term Care Equality Index (LEI). DesignA single-site formative evaluation was completed to support quality improvement and identify opportunities for growth using the LEI. The LEI is a facility benchmarking tool to support more inclusive environments for LGBTQ+ residents and employees. The LEI offers 4 evaluation criteria: (1) Non-Discrimination and Staff Training; (2) LGBTQ+ Resident Services and Support; (3) Employee Benefits and Policies; and (4) Resident and Community Engagement. Facilities receive ratings based on the number of requirements achieved in each category. Participants and Methods: Older LGBTQ+ veterans, current CLC residents, interdisciplinary CLC providers and leadership, and national Geriatrics and Extended Care program managers collaborated to pilot the LEI and develop tools and materials to support other VA facilities' participation in the LEI. ResultsQualitative interviews with veterans and CLC residents supported inclusion of gender identity and sexual orientation in resident handbooks, discussions about person-centered care, and opportunities for additional staff training and community engagement (eg, observing Pride Month in June). Resources to support VA long-term care facilities' participation in the LEI were developed. Conclusions and ImplicationsThe LEI offers a structured approach to identifying areas for improvement in providing high-quality and equitable care in long-term care settings. Practical suggestions for CLCs and other nursing home settings considering the LEI for the first time are discussed.

NEUROSCIENTIFIC EVIDENCE AND CARE LEAVING: A MULTIDISCIPLINARY CRITICAL COMMENTARY

While neuroscientific literature suggests that some parts of the brain are not fully developed until the mid-20s, public discourse is skewed toward early child development (ECD) because of its supposed long-term economic benefits. Some researchers have gone so far as to say that society overinvests in remedial programs for disadvantaged adolescents. Such claims resist advocacy efforts for extended care for children in out-of-home care and discourage policy and legislative concerns regarding investing in early adulthood. In this commentary, we unpack the literature on brain development and critically discuss its selective use by legislators and policymakers for investments in ECD. Despite the availability of neuroscientific and economic evidence, it is not prominent in the discourse surrounding supportive interventions like extending care. Using Bourdieu’s theory of social reproduction, we discuss how preference is given to only the type of knowledge that preserves the social structures that work to ensure the multigenerational flow of capital among dominant groups. Also, social institutions act within the dimensions set by the social structure, constantly shaping and reshaping ways of facilitating capital preservation among the upper classes. We conclude that, in addition to moral argument, the current neuroscientific evidence may support investment in extended care programs.

Differential impact of telehealth extended-care programs for weight-loss maintenance in African American versus white adults.

Extended-care interventions have been demonstrated to improve maintenance of weight loss after the end of initial obesity treatment; however, it is unclear whether these programs are similarly effective for African American versus White participants. The current study examined differences in effectiveness of individual versus group telephone-based extended-care on weight regain, compared to educational control, in 410 African American (n = 82) and White (n = 328) adults with obesity (mean ± SD age = 55.6 ± 10.3years, BMI = 36.4 ± 3.7kg/m2). After controlling for initial weight loss, multivariate linear models demonstrated a significant interaction between treatment condition and race, p = .048. Randomization to the individual telephone condition produced the least amount of weight regain in White participants, while the group condition produced the least amount of weight regain in African American participants. Future research should investigate the role of social support in regain for African American versus White participants and examine whether tailoring delivery format by race may improve long-term outcomes.

Ending Australia’s Status as a “Leaving Care Laggard”: The Case for a National Extended Care Framework to Lift the Outcomes for Young People Transitioning From Out-of-Home Care

ABSTRACT Young people transitioning from out-of-home care, commonly called care leavers, are known to be a vulnerable group. Many experience poor outcomes leading them to become homeless or involved in the criminal justice system. Yet compared to most other Anglophone democracies, Australia lacks mandatory assistance for care leavers beyond 18 years of age. There are also major legislative, policy, and program differences between care leaver entitlements in the individual states and territories. This paper argues that the Commonwealth Government should introduce a nationally consistent extended care system that would require all jurisdictions to provide a minimum standard of support until at least 21 years of age. A uniform set of extended care standards is even more vital in the context of COVID-19. IMPLICATIONS Many Australian care leavers have poor life chances despite recent advances in the support programs provided by the states and territories. A nationally consistent extended care program is likely to progress improved opportunities and outcomes for care leavers.

Postoperative health-related quality of life of patients with gynecological malignancy: a meta-analysis.

We sought to describe the short-term (1, 3, 6, 12 months) QoL changes after surgery for patients with gynecological malignancies in a meta-analysis. We collected studies based on the PICOS (patients, intervention, comparison, outcome, and study design) framework (P: patients with gynecological malignancy; I: surgery; C: presurgery; O: QoL scores; S: randomized controlled trials, case-control studies, or cohort studies) in the Cochrane Library, MEDLINE, EMBASE, Web of Science, EBSCO, and China National Knowledge Infrastructure (CNKI) databases up to June 28, 2020. Then, two reviewers independently performed article screening, data extraction, and study quality evaluation. Stata 15.0 software was utilized for data analysis. Nine studies with 1476 patients were ultimately included. QoL in global health status improved until 12 months after surgery with a maximum improvement (6.99 [0.31, 13.68], P = 0.04), and QoL in emotional functioning reduced significantly until 12 months after surgery with a maximum reduction (14.87 [10.29, 19.45], P < 0.00001). All of the symptom scales were reduced significantly until 12 months postoperation, indicating quality of life improvement. There was a clinical reduction in QoL but symptom experience (-3.31 [-5.51, -1.12], P=0.003) at six months after surgery compared with baseline (presurgery), with only sexual worry being statistically significant (4.61 [0.95, 8.27], P=0.01). The recovery time varied among each dimension of the postoperative QoL of patients with gynecological malignancies; only a few functions and symptoms began to improve at 1 month postoperation and more at 12 months postoperation. Therefore, it is vitally important to develop extended care programs targeting the multidimensional aspects of QoL for patients with gynecological malignancies after surgery.

Factors Associated with Weight Loss Maintenance and Weight Regain Among African American and White Adults Initially Successful at Weight Loss.

Providing ongoing treatment through extended care programs can improve weight loss maintenance (WLM), but the effectiveness of these programs for African Americans (AA) are mixed and may be due to unique cultural factors. To identify, prioritize, and organize factors associated with WLM as experienced by AA and White adults initially successful with weight loss. Adults identified their greatest amount of lifetime weight loss, and those achieving ≥5% weight loss were classified as maintainers (continued >5% weight reduction for ≥1 year) or regainers (≤5% weight reduction) based on current weight. The nominal group technique was conducted to identify and rank WLM facilitators and barriers. Online card sorting tasks and hierarchical clustering were performed to illustrate conceptual relationships between facilitators (maintainers only) and barriers (regainers only). Participants (maintainers, n = 46; regainers, n = 58; 81.7% women, 48.1% AA) identified known factors associated with successful weight management (daily weighing, self-monitoring, regular physical activity, mindful eating). However, the perceived importance of these factors differed between groups (maintainer vs. regainers; AA vs. Whites). Unique factors affecting WLM were also identified (refresher groups recommended by White maintainers and regainers; self-accountability identified by AA maintainers). Salient facilitators and barriers were best represented in 2-3 clusters; each group had ≥1 unique cluster(s) revealing group-specific higher-order domains associated with successful WLM. As lifestyle interventions for WLM (particularly for AA) are developed, attention to the preferences, and lived experiences of these groups is recommended. Strategies targeting physical activity maintenance and autonomy-supportive approaches may improve WLM among AA.

Effect of Telehealth Extended Care for Maintenance of Weight Loss in Rural US Communities

Lifestyle interventions for obesity produce reductions in body weight that can decrease risk for diabetes and cardiovascular disease but are limited by suboptimal maintenance of lost weight and inadequate dissemination in low-resource communities. To evaluate the effectiveness of extended care programs for obesity management delivered remotely in rural communities through the US Cooperative Extension System. This randomized clinical trial was conducted from October 21, 2013, to December 21, 2018, in Cooperative Extension Service offices of 14 counties in Florida. A total of 851 individuals were screened for participation; 220 individuals did not meet eligibility criteria, and 103 individuals declined to participate. Of 528 individuals who initiated a 4-month lifestyle intervention, 445 qualified for randomization. Data were analyzed from August 22 to October 21, 2019. Participants were randomly assigned to extended care delivered via individual or group telephone counseling or an education control program delivered via email. All participants received 18 modules with posttreatment recommendations for maintaining lost weight. In the telephone-based interventions, health coaches provided participants with 18 individual or group sessions focused on problem solving for obstacles to the maintenance of weight loss. The primary outcome was change in body weight from the conclusion of initial intervention (month 4) to final follow-up (month 22). An additional outcome was the proportion of participants achieving at least 10% body weight reduction at follow-up. Among 445 participants (mean [SD] age, 55.4 [10.2] years; 368 [82.7%] women; 329 [73.9%] white), 149 participants (33.5%) were randomized to individual telephone counseling, 143 participants (32.1%) were randomized to group telephone counseling, and 153 participants (34.4%) were randomized to the email education control. Mean (SD) baseline weight was 99.9 (14.6) kg, and mean (SD) weight loss after the initial intervention was 8.3 (4.9) kg. Mean weight regains at follow-up were 2.3 (95% credible interval [CrI], 1.2-3.4) kg in the individual telephone counseling group, 2.8 (95% CrI, 1.4-4.2) kg for the group telephone counseling group, and 4.1 (95% CrI, 3.1-5.0) kg for the education control group, with a significantly smaller weight regain observed in the individual telephone counseling group vs control group (posterior probability >.99). A larger proportion of participants in the individual telephone counseling group achieved at least 10% weight reductions (31.5% [95% CrI, 24.1%-40.0%]) than in the control group (19.1% [95% CrI, 14.1%-24.9%]) (posterior probability >.99). This randomized clinical trial found that providing extended care for obesity management in rural communities via individual telephone counseling decreased weight regain and increased the proportion of participants who sustained clinically meaningful weight losses. ClinicalTrials.gov Identifier: NCT02054624.

Design of the Rural LEAP randomized trial: An evaluation of extended-care programs for weight management delivered via group or individual telephone counseling

Obesity is a major contributor to the greater prevalence of chronic disease morbidity and mortality observed in rural versus nonrural areas of the U.S. Nonetheless, little research attention has been given to modifying this important driver of rural/urban disparities in health outcomes. Although lifestyle treatments produce weight reductions of sufficient magnitude to improve health, the existing research is limited with respect to the long-term maintenance of treatment effects and the dissemination of services to underserved populations. Recent studies have demonstrated the feasibility of delivering lifestyle programs through the infrastructure of the U.S. Cooperative Extension Service (CES), which has >2900 offices nationwide and whose mission includes nutrition education and health promotion. In addition, several randomized trials have shown that supplementing lifestyle treatment with extended-care programs consisting of either face-to-face sessions or individual telephone counseling can improve the maintenance of weight loss. However, both options entail relatively high costs that inhibit adoption in rural communities. The delivery of extended care via group-based telephone intervention may represent a promising, cost-effective alternative that is well suited to rural residents who tend to be isolated, have heightened concerns about privacy, and report lower quality of life. The Rural Lifestyle Eating and Activity Program (Rural LEAP) is a randomized trial, conducted via CES offices in rural communities, targeted to adults with obesity (n = 528), and designed to evaluate the effectiveness and cost-effectiveness of extended-care programs delivered via group or individual telephone counseling compared to an education control condition on long-term changes in body weight.

Similar weight loss and maintenance in African American and White women in the Improving Weight Loss (ImWeL) trial

ABSTRACT Objective: African Americans (AA) are often underrepresented and tend to lose less weight than White participants during the intensive phase of behavioral obesity treatment. Some evidence suggests that AA women experience better maintenance of lost weight than White women, however, additional research on the efficacy of extended care programs (i.e. continued contacts to support the maintenance of lost weight) is necessary to better understand these differences. Methods: The influence of race on initial weight loss, the likelihood of achieving ≥5% weight reduction (i.e. extended care eligibility), the maintenance of lost weight and extended care program efficacy was examined in 269 AA and White women (62.1% AA) participating in a 16-month group-based weight management program. Participants achieving ≥5% weight reduction during the intensive phase (16 weekly sessions) were randomized to a clustered campaign extended care program (12 sessions delivered in three, 4-week clusters) or self-directed control. Results: In adjusted models, race was not associated with initial weight loss (p = 0.22) or the likelihood of achieving extended care eligibility (odds ratio 0.64, 95% CI [0.29, 1.38]). AA and White women lost −7.13 ± 0.39 kg and −7.62 ± 0.43 kg, respectively, during initial treatment. There were no significant differences in weight regain between AA and White women (p = 0.64) after adjusting for covariates. Clustered campaign program participants (AA: −6.74 ± 0.99 kg, White: −6.89 ± 1.10 kg) regained less weight than control (AA: −5.15 ± 0.99 kg, White: −4.37 ± 1.04 kg), equating to a 2.12 kg (p = 0.03) between-group difference after covariate adjustments. Conclusions: Weight changes and extended care eligibility were comparable among all participants. The clustered campaign program was efficacious for AA and White women. The high representation and retention of AA participants may have contributed to these findings.

Lessons Learned From a Multisite Evaluation of Geriatric and Extended Care Programs.

With the increased use of multisite evaluation and implementation studies in health care, our team of evaluators reflects on our evaluation of a large-scale multiyear geriatric and extended care program implementation. We share lessons from conducting multiple rounds of data collection, analyses, and reporting. We also identify some key factors that can facilitate or hinder multisite evaluation efforts involving programs with different models of implementation. This article strives to improve the quality of large-scale evaluations of health programs implementation. Knowledge gained from this complex evaluation will inform public health programs funders, implementers, and key program staff to better plan for, engage in, and benefit from effective complex evaluations to promote health in diverse settings.

Characterizing the Pattern of Weight Loss and Regain in Adults Enrolled in a 12-Week Internet-Based Weight Management Program.

ObjectiveWhile the trajectory of weight change during/after behavioral weight management interventions is believed to include a period of weight loss followed by maintenance and later regain, the sparse data produced by existing study designs (conducting assessments at 3–6 month intervals) has limited investigation into the precise pattern.MethodsSeventy-five adults were asked to self-weigh daily via “smart” scales during a 12 week, Internet-based weight loss program and 9 months with no further intervention. Longitudinal change-point mixed-effect models were used to characterize overall weight change patterns and identify when individuals moved from weight loss to maintenance/regain.ResultsAnalyses suggested a 3-phase model. During the first phase, participants lost weight at a (mean±SE) rate of −0.46±.04 kg/week; after 77.66±3.96 days, they transitioned to regain (0.07±0.02 kg/week). The next transition occurred at 222.55±7.23 days, after which the rate of regain decreased slightly (0.06±.02 kg/week). Exploratory analyses identified baseline/demographic factors predicting the timing of transition points and slope of weight change within phases.ConclusionIn contrast to the hypothesized trajectory, results demonstrated that participants transitioned immediately from weight loss to regain (with no “maintenance” period) and later to a slower rate of regain. Future studies should investigate whether extended-care programs change or merely delay this pattern.

Comparison of an alternative schedule of extended care contacts to a self-directed control: a randomized trial of weight loss maintenance

BackgroundBehavioral interventions for obesity produce clinically meaningful weight loss, but weight regain following treatment is common. Extended care programs attenuate weight regain and improve weight loss maintenance. However, less is known about the most effective ways to deliver extended care, including contact schedules.MethodsWe compared the 12-month weight regain of an extended care program utilizing a non-conventional, clustered campaign treatment schedule and a self-directed program among individuals who previously achieved ≥5% weight reductions. Participants (N = 108; mean age = 51.6 years; mean weight = 92.6 kg; 52% African American; 95% female) who achieved ≥5% weight loss during an initial 16-week behavioral obesity treatment were randomized into a 2-arm, 12-month extended care trial. A clustered campaign condition included 12 group-based visits delivered in three, 4-week clusters. A self-directed condition included provision of the same printed intervention materials but no additional treatment visits. The study was conducted in a U.S. academic medical center from 2011 to 2015.ResultsPrior to randomization, participants lost an average of −7.55 ± 3.04 kg. Participants randomized to the 12-month clustered campaign program regained significantly less weight (0.35 ± 4.62 kg) than self-directed participants (2.40 ± 3.99 kg), which represented a significant between-group difference of 2.28 kg (p = 0.0154) after covariate adjustments. This corresponded to maintaining 87% and 64% of lost weight in the clustered campaign and self-directed conditions, respectively, which was a significant between-group difference of 29% maintenance of lost weight after covariate adjustments, p = 0.0396.ConclusionsIn this initial test of a clustered campaign treatment schedule, this novel approach effectively promoted 12-month maintenance of lost weight. Future trials should directly compare the clustered campaigns with conventional (e.g., monthly) extended care schedules.Trial registrationClinicaltrials.gov NCT02487121. Registered 06/26/2015 (retrospectively registered)

Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol.

BackgroundThe program “Implementing Goals of Care Conversations with Veterans in VA LTC Settings” is proposed in partnership with the US Veterans Health Administration (VA) National Center for Ethics in Health Care and the Geriatrics and Extended Care Program Offices, together with the VA Office of Nursing Services. The three projects in this program are designed to support a new system-wide mandate requiring providers to conduct and systematically record conversations with veterans about their preferences for care, particularly life-sustaining treatments. These treatments include cardiac resuscitation, mechanical ventilation, and other forms of life support. However, veteran preferences for care go beyond whether or not they receive life-sustaining treatments to include issues such as whether or not they want to be hospitalized if they are acutely ill, and what kinds of comfort care they would like to receive.MethodsThree projects, all focused on improving the provision of veteran-centered care, are proposed. The projects will be conducted in Community Living Centers (VA-owned nursing homes) and VA Home-Based Primary Care programs in five regional networks in the Veterans Health Administration. In all the projects, we will use data from context and barrier and facilitator assessments to design feedback reports for staff to help them understand how well they are meeting the requirement to have conversations with veterans about their preferences and to document them appropriately. We will also use learning collaboratives—meetings in which staff teams come together and problem-solve issues they encounter in how to get veterans’ preferences expressed and documented, and acted on—to support action planning to improve performance.DiscussionWe will use data over time to track implementation success, measured as the proportions of veterans in Community Living Centers (CLCs) and Home-Based Primary Care (HBPC) who have a documented goals of care conversation soon after admission. We will work with our operational partners to spread approaches that work throughout the Veterans Health Administration.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-016-0497-0) contains supplementary material, which is available to authorized users.

Application of structure-process-result three dimensional quality assessment program in extended care for closed Achilles tendon rupture patients

Objective To explore the influence of the structure-process-result three dimensional quality assessment program on extended care effect for minimally invasive surgical treatment of closed Achilles tendon rapture. Methods A total of 100 patients with closed Achilles tendon rupture who accepted the minimally invasive surgery in Zhoushan Traditional Chinese Hospital of Bone Fracture from June 2011 to June 2014 were chosen for the study. They were randomly divided into the control group(50 cases) and the observation group(50 cases) based on the random number table. The conventional extended care after discharge were performed on the patients in the control group, while the extended care program based on the structure-process-results three dimensional quality assessment program was performed on the patients in the observation group. The curative effects, quality of life, the patient′s satisfaction were observed and compared between two groups three months after discharge. Results The curative effects of the patients in the observation group were significantly higher than those in the control group(P<0.05). The scores of physiological function, vitality, body pain, social function, mental health, emotional function, general health in the patients three months after the discharge were significant higher than that in the control group(P<0.05). The satisfaction of patients in the observation group three months after the discharge was significantly higher than that in the control group(P<0.05). Conclusions Structure-process-result three dimensional quality assessment program can improve the quality of extended care. It not only effectively improves the rehabilitation of patients after discharge and the quality of life, but also improves the patient′s satisfaction. Key words: Closed Achilles tendon rupture; Extended care; Quality of life; Minimally invasive surgery; Structure-process-result dimensional quality assessment program

Comparing Costs of Telephone vs Face-to-Face Extended-Care Programs for the Management of Obesity in Rural Settings

BackgroundA major challenge after successful weight loss is continuing the behaviors required for long-term weight maintenance. This challenge can be exacerbated in rural areas with limited local support resources. ObjectiveThis study describes and compares program costs and cost effectiveness for 12-month extended-care lifestyle maintenance programs after an initial 6-month weight-loss program. DesignWe conducted a 1-year prospective randomized controlled clinical trial. Participants/settingThe study included 215 female participants age 50 years or older from rural areas who completed an initial 6-month lifestyle program for weight loss. The study was conducted from June 1, 2003 to May 31, 2007. InterventionThe intervention was delivered through local Cooperative Extension Service offices in rural Florida. Participants were randomly assigned to a 12-month extended-care program using either individual telephone counseling (n=67), group face-to-face counseling (n=74), or a mail/control group (n=74). Main outcome measuresProgram delivery costs, weight loss, and self-reported health status were directly assessed through questionnaires and program activity logs. Costs were estimated across a range of enrollment sizes to allow inferences beyond the study sample. Statistical analyses performedNonparametric and parametric tests of differences across groups for program outcomes were combined with direct program cost estimates and expected value calculations to determine which scales of operation favored alternative formats for lifestyle maintenance. ResultsMedian weight regain during the intervention year was 1.7 kg for participants in the face-to-face format, 2.1 kg for the telephone format, and 3.1 kg for the mail/control format. For a typical group size of 13 participants, the face-to-face format had higher fixed costs, which translated into higher overall program costs ($420 per participant) when compared with individual telephone counseling ($268 per participant) and control ($226 per participant) programs. Although the net weight lost after the 12-month maintenance program was higher for the face-to-face and telephone programs compared with the control group, the average cost per expected kilogram of weight lost was higher for the face-to-face program ($47/kg) compared with the other two programs (approximately $33/kg for telephone and control). ConclusionsBoth the scale of operations and local demand for programs are important considerations in selecting a delivery format for lifestyle maintenance. In this study, the telephone format had a lower cost but similar outcomes compared with the face-to-face format.

The Association Between Rate of Initial Weight Loss and Long-Term Success in Obesity Treatment: Does Slow and Steady Win the Race?

Controversy exists regarding the optimal rate of weight loss for long-term weight management success. This study examined whether gradual initial weight loss was associated with greater long-term weight reduction than rapid initial loss. Groups were drawn from participants in the TOURS trial, which included a sample of middle-aged (mean = 59.3 years) obese women (mean BMI = 36.8) who received a 6-month lifestyle intervention followed by a 1-year extended care program. Participants were encouraged to reduce caloric intake to achieve weight losses of 0.45 kg/week. Groups were categorized as "FAST" (> or =0.68 kg/week, n = 69), "MODERATE" (> or =0.23 and <0.68 kg/week, n = 104), and "SLOW" (<0.23 kg/week, n = 89) based on rate of weight loss during first month of treatment. The FAST, MODERATE, and SLOW groups differed significantly in mean weight changes at 6 months (-13.5, -8.9, and -5.1 kg, respectively, ps < 0.001), and the FAST and SLOW groups differed significantly at 18 months (-10.9, -7.1, and -3.7 kg, respectively, ps < 0.001). No significant group differences were found in weight regain between 6 and 18 months (2.6, 1.8, and 1.3 kg, respectively, ps < 0.9). The FAST and MODERATE groups were 5.1 and 2.7 times more likely to achieve 10% weight losses at 18 months than the SLOW group. Collectively, findings indicate both short- and long-term advantages to fast initial weight loss. Fast weight losers obtained greater weight reduction and long-term maintenance, and were not more susceptible to weight regain than gradual weight losers.