First Year Of Care Research Articles

The start of caring for an elderly dependent family member: a qualitative metasynthesis

BackgroundThe family often takes care of an elderly person who suddenly becomes dependent. This greatly affects different aspects of the caregivers’ lives. The aim of this study is to explore the initial experiences, during the first year of care, of persons who suddenly become caregivers for elderly dependent relatives.MethodsA search in CINAHL, PsycINFO, WOS, Medline, and Scopus and a metasynthesis of qualitative research were conducted including 19 articles.ResultsThree categories were developed to explain the process of becoming a caregiver ‘taking on the role’ (life changes, uncertainty and confusion, and acceptance or resistance); ‘beginning to realise’ (new needs, impact, and appraisal); and ‘implementing strategies’ (seeking help and self-learning, reordering family and social relationships, solving problems, and devising strategies to decrease negative emotions and stress).ConclusionsThe synthesis provides a comprehensive understanding of the experience of becoming a caregiver in order to help health-care professionals to adapt care plans to this situation.

Epidemiological and economic burden of potentially HPV-related cancers in France

Human papillomaviruses (HPV) infection is now known to be responsible for almost all cervical cancers, and for a substantial fraction of Head and Neck cancers (HNCs). However, comprehensive epidemiological and economic data is lacking in France, especially for rarer potentially HPV-related cancers, which include anal, vulvar and vaginal cancers. Using the national comprehensive database of French public and private hospital information (PMSI), we assessed prevalence and incidence of patients with in-hospital diagnosis for potentially HPV-related cancers in 2013, and estimated costs related to their management over a 3-year period after diagnosis in France. Concerning female genital cancers, 7,597, 1,491 and 748 women were hospitalized for cervical, vulvar and vaginal cancer in 2013, respectively, with 3,120, 522 and 323 of them being new cases. A total of 4,153 patients were hospitalized for anal cancer in 2013, including 1,661 new cases. For HNCs, 8,794 and 14,730 patients were hospitalized for oral and oropharyngeal cancer in 2013, respectively; 3,619 and 6,808 were new cases. Within the 3 years after cancer diagnosis, the average cost of hospital care per patient varied from €28 K for anal cancer to €41 K for oral cancer. Most expenditures were related to hospital care, before outpatient care and disability allowance; they were concentrated in the first year of care. The total economic burden associated with HPV-potentially related cancers was about €511 M for the French National Health Insurance over a 3 years period (2011 to 2013), ranging from €8 M for vaginal cancer to €222 M for oropharyngeal cancer. This study reported the most up-to-date epidemiological and economic data on potentially HPV-related cancers in France. These results may be used to evaluate the potential impact of new preventive strategies, namely the generalized organized screening of cervical cancer and the nine-valent HPV vaccine, indicated in the prevention of cervical, vaginal, vulvar and anal cancers.

Medical oncologists\u2019 willingness to participate in bundled payment programs

BackgroundBundled payment programs play an increasingly important role in transforming reimbursement for oncologic care. We assessed determinants of oncologists’ willingness to participate in bundled payment programs for breast cancer. We hypothesized that providers would be more likely to participate in bundled payment programs if offered higher levels of reimbursement for each episode of care.MethodsOncologists from Florida, New Jersey, New York, and Pennsylvania were identified in the AMA database or by patients listed in state cancer registries. Providers were randomized to receive one of four versions of a survey describing bundled payment programs offering different levels of compensation for the first year of localized breast cancer treatment ($5000, $10,000, $15,000, or $20,000). Physicians rated their likelihood of participation in a bundled program on a Likert scale. Logistic regression was used to analyze determinants of likelihood of participation in bundling.ResultsAmong 460 respondents, only 17% of oncologists were highly likely to participate in a bundled program paying $5000 for the first year of care, rising to 41% for the $15,000 program, but falling to 34% for the $20,000 program. Likelihood of participation was higher among oncologists who were male, older, and believed that cancer patients should not be offered high-cost drugs with minimal survival benefit.ConclusionOur results suggest that medical oncologists have limited enthusiasm for bundled payments, and higher payments may not overcome resistance to bundling among a substantial proportion of physicians.

Empirical estimation of life expectancy from a linked health database of adults who entered care for HIV.

BackgroundWhile combination antiretroviral therapy (cART) has significantly improved survival times for persons diagnosed with HIV, estimation of life expectancy (LE) for this cohort remains a challenge, as mortality rates are a function of both time since diagnosis and age, and mortality rates for the oldest age groups may not be available.MethodsA validated case-finding algorithm for HIV was used to update the cohort of HIV-positive adults who had entered care in Ontario, Canada as of 2012. The Chiang II abridged life table algorithm was modified to use mortality rates stratified by time since entering the cohort and to include various methods for extrapolation of the excess HIV mortality rates to older age groups.ResultsAs of 2012, there were approximately 15,000 adults in care for HIV in Ontario. The crude all-cause mortality rate declined from 2.6% (95%CI 2.3, 2.9) per year in 2000 to 1.3% (1.2, 1.5) in 2012. Mortality rates were elevated for the first year of care compared to subsequent years (rate ratio of 2.6 (95% CI 2.3, 3.1)). LE for a 20-year old living in Ontario was 62 years (expected age at death is 82), while LE for a 20-year old with HIV was estimated to be reduced to 47 years, for a loss of 15 years of life. Ignoring the higher mortality rates among new cases introduced a modest bias of 1.5 additional years of life lost. In comparison, using 55+ as the open-ended age group was a major source of bias, adding 11 years to the calculated LE.ConclusionsUse of age limits less than the expected age at death for the open-ended age group significantly overstates the estimated LE and is not recommended. The Chiang II method easily accommodated input of stratified mortality rates and extrapolation of excess mortality rates.

Multiple gaps in care common among newly diagnosed HIV patients

The objective of this study was to identify frequency and predictors of gaps in care in a longitudinal cohort of HIV-infected patients in urban New England. We conducted a retrospective cohort study in Providence, RI, of 581 newly diagnosed HIV patients >18 entering into care from 2004 to 2010, and followed their care through the end of 2011. The outcome of interest was gaps in care, defined as an interruption of medical care for >6 months. Time to the first gap was characterized using Kaplan–Meier (KM) curves. Anderson–Gill proportional hazards (AGPH) model was used to identify the risk factors of recurrent gaps in care. During the study period, 368 patients (63%) experienced at least 1 gap in care, 178 (30%) had ≥2 gaps, 84 (14.5%) had ≥3 gaps, and 21 (3.6%) died; 77% of the gaps were followed by a re-linkage with care The KM curves estimate that one-quarter of patients (95% CI = 22–29%) would experience ≥1 gap in care by Year 1; nearly one-half (CI = 45–54%) by Year 2; and 90% (CI = 93–96%) by Year 8. A prior gap was a strong predictor (HR = 2.36; CI = 2.16–2.58) of subsequent gaps; other predictors included age <25 (HR = 1.29; CI = 1.04–1.60), and no prescription of ART in first year of care (HR = 1.23; CI = 1.01–1.50). The results of this study suggest that a significant proportion of newly diagnosed HIV-infected patients will experience multiple gaps in care and yet re-engagement is possible. Interventions should focus on both prevention of gaps as well as re-engaging those lost to follow-up.

Impact of Poor Retention in HIV Medical Care on Hepatitis B Vaccination.

We identified factors associated with complete hepatitis B vaccination of patients with HIV. Retrospective analysis of patients undergoing HIV clinic orientation from 2000 to 2010. Vaccine-eligible patients had negative hepatitis B serologies at baseline. Receipt of at least 3 doses was defined as complete vaccination. Of 1242 patients, 519 (42%) were completely vaccinated. Complete vaccination was positively associated with missing ≤25% of the visits during the first year of care (adjusted odds ratio [aOR] = 2.35, 95% confidence interval [CI]: 1.79-3.09), being naive to care (aOR = 1.50, 95% CI: 1.13-1.99), and living at the clinic's county (aOR = 1.33, 95% CI: 1.02-1.75). Complete vaccination was negatively associated with failure to remain in care >2 years (aOR = 0.18, 95% CI: 0.13-0.24), history of intravenous drug use (aOR = 0.48, 95% CI: 0.27-0.87), and baseline CD4 count <200 cells/mm(3) (aOR = 0.69, 95% CI: 0.53-0.92). Poor retention in HIV care is strongly associated with suboptimal hepatitis B vaccination.

Outcomes of HIV-Infected Patients Receiving Care at Multiple Clinics

Receiving care at multiple clinics may compromise the therapeutic patient-provider alliance and adversely affect the treatment of people living with HIV. We evaluated 12,759 HIV-infected adults in Philadelphia, PA between 2008 and 2010 to determine the effects of using multiple clinics for primary HIV care. Using generalized estimating equations with logistic regression, we examined the relationship between receiving care at multiple clinics (≥ 1 visit to two or more clinics during a calendar year) and two outcomes: (1) use of ART and (2) HIV viral load ≤ 200 copies/mL for patients on ART. Overall, 986 patients (8 %) received care at multiple clinics. The likelihood of attending multiple clinics was greater for younger patients, women, blacks, persons with public insurance, and for individuals in their first year of care. Adjusting for sociodemographic factors, patients receiving care at multiple clinics were less likely to use ART (AOR = 0.62, 95 % CI 0.55-0.71) and achieve HIV viral suppression (AOR = 0.78, 95 % CI 0.66-0.94) than individuals using one clinic. Qualitative data are needed to understand the reasons for visiting multiple clinics.

The effect of weekly short message service communication on patient retention in care in the first year after HIV diagnosis: study protocol for a randomised controlled trial (WelTel Retain)

IntroductionInterventions to improve retention in care after HIV diagnosis are necessary to optimise the timely initiation of antiretroviral therapy (ART) and HIV/AIDS control outcomes. Widespread mobile phone use presents new...

Do Ethnic Disparities Extend to Subspecialty Diabetes Care?

It is unclear if disparities described in diabetes primary care extend to subspecialty diabetes care. This retrospective observational study examined disparities in diabetes outcomes in a subspecialty practice by assessing glycemic improvement in type 2 diabetes patients during the first year of enrollment. Electronic data were gathered on 3,945 subjects. The outcome was the proportion of white and minority (Asian, black, and Hispanic) subjects achieving a hemoglobin A1C (A1C) level of ≤7% after the first year of care. Logistic regression was used to identify factors associated with odds of achieving A1C ≤7%. Minority patients had greater diabetes duration, more social disadvantages and missed appointments, and worse control at presentation than whites. The proportion of patients reaching target A1C rose from 37 to 52% among white patients and from 28 to 40% among minority patients. Significant differences between whites and minorities in the rates of patients reaching A1C ≤7% were found only among those with higher initial A1C (iA1C) levels (32% vs. 20.9%; P = .002 in third iA1C quartile, and 28.2% vs. 17.9%; P = .0003 in fourth iA1C quartile). The interaction between race/ethnicity and the top two iA1C quartiles remained significant in the fully adjusted model. Reaching an A1C level of ≤7% depends strongly upon the glycemic level at initial presentation to specialty care, not race. However, minority patients with the highest baseline A1C levels do not improve to the same degree as white patients, and therefore should be targeted for more intensive diabetes care management.

Cost Comparison of Continuous-Flow Left Ventricular Assist Devices as Destination Therapy in Patients Over/Under Age 70

Purpose The use of continuous-flow left ventricular assist devices (CF-LVADs) as destination therapy (DT) has been increasing, but resource utilization has not been well described in a population outside of a clinical trial. We hypothesized that cost of implant hospitalization and inpatient costs over the 1 st year would not be significantly different in patients over the age of 70. Methods and Materials All consecutive DT CF-LVAD implants at a single center between 2008-2010 were retrospectively identified (n=19). We compared the cost of implant hospitalization and total cost of care at the implant center (rehab plus subsequent inpatient hospital costs) over the first year after implant. We only included direct costs, excluding indirect costs incurred to support infrastructure, e.g. utilities, administration, maintenance, nursing, etc. Results There was no significant difference between baseline INTERMACS scores in patients ≥70 compared to Conclusions We did not observe increased cost of implant hospitalization or for the first year of care for DT CF-LVAD patients over the age of 70, despite comparable severity of illness. These findings suggest that age alone does not appear to adversely impact cost of care, and should be carefully considered when making decisions regarding individual suitability for implant.

Economic Burden of Intracranial Vascular Malformations in Adults

Although intracranial vascular malformations (IVMs) are the leading cause of intracerebral hemorrhage (ICH) in young adults, there has not been a cost-of-illness study on an unselected cohort. We measured the direct healthcare costs (inpatient, outpatient, intervention, and brain imaging) incurred by every adult within 3 years after their first presentation with a brain arteriovenous malformation (AVM) or cavernous malformation (CM) in a prospective, population-based study. We estimated the indirect cost of lost productivity for the whole cohort over the same period by projecting questionnaire responses from living consenting adults. 369 adults (AVM=229 [62%], CM=140 [38%]) incurred healthcare costs of pound 5.96 million over 3 years, of which AVMs accounted for 90%, inpatient care accounted for 75%, and the first year of care accounted for 69%. Median 3-year healthcare costs were statistically significantly higher for adults presenting with ICH, aged <65 years, receiving interventional treatment, and adults with AVMs rather than CMs ( pound 15,784 versus pound 1385, P<0.0005). Healthcare costs diminished with increasing AVM nidus size (P=0.005). Mean 3-year costs of lost productivity per questionnaire respondent (n=145) were pound 17,111 for AVMs and pound 6752 for CMs (P=0.1), and the projected 3-year cost of lost productivity for all 369 adults was pound 8.7 million. The costs of healthcare and lost productivity attributable to IVMs are considerable, and highest in those aged <65 years, presenting with ICH, receiving interventional treatment, and harboring AVMs rather than CMs. Long-term studies of the cost-effectiveness of interventional treatment are needed.

Missed Visits and Mortality among Patients Establishing Initial Outpatient HIV Treatment

Dramatic increases in the number of patients requiring linkage to treatment for human immunodeficiency virus (HIV) infection are anticipated in response to updated Centers for Disease Control and Prevention HIV testing recommendations that advocate routine, opt-out HIV testing. A retrospective analysis nested within a prospective HIV clinical cohort study evaluated patients who established initial outpatient treatment for HIV infection at the University of Alabama at Birmingham 1917 HIV/AIDS Clinic from 1 January 2000 through 31 December 2005. Survival methods were used to evaluate the impact of missed visits during the first year of care on subsequent mortality in the context of other baseline sociodemographic, psychosocial, and clinical factors. Mortality was ascertained by query of the Social Security Death Index as of 1 August 2007. Among 543 study participants initiating outpatient care for HIV infection, 60% missed a visit within the first year. The mortality rate was 2.3 deaths per 100 person-years for patients who missed visits, compared with 1.0 deaths per 100 person-years for those who attended all scheduled appointments during the first year after establishing outpatient treatment (P = .02). In Cox proportional hazards analysis, higher hazards of death were independently associated with missed visits (hazard ratio, 2.90; 95% confidence interval, 1.28-6.56), older age (hazard ratio, 1.58 per 10 years of age; 95% confidence interval, 1.12-2.22), and baseline CD4+ cell count < 200 cells/mm(3) (hazard ratio, 2.70; 95% confidence interval, 1.00-7.30). Patients who missed visits within the first year after initiating outpatient treatment for HIV infection had more than twice the rate of long-term mortality, compared with those patients who attended all scheduled appointments. We posit that early missed visits are not causally responsible for the higher observed mortality but, rather, identify those patients who are more likely to exhibit health behaviors that portend increased subsequent mortality.

Pediatric short-bowel syndrome: the cost of comprehensive care

Background:Little information is available about the financial charges incurred by patients with short-bowel syndrome (SBS). This is particularly true for pediatric SBS patients who receive some of the most complex medical care. Objectives:The aims of this study were to determine the total cost of care for these patients and to analyze their utilization of home and hospital-based health care services. Design:This was a retrospective review of the total charges incurred by 41 children with SBS over the past decade, encompassing both inpatient and home-care charges. Results:The mean (± SD) total cost of care for pediatric SBS was US$505 250 ± US$248 398 (corrected for inflation to the year 2005) for the first year of care alone. Inpatient hospitalization accounted for most of these expenses (US$416 818 ± US$242 689, or 82% of the total), and this was attributable to prolonged requirements for intensive care resources, numerous surgical procedures, and multiple readmissions during the first year of diagnosis. Hospital-based costs steadily declined in subsequent years, but home-care services, in stark contrast, unexpectedly increased every year for the first 5 y of diagnosis—a trend that was highly significant (P < 0.005), reaching US$184 520 ± US$111 075 for the fifth year of home care. This increasing cost was attributable to increasing complications of parenteral nutrition, especially infectious complications. Although per-patient charges varied widely, the mean total cost of care per child over a 5-y period was US$1 619 851 ± US$1 028 985. A strong correlation was found between higher charges and infants with <10% of predicted small-bowel length. Conclusions:This study was the first to calculate the total costs for pediatric SBS patients and to provide an in-depth analysis of these patients’ actual utilization of health care services. This information may help guide health care providers and families who have children with SBS. The comprehensive care of pediatric SBS patients costs significantly more than has previously been estimated. Contrary to previous views, home care significantly increases each year after diagnosis.

758 Pediatric Short Bowel Syndrome: the Cost of Caring for These Complex Patients

Background: The economic impact of care for short bowel syndrome (SBS) patients is unknown. Our institution provides not only inpatient care for a large pediatric SBS population, but also operates a comprehensive home-care program (including infusion, durable medical equipment and nursing), allowing us to assess total cost of care (COC) incurred with SBS. Methods: This study examined actual COC (defined from the payers' viewpoint, i.e., charges) of pediatric SBS. All charges were adjusted for inflation to mid-decade (2005) U.S. dollars. Costs were stratified as “Hospital care” (inpatient stays, procedures, and outpatient clinic charges) or “Home-based care” (parenteral nutrition, enteral supplements, home nursing charges, pump charges, pharmaceuticals, and rentals). Total COC for all patients for the first 5 years after onset of SBS were assessed for each year. To detect the significance of potential secular trends, linear regression was performed using the least squares method. P<0.05 was considered significant. Data includes all patients in a pre-transplant state. Results: A total of 41 patients were studied, all with SBS diagnosed in infancy. In-patient hospital days averaged 136±188 (mean ± SD; median: 82 days) and incurred a cost of $452,527±578,659 (median: $296,808) at an average of $3,315±$1,187 per day. Home-based care averaged $93,014±69,433 (median: $83,572) per patient during the first year of care alone. Interestingly, the cost of home care was found to increase every year for the first five years of diagnosis, a trend that was highly significant (P<0.005), reaching $190,056±111,075 (median: $209,069) for the fifth year of home care. This increasing cost was attributable to increasing complications of PN, especially infectious complications. Although charges per patient varied widely, the mean total cost of care per child was $808,970±497,753 over the first 5 years post-diagnosis. To better understand which patient's had the highest COC, financial data was then correlated with patient's clinical outcomes. Regression analysis results showed that the only factor which predicted increased COC was infants with bowel length <10%of predicted for their gestational age (C.I. $174,265 $703,209, P=0.003). Conclusions: This study is one of the first to estimate total COC for pediatric SBS patients. This information may help guide healthcare providers and patient's families of children with SBS. Importantly, the comprehensive care of pediatric SBS patients costs significantly more than has previously been assumed. Contrary to previous views, the SBS COC does not diminish with time; but significantly increases each year.

The impact of total body photography on biopsy rate in patients from a pigmented lesion clinic

Total body cutaneous photography is increasingly being used by dermatologists to monitor patients at risk for the development of melanoma, but limited evidence exists regarding the impact of such photography on melanoma and melanoma-related outcomes. We sought to compare biopsy number in patients with multiple atypical nevi in their first year of care at our pigmented lesion clinic (PLC) between those who received total body skin examination alone and those who received total body skin examination and total body digital photography (TBDP). We sought to identify predictors of biopsy number and number of dysplastic nevi diagnosed in patients with multiple atypical nevi. A chart review was performed of patients attending the PLC during the years 1998 to 2003 to identify the number of biopsies performed in the first year of care. Patient demographics, melanoma risk factors, and melanoma outcome events were also abstracted from the charts. The mean number of biopsies performed in patients in their first year of care at the PLC in those who did not receive TBDP was equal to the mean number of biopsies performed in patients who did receive TBDP (0.82 and 0.8, respectively). Linear regression analysis revealed that the interaction term between a lack of both personal history of melanoma and severe dysplastic nevi (-0.930, P = .005) has a significant protective effect on the number of biopsies. Similar regression analysis also showed that the interaction term between a lack of both personal history of melanoma and of severe dysplastic nevi (-1.209, P < .0001), increasing provider experience (-0.047, P = .029), and increased number of biopsies before the initial PLC (-0.028, P = .050) have a statistically significant protective effect on the number of dysplastic nevi diagnosed in the first year of PLC. TBDP did not have an effect on the number of biopsies or on the number of dysplastic nevi diagnosed in the first year of care at the PLC. This study is limited by being retrospective in nature, having a small sample size, and having a short follow-up period. Overall, this small retrospective study does not provide evidence that would suggest that TBDP changes provider behavior in caring for patients at high risk for melanoma. Rather, our study supports the fact that a patient's positive history of melanoma and a history of severe dysplastic nevi have the most significant impact on provider biopsy behavior, resulting in a lower threshold to biopsy suggestive lesions.

Patterns of referral, management and survival of patients diagnosed with prostate cancer in Scotland during 1988 and 1993: results of a national, retrospective population-based audit.

To examine patterns of referral, management and survival of men with prostate cancer, and to document changes over time. All men registered with prostate cancer in 1988 and 1993 were identified from the Scottish Cancer Registry. Data were abstracted according to standard definitions from the available medical records of 930 men in 1988 and 1355 in 1993. There was limited evidence of multidisciplinary care, with only 8% of patients in 1988 being managed by both a urologist and a clinical oncologist within a year of diagnosis, increasing to 13% in 1993. Only a small proportion of patients were managed by clinical oncologists during the first year of care (14% in 1988 and 20% in 1993). Documentation of thorough staging information was poor, with a T stage being recorded in <30% of cases in both years. Documentation of metastatic status increased from 53% to 63% between 1988 and 1993, paralleling an increase in the use of bone scans. The proportion of cases with pathological grading obtained at diagnosis increased from 63% in 1988 to 68% by 1993. The use of PSA testing and core biopsies increased between the years while the use of transurethral prostatectomy decreased. More patients received radical radiotherapy within a year of diagnosis in 1993 than 1988, increasing from 6% to 9%, and more radical prostatectomies were also undertaken (0.2% to 2.3%). Nonetheless, most patients (81% in 1993) with no documented evidence of metastases received no active intervention (radical radiotherapy, radical prostatectomy, or 'watchful waiting'). The survival at 5 years increased nonsignificantly from 34% for the 1988 cohort to 38% for the 1993 cohort. This audit reveals considerable inconsistency in the management of men with prostate cancer in Scotland. Against a background of controversy about numerous aspects of the management of this disease, the need for a multidisciplinary approach, comprehensive staging and appropriate documentation is highlighted.

Utilization of psychiatric in-patient care among new patients in a comprehensive community-care system: a 3-year follow-up study.

Utilization of psychiatric in-patient care among 537 new patients was studied in the Department of Psychiatry in Oulu, Finland, during a 3-year follow-up period. Hospitalization during the second and third years of the follow-up was predicted by hospitalization and number of emergency out-patient contacts during the first year of the study, diagnosis of functional psychosis or personality disorder, and previous in-patient care. In total, 5% of the cohort fulfilled our criteria for 'revolving-door' patients. The 'revolving-door' phenomenon was associated with in-patient care at the first contact with the psychiatric services and diagnosis of psychosis or personality disorder. In total, 2% of the cohort became long-stay hospital patients, and this was predicted by psychosis diagnosis. The clinical implications of these findings are that increased attention should be paid to the first assessment of new patients and to the interaction between psychiatric services and patients during the first year of care.

Family Caregiving and Marital Satisfaction: Findings from a 1-Year Panel Study of Women Caring for Parents with Dementia

This study uses quantitative and qualitative data collected from 94 daughters and daughters-in-law to examine the effects of care giving on marital satisfaction across the first year of caring for an elderly parent with dementia. While there was no change in mean marital satisfaction scores. More than one-third of the women reported notably lower or higher scores by the end of the year. Analyses indicated that changes in the women's marital satisfaction were associated with variations' in their husbands' emotional support and hindrance of the caregiving effort. Husbands' support and hindrance were affected by the husbands' perceptions that caregiving interfered with their wives' performance of traditional family roles. Husbands' instrumental support did not help to explain changes in caregivers' marital satisfaction across the year. During the past 15 years a great deal of attention has been directed toward understanding the effects of women's multiple roles on marital quality. While this literature has examined the effects of several important roles, including employment (cf. Barker, 1993; Booth, Johnson, White, & Edwards, 1984; Ladewig & McGee, 1986; Spitze & South, 1985; Vannoy & Philliber, 1992), parenthood (cf. Belsky, Lang, & Rovine, 1985; Cowan et al., 1985; Feldman & Nash, 1984; Miller & Sollie, 1980; White & Booth, 1985), and becoming a college student in midlife (Suitor, 1987, 1988), limited attention has been paid to the effects of the increasingly common role of caring for elderly impaired parents. The few studies that exist on the effects of caregiving on adult children's marital quality have been limited by the use of cross-sectional data. These investigations have found that relatively few adult children or children-in-law report that caregiving affects their marital relationships detrimentally (cf. Cantor, 1983; Horowitz, 1985; Kleban, Brody, Schoonover, & Hoffman, 1989), but the reliance on cross-sectional data limits the reliability of these findings. In contrast, the present study uses longitudinal data collected from 94 women at the beginning and the end of the first year of caring for a parent or parent-in-law with dementia to examine changes in marital satisfaction. In addition to investigating the extent of changes in marital satisfaction across the first year of care, this study uses a combination of quantitative and qualitative data to explore the factors that may lead to these changes. CONCEPTUAL FRAMEWORK Status Transitions and Interpersonal Relations Research on interpersonal relationships has demonstrated that relations with friends and family members are often changed by status transitions such as becoming divorced, widowed, unemployed, returning to school, or reentering the labor force. The transitions that appear to have the greatest potential for transforming relationships are those that result in the violation of expectations regarding the individual's performance of roles specific to those relationships. Thus, for example, unemployment often produces conflict in men's relationships with their wives (Larson, 1984; Lorenz, Conger, Simon, Whitbeck, & Elder, 1991; Newman, 1988), as well with their parents and siblings (cf. Newman, 1988), due to changes in the husbands' ability to provide economically for their wives and children and to maintain economic independence from their other relatives. For women, the transitions that appear to be the most likely to produce conflict in preexisting relationships are those that cause the women to violate the cultural mandate (Coser, 1991) that women give highest priority to their family responsibilities. While such violations have the potential to create conflict in a variety of role relationships, the marital relationship appears to be particularly vulnerable to these effects. For example, women who return to school full-time while raising small children experience increased discord in their marriages, because their commitment to academic life interferes with their performance of traditional family roles (Suitor, 1987). …

Care of the Ill Child in Day-Care Settings

Children experience many minor illnesses during the toddler and preschool years, and illness frequency is compounded by attendance in out-of-home child care programs. Although most of these illnesses are uncomplicated, some lead to complications that require medical evaluation and treatment. A majority of working parents of childbearing age have children in day care, and these illnesses have an impact on both the child's health and the parents' attendance at work. As a result, in-home and out-of-home sick-child care programs have emerged. The common infectious diseases of children in child day care are also common among children not in out-of-home care. They can be identified as those primarily affecting the respiratory system, gastrointestinal system, and skin and those that may affect multiple organs. Respiratory infections predominate, followed by vomiting and diarrheal illnesses. Wald et al1 followed a cohort of children through the first 3 years of life; 97 received exclusive care at home, 23 received care in a group setting out of the home, and 33 attended day-care centers. During the first year of care, children in center care experienced significantly more infections than children in home care. Children in group care and center care were significantly more likely than children in home care to experience six or more infections and four or more severe illnesses. The majority (76% to 89%) of infections were respiratory, and otitis media complicated 28% to 44% of these respiratory infections.2 Children in nonparental home care experienced an average of 41 days of illness during the year; the average increased to 78 days in group care, and 96 days in center care.

Cost analysis of early trabeculectomy versus conventional management in primary open angle glaucoma

The financial cost of managing primary open angle glaucoma by trabeculectomy at diagnosis was compared with the cost of a more conventional sequence of medical therapy followed by trabeculectomy only in unsuccessful cases. Costs were estimated at 1989 prices for 104 patients studied in a prospective randomised multicentre trial which had been running for eight years. Separate estimates were made for operative costs, inpatient costs, and outpatient costs including visual field tests and medications. Values were adjusted to allow for the observed mortality rate within the group. Conventionally managed patients with bilateral glaucoma required an average total expenditure of 2,570 pounds for the eight year period, compared with 2,560 pounds for those treated by early surgery. In both groups expenditure was greatest in the first year of care, and declined over the eight years. Although early surgery incurred a higher cost within the first year, in subsequent years the conventionally managed group was consistently more expensive and so overall costs were similar. Inpatient care was the most expensive item in both groups (62% of total cost in conventional management, and 77% with early surgery). Our current practice is to admit patients for a shorter period than the average of 7.6 days at the time of this trial. We have therefore produced cost estimates based on a shorter inpatient stay of one and four days per operation, and in both cases early surgery becomes the less expensive strategy. The results have been presented in a form that allows substitution of regional and temporal variations in costs and medical practice.